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Candida  auris   is   an  emerging  mul/drug-­‐resistant   (MDR)   fungus  associated  with  invasive  infec/ons  and  high  mortality.  Since  the  first   report   of   C.   auris,   isolated   from   a   pa/ent’s   ear   canal   in  2009,   it   has   been   implicated   in   mul/ple   healthcare-­‐associated  outbreaks  of  candidemia.  Between  2009–2016  cases  of  C.  auris  have  been  reported  worldwide.  This  report  describes  the  first  9  confirmed   cases   of   C.   auris   in   Central   America,   iden/fied   in   a  hospital   in  Panama  City,  Panama,  and  highlights   the  challenges  of  accurate   iden/fica/on  and  methods  for  suscep/bility   tes/ng  using  current  phenotypic  systems,  such  as  Vitek®  2  (bioMérieux)  and  Etest®.      

INTRODUCTION  

A   total   of   14   Isolates,   from   9   pa/ents,   that   were   ini/ally  iden/fied   as   Candida   haemulonii   or   Candida   spp.   by   Vitek®   2  automated  system  (bioMérieux)  at  one  of  the  largest  acute  care  hospitals   (>500   beds)   in   Panama   City,   Panama.  Matrix-­‐assisted  laser   desorp/on/ioniza/on   (MALDI-­‐TOF)   was   performed   by  Vitek®  MS  (bioMérieux)   in  Panama  city.  Results  were  confirmed  at   CDC   (Atlanta,   USA)   by   Microflex®   (Bruker)   systems,   and   by  DNA  sequencing  the  D1/D2  region  of  the  28S.                    We   compared   results   of   an/fungal   suscep/bility   obtained   by  Vitek®   2   automated   system   for   fluconazole   and   echinocandins,  specifically   anidulafungin   and   caspofungin;   results   were  compared  to  CLSI  broth  microdilu/on  using  custom-­‐made  frozen  panels   (TREK   Diagnos/c   Systems,   Thermo   Scien/fic.   Oakwood  Village,   OH,   United   States).   Amphotericin   B   MICs   obtained   by  Vitek®  2  were  compared  to  results  from  Etest®.    All  medical  chart  abstrac/on  was  performed  by  a  local  clinician.  Local  and  CDC  ethics  commiiee  reviewed  and  determined  that  it  met  criteria  for  non-­‐research  public  health  response.      

METHODS  

Fourteen   isolates   originally   iden/fied   as   Candida  haemulonii   (n=13)   or   Candida   spp.   (n=1),   recovered  from   9   pa/ents   during   July–October   2016   (Figure   2),  were   confirmed   as   C.   auris   by   both   Vitek®   MS   and  Microflex®  MALDI-­‐TOF  plamorms  and  by  sequencing  of  the   D1/D2   region.   Six   (67%)   of   nine   pa/ents   were  male,  and  the  median  age  was  48  years  (range:  20–78).  The  median   length   of   admission   was   89   days   (range:  30–208),  and  the  median  /me  from  admission  to  first  posi/ve   culture   was   34   days   (range:   21–136).   All  pa/ents  were   admiied   to   intensive   care   units   (ICUs).  Median   /me   from   posi/ve   culture   date   to   death   in  those  who   died  was   45   days   (range:   8–72)   (Table   1).  Treatment  and  outcome  informa/on  was  available  for  all  9  pa/ents  (Table  2).      

RESULTS  

CONCLUSIONS  These   reports   of   culture   posi/ve   C.   auris   represent   the   first  documented   emergence   of   the   organism   in   Central   America,  coming  shortly  aper  reports  from  Venezuela  and  Colombia.  The  in-­‐hospital  mortality  rate  among  the  Panama  pa/ents  was  high  (78%),   likely   related   to   the   pa/ents’   underlying   reasons   for  admission   to   the   ICU.     Given   the   large   size   of   the   hospital,  clustering   of   cases   by   /me,   and   paucity   of   C.   auris   iden/fied  elsewhere   in   the   hospital,   healthcare-­‐associated   transmission  appears  likely.      Regional   awareness   of   this   organism   among   laboratorians   and  clinicians  is  cri/cal  for  prompt  iden/fica/on  with  MALDI-­‐TOF  or  DNA   sequencing,   improved   outcomes   for   pa/ents,   and   early  implementa/on   of   infec/on   preven/on   and   control  measures.  We   highlight   the   importance   of   correct   iden/fica/on   and  suscep/bility  tes/ng  for  this  species  of  Candida.    

REFERENCES  1.  CDC   C.   auris   Clinical   Alert   to   U.S.   Healthcare   Facili/es   Available   at:    

hips://www.cdc.gov/fungal/diseases/candidiasis/candida-­‐auris-­‐alert.html  

2.  Calvo  B,  et  al.  J  Infect.  2016;73:369-­‐374.  3.   Vallabhaneni   S,   et   al.   MMWR   Morb   Mortal   Wkly   Rep.  2016;65:1234-­‐1237.  4.  Lockhart  SR,  et  al.  Clin  Infect  Dis.  2017;64:134-­‐140.  5.  Kathuria  S,  et  al.  Clin  Microbiol.  2015;53:1823-­‐1830.  

ACKNOWLEDGEMENTS  Anastasia   Litvintseva,   Reina   Turcios-­‐Ruiz,   Loren   Cadena,   Alex  Bandea   and   Colleen   Lysen   at   CDC.   Itza   Barahona   de   Mosca,  Lourdes   Garcia   and   Felicia   Tulloch   at   Ministerio   de   Salud   de  Panama.  Rubén  Ramos  at   the   Ins/tuto  Conmemora/vo  Gorgas  de   Estudios   de   la   Salud,   Panama.   Angel   Cedeño,   Medical  Director   of   Hospital   Santo   Tomas   and   Gloria   Acevedo   and   her  team   at   the   group   of   Infec/on   control   and   preven/on  commiiee  of  Hospital  Santo  Tomas.    

Ana  Belen  Araúz1,  Diego  H  Caceres2,3,  Erika  San/ago1,  Paige  Armstrong2,4,  Susan  Arosemena  1,  Carolina  Ramos1,  Andres  Espinosa-­‐Bode2,  Jovanna  Borace1,  Lizbeth  Hayer  5,  Israel  Cedeño  5,  Brendan  R  Jackson2,  Nestor  Sosa  6,  Elizabeth  L  Berkow2,  Shawn  R  Lockhart2,  Amalia  Rodriguez-­‐French1  and  Tom  Chiller2    

1  Hospital  Santo  Tomas,  Panama  City,  Panama.  2  Centers  for  Disease  Control  and  Preven/on,  Atlanta,  GA,  United  States  of  America.  3  ORISE,  Oak  Ridge,  Tennessee,  United  States  of  America.  4  Epidemic  Intelligence  Service.  Atlanta,  GA,  United  States  of  America.  5  Ministerio  de  Salud  de  Panama,  Panama  City,  Panama.  6  Ins/tuto  Conmemora/vo  Gorgas  de  Estudios  de  la  Salud,  Panama  City,  Panama  

First  nine  cases  of  Candida  auris  infecDon  Reported  in  Central  America:  Importance  of  acurate  diagnosis  and  suscepDbility  tesDng  

anabelenarauz@gmail.com

Table  2.  CharacterisDcs  and  treatment  received  by  the  9  paDents  with  C.  auris  isolated  from  culture,  Panama  

Figure  2.  Epidemiological  curve  of  culture-­‐posiDve  C.  auris  infecDons  during  epidemiological  weeks  26  to  44  of  2016  

 Table  1.  CharacterisDcs  of  9  paDents  with  C.  auris  posiDve  cultures    

Thirteen  of  the  14  isolates  were  available  for  fluconazole  suscep/bility  tes/ng  by  the  Vitek®  2  system  and  broth  microdilu/on.  Twelve  (92%)  isolates  were  resistant  to  fluconazole  by  Vitek®  2,  and  10  (77%)  were  resistant  by  broth  microdilu/on.  The  fluconazole  MIC50  was  32  µg/mL  by  Vitek®  2  and  was  64  µg/mL  by  broth  microdilu/on.  Twelve  isolates  were  available  for  amphotericin  B  suscep/bility  tes/ng;  all  were  iden/fied  as  resistant  by  the  Vitek®  2  system,  but  only  1  (8%)  by  Etest®.  The  MIC50  for  amphotericin  B  was  6  µg/mL  by  Vitek®  2  and  0.38  µg/mL  by  Etest®(figure  1  A  and  B).  All  isolates  (n=13)  were  suscep/ble  to  anidulafungin  and  caspofungin  by  Vitek®  2  and  broth  microdilu/on.    

 

Candida  auris  is  an  emerging  mul/drug-­‐resistant  (MDR)  fungus  associated  with  invasive  infec/ons  and  high  mortality.  This  report  describes  the  first  9  cases  of  C.  auris  in  Central  America  in  a  hospital  in  Panama  City,  Panama,  and  highlights  the  challenges  of  accurate  iden/fica/on  and  methods  for  suscep/bility  tes/ng.  

ABSTRACT  

 Variable                                                                                                                                                                                                                                                                              n  (%)

Mean  age  in  years  (range) 53  (42-­‐78)

Sex  (male) 6  (67)

Crude  mortality 7  (78%)

30  days  aper  C.  auris  isolated 2  (22%)

Comorbidi/es  prior  to  hospitaliza/on  

Diabetes 1  (11)

Hematologic  malignancy 0  (0)

Solid  organ  transplant 0  (0)

Hospitaliza/on  

ICU 9  (100)

Mechanical  ven/la/on 9  (100)

Total  parenteral  nutri/on 0  (0)

Central  venous  catheter  present  in  the  7  days  prior  to  C.  auris  posi/ve  culture 9  (100)

Urinary  catheter  present  in  the  7  days  preceding  culture 9  (100)

Surgical  procedure  in  90  days  prior  to  C.  auris  posi/ve  culture* 9  (100)

An/fungal  received  in  90  days  prior  to  C.  auris  posi/ve  culture 7  (78)

An/bio/c  received  prior  to  C.  auris  posi/ve  culture 9  (100)

*  including  tracheostomy

#   Reason  for  Admission   Source  of  C.  auris  Culture   AnDfungal  Received  a]er  posiDve  for  C.  auris  

Time  from  Admission  to  posiDve  culture  (days)  

Outcome    (at  discharge)  

1   Polytrauma,  blunt  injury   2  posi/ve  urine  cultures   Voriconazole   48   Deceased  

2   Sepsis   2  posi/ve  urine  cultures   Voriconazole   49   Deceased  

3   Urosepsis   Urine   Fluconazole   34   Deceased  

4   Polytrauma,  blunt  injury   3  posi/ve  urine  cultures   Voriconazole   22   Alive  

5   Penetra/ng  trauma  to  chest  and  abdomen   Blood,  Pleural  Fluid   Anidulafungin   21   Alive  

6   Ischemic  cerebrovascular  accident   Urine   Fluconazole   22   Deceased  

7   Second  degree  burn  (50%  body  surface  area)   Urine   Voriconazole   29   Deceased  

8   Craniopharyngioma   Central  Venus  Catheter  /p   Fluconazole   136   Deceased  

9   Hypertensive  emergency   Urine   Voriconazole   39   Deceased