PART 1. Candida Auris. Is it ethical for the public not be notified about new “super bugs” in hospitals so they can decide whether or not to go to affected hospitals?

“Last May, an elderly man was admitted to the Brooklyn branch of Mount Sinai Hospital for abdominal surgery. A blood test revealed that he was infected with a newly discovered germ as deadly as it was mysterious. Doctors swiftly isolated him in the intensive care unit.

The germ, a fungus called Candida auris, preys on people with weakened immune systems, and it is quietly spreading across the globe. Over the last five years, it has hit a neonatal unit in Venezuela, swept through a hospital in Spain, forced a prestigious British medical center to shut down its intensive care unit, and taken root in India, Pakistan and South Africa.

Recently C. auris reached New York, New Jersey and Illinois, leading the federal Centers for Disease Control and Prevention to add it to a list of germs deemed “urgent threats.”

The man at Mount Sinai died after 90 days in the hospital, but C. auris did not. Tests showed it was everywhere in his room, so invasive that the hospital needed special cleaning equipment and had to rip out some of the ceiling and floor tiles to eradicate it.

“Everything was positive — the walls, the bed, the doors, the curtains, the phones, the sink, the whiteboard, the poles, the pump,” said Dr. Scott Lorin, the hospital’s president. “The mattress, the bed rails, the canister holes, the window shades, the ceiling, everything in the room was positive.””  (A)

“Back in 2009, a 70-year-old Japanese woman’s ear infection puzzled doctors. It turned out to be the first in a series of hard-to-contain infections around the globe, and the beginning of an ongoing scientific and medical mystery.

The fungus that infected the Japanese woman, Candida auris, kills more than 1 in 3 people who get an infection that spreads to their blood or organs. It hits people who have weakened immune systems, and is most often found in places like care homes and hospitals. Once it shows up, it’s hard to get rid of: unlike most species of fungi, Candida auris spreads from person to person and can live outside the body for long periods of time.

Mount Sinai wasn’t the first hospital to face this task: a London hospital found itself with an outbreak in 2016, and the only way to stop it was to rip out fixtures…

Scientists still aren’t sure exactly where this happened or when. That’s one of the things they’re working on now, says Cuomo, because figuring out how the fungus evolved could help researchers develop treatments for it…

Although the “superbug” moniker might sound alarmist, Candida auris qualifies for two reasons, says Cuomo. First, all strains of the yeast are resistant to antifungals. There are three major kinds of antifungals used to treat humans, and some strains of Candida auris are resistant to all of them, while other strains are resistant to one or two. That limits the treatment options for someone who has been infected—someone who is probably already in poor health. The other reason is “this really scary property of not being able to get rid of it,” Cuomo says.” (B)

“Superbugs are a terrifying prospect because of their resistance to treatment, and one superbug that is sweeping all over the world is the Candida auris.

C. auris is a fungus that causes serious infections in various parts of the body, including the bloodstream and the ear.

While its discovery has been relatively recent in 2009, this fungus has already wreaked havoc in hospitals in more than 20 different countries, including the United States, United Kingdom, and Spain, among others.

In the United States, CDC reports a total of 587 clinical cases of C. auris infections as of February. Most of it occurred in the areas of New York City, New Jersey, and Chicago.” (C)

“The CDC issued a public alert in January about a drug-resistant bacteria that a dozen Americans contracted after undergoing elective surgeries at Grand View Hospital in Tijuana, Mexico. Yet when similar outbreaks occur at U.S. hospitals, the agency does not issue a public warning. This is due to an agreement with states that prohibits the CDC from publicly disclosing hospitals undergoing outbreaks of drug-resistant infections, according to NYT.

Patient advocates are pushing for more transparency into hospital-based infection outbreaks, saying the lack of warning could put patients at risk of harm.

“They might not get up and go to another hospital, but patients and their families have the right to know when they are at a hospital where an outbreak is occurring,” Lisa McGiffert, an advocate with the Patient Safety Action Network, told NYT. “That said, if you’re going to have hip replacement surgery, you may choose to go elsewhere.”..

The CDC declined NYT’s request for comment. Agency officials have previously told the publication the confidentiality surrounding outbreaks is necessary to encourage hospitals to report the drug-resistant infections.” (D)

“New Jersey is among the states worst affected by an increasing incidence of the potentially deadly fungus Candida auris, whose resistance to drugs is causing headaches for hospitals, state and federal health officials said on Monday.

There were 104 confirmed and 22 probable cases of people infected by the fungus in New Jersey by the end of February, according to the federal Centers for Disease Control and Prevention, up sharply from a handful when the fungus was first identified in the state about two years ago.

The state’s number of cases — now the third-highest after New York and Illinois — has risen in tandem with an increase, first overseas, and now in the United States, in a trend that some doctors attribute to the overuse of drugs to treat infections, prompting the mutation of infection sources, in this case, a fungus.

The fungus mostly affects people who have existing illnesses, and may already be hospitalized with compromised immune systems, health officials said.

Nicole Kirgan, a spokeswoman for the New Jersey Department of Health, said she didn’t know whether any of the state’s cases have been fatal, and couldn’t say which hospitals are treating people with the fungus because they have not, so far, been required to report their cases to state officials.

Although the fungus has been known to medical professionals in New Jersey for two or more years, it was not widely known to the public. Its profile was raised by a front-page story in The New York Times on Sunday describing its growing presence in overseas hospitals and, increasingly, in the U.S.

The best defense against spreading the fungus is rigorous handwashing, and disinfecting hospital rooms and equipment that have come into contact with a patient, Kirgan said.

But Dr. Ted Louie, an infectious disease specialist at Robert Wood Johnson University Hospital in New Brunswick, said many hospitals don’t know how to eradicate the fungus once it has occurred.

Some disinfectants commonly used in hospitals have proved ineffective in removing the fungus, Dr. Louie said, so hospitals have been urged to use other disinfecting agents, although it’s not yet clear which of them work, if any.

“This is a fairly new occurrence and we are still learning how to deal with it,” he said. “We have to figure out which disinfectant procedures may be best to try to eradicate the infection, so at this point, I don’t think we have good enough information to advise.”  (E)

“Adding to the difficulty of treating candida auris is finding it in the first place. The infection is often asymptomatic, showing few to no immediate symptoms, said Chauhan. The symptoms that do appear, such as fever, are often confused for bacterial infections, he said.

“Most routine diagnostic tests don’t work very well for candida auris,” he said. “They’re often misidenfitied as other species.”

The best way to identify candida auris is by looking under a microscope, which often takes time because it requires doctors to grow the fungus, Chauhan said.

As with most infectious diseases, the best course of action is good hygiene and sterilization protocol. Washing your hands and using hand sanitizer after helps to prevent transmission and infection, Chauhan said.

Doctors and healthcare workers should use protective gear, and people visiting loved ones in hospitals and long-term care centers should take proper precautions, he said.

The Center for Disease Control recommends using a special disinfectant that is used to treat clostridium difficile spores. The disinfectant has been effective in wiping out clostridium difficile, known as c. diff, and disinfects surfaces contaminated with candida auris, as well.”  (F)

“Hospitals and nursing homes in California and Illinois are testing a surprisingly simple strategy against the dangerous, antibiotic-resistant superbugs that kill thousands of people each year: washing patients with a special soap.

The efforts — funded with roughly $8 million from the federal government’s Centers for Disease Control and Prevention — are taking place at 50 facilities in those two states.

This novel approach recognizes that superbugs don’t remain isolated in one hospital or nursing home but move quickly through a community, said Dr. John Jernigan, who directs the CDC’s office on health care-acquired infection research.

“No health care facility is an island,” Jernigan said. “We all are in this complicated network.”

At least 2 million people in the U.S. become infected with an antibiotic-resistant bacterium each year, and about 23,000 die from those infections, according to the CDC…

Containing the dangerous bacteria has been a challenge for hospitals and nursing homes. As part of the CDC effort, doctors and health care workers in Chicago and Southern California are using the antimicrobial soap chlorhexidine, which has been shown to reduce infections when patients bathe with it. Though chlorhexidine is frequently used for bathing in hospital intensive care units and as a mouthwash for dental infections, it is used less commonly for bathing in nursing homes…

The infection-control work was new to many nursing homes, which don’t have the same resources as hospitals, Lin said.

In fact, three-quarters of nursing homes in the U.S. received citations for infection-control problems over a four-year period, according to a Kaiser Health News analysis, and the facilities with repeat citations almost never were fined. Nursing home residents often are sent back to hospitals because of infections.

In California, health officials are closely watching the CRE bacteria, which are less prevalent there than elsewhere in the country, and they are trying to prevent CRE from taking hold, said Dr. Matthew Zahn, medical director of epidemiology at the Orange County Health Care Agency. “We don’t have an infinite amount of time,” he said. “Taking a chance to try to make a difference in CRE’s trajectory now is really important.””  (G)

“The C.D.C. declined to comment, but in the past officials have said their approach to confidentiality is necessary to encourage the cooperation of hospitals and nursing homes, which might otherwise seek to conceal infectious outbreaks.

Those pushing for increased transparency say they are up against powerful medical institutions eager to protect their reputations, as well as state health officials who also shield hospitals from public scrutiny…

Hospital administrators and public health officials say the emphasis on greater transparency is misguided. Dr. Tina Tan, the top epidemiologist at the New Jersey Department of Health, said that alerting the public about hospitals where cases of Candida auris have been reported would not be useful because most people were at low risk for exposure and public disclosure could scare people away from seeking medical care.

“That could pose greater health risks than that of the organism itself,” she said.

Nancy Foster, the vice president for quality and patient safety at the American Hospital Association, agreed, saying that publicly identifying health care facilities as the source of an infectious outbreak was an imperfect science.

“That’s a lot of information to throw at people,” she said, “and many hospitals are big places so if an outbreak occurs in a small unit, a patient coming to an ambulatory surgical center might not be at risk.”

Still, hospitals and local health officials sometimes hide outbreaks even when disclosure could save lives. Between 2012 and 2014, more than three dozen people at a Seattle hospital were infected with a drug-resistant organism they got from a contaminated medical scope. Eighteen of them died, but the hospital, Virginia Mason Medical Center, did not disclose the outbreak, saying at the time that it did not see the need to do so.

Art Caplan, a bioethicist at the NYU School of Medicine, said the issue of full disclosure can be tricky, especially when large hospitals that see huge numbers of seriously ill patients are compared with smaller institutions. “If you’re a hospital of last resort, you’re going to see repeat customers with tough infections, many of them drug resistant,” he said.

Still, he thought there was a greater value in promoting transparency. Public awareness about the lives lost to drug resistant infections, he said, could pressure hospitals to change the way they deal with infection control.

“Who’s speaking up for the baby that got the flu from a hospital worker or for the patient who got MRSA from a bedrail?” he asked, referring to a potentially deadly bacterial infection. “The idea isn’t to embarrass or humiliate anyone, but if we don’t draw more attention to infectious disease outbreaks, nothing is going to change.” (H)

“Many have heard of the rise of drug-resistant infections. But few know about an issue that’s making this threat even scarier in the United States: the shortage of specialists capable of diagnosing and treating those infections. Infectious diseases is one of just two medicine subspecialties that routinely do not fill all of their training spots every year in the National Resident Matching Program (the other is nephrology). Between 2009 and 2017, the number of programs filling all of their adult-infectious-disease training positions dropped by more than 40 percent.

This could not be happening at a worse time. Antibiotic-resistant microbes, known as superbugs, are pinballing around the world, killing hundreds of thousands of people every year. The Times recently reported on Candida auris, a deadly new fungus that has infected hospital patients in Illinois, New Jersey and New York.

Everyone who works in health care agrees that we need more infectious-disease doctors, yet very few actually want the job. What’s going on?

The problem is that infectious-disease specialists care for some of the most complicated patients in the health care system, yet they are among the lowest paid. It is one of the only specialties in medicine that sometimes pays worse than being a general practitioner. At many medical centers, a board-certified internist accepts a pay cut of 30 percent to 40 percent to become an infectious-disease specialist.

This has to do with the way our insurance system reimburses doctors. Medicare assigns relative value units to the thousands of services that doctors provide, and these units largely determine how much physicians are paid. The formula prioritizes invasive procedures over intellectual expertise.

The problem is that infectious-disease doctors don’t really do procedures. It is a cognitive specialty, providing expert consultation, and insurance doesn’t pay much for that…

Infectious-disease specialists are often the only health care providers in a hospital — or an entire town — who know when to use all of the new antibiotics (and when to withhold them). These experts serve as an indispensable cog in the health care machine, but if trends continue, we won’t have enough of them to go around. The terrifying part is that most patients won’t even know about the deficit. Your doctor won’t ask a specialist for help because in some parts of the country, the service simply won’t be available. She’ll just have to wing it…

We must hurry. Superbugs are coming for us. We need experts who know how to treat them.” (I)

People visiting patients at the hospital, and most hospitalized patients, have little to fear from a novel fungal disease that has struck more than 150 people in Illinois — all in the Chicago area — a Memorial Medical Center official said Friday.

“For normal, healthy people, this is not a concern,” Gina Carnduff, Memorial Health System director of infection prevention, said in reference to Candida auris infections.

Carnduff, who is based at Memorial Medical Center, said only the “sickest of the sick” patients are at risk of catching or spreading the C. auris infection or dying from it.

Those patients, she said, include people who have stayed for long periods at health care facilities — such as skilled-care nursing homes or long-term acute-care hospitals — and who are on ventilators or have central venous catheter lines or feeding tubes…

Officials from both Memorial Medical Center and HSHS St. John’s Hospital said their institutions already are using the bleach-based cleaning solutions known to prevent the spread of C. auris and other infections.

The Illinois Department of Public Health’s website says more than one in every three people with “invasive C. auris infection” affecting the blood, heart or brain will die…

The state health department says 154 confirmed cases of C. auris and four probable cases have been identified, all in the Chicago area. Ninety-five cases were in Chicago, 56 were in Cook County outside of Chicago, and seven were spread among the counties of DuPage, Lake and Will.

Eighty-five of the 158 people making up the confirmed and probable cases have died, but only one death was “directly attributed” to the infection, Arnold said. It’s not known whether C. auris played a role in the deaths of the other 84 people, she said. (J)

“There is also the fact that some lab tests will not identify the superbug as the source of an illness, which means that some patients will receive the wrong treatment, increasing the duration of the infection and the chance to transmit the fungus to another person.” (K)

“Hospitals, state health departments and the Centers for Disease Control and Prevention are putting up a wall of silence to keep the public from knowing which hospitals harbor Candida auris.

New York health officials publish a yearly report on infection rates in each hospital. They disclose rates for infections like MRSA and C. Diff. But for several years, the same officials have been mum about the far deadlier Candida auris. That’s like posting “Wanted” pictures for pickpockets but not serial murderers.

Health officials say they’ll disclose the information in their next yearly report. That could be many months from now. Too late. Patients need information in real time about where the risks are…

Dr. Eleanor Adams, a state Health Department researcher, examined all the facilities in New York City affected by Candida auris over a four-year period. Adams found serious flaws, including “inadequate disinfection of shared equipment” to take vital signs, hasty cleaning and careless compliance with rules to keep infected patients isolated…”  (L)

“Remedies for curtailing the advance of C. auris are familiar. Health care facilities must undergo stringent infection controls, test for new cases and quickly identify any sources passing it along. Visitors and medical workers must wash their hands after touching patients or surfaces. The yeast spreads widely throughout patients’ rooms. Some cleanups have reportedly required removing ceiling and floor tiles.

C. auris isn’t simply an opportunistic infection. Its rise is additional evidence that becoming too reliant on certain types of drugs may have unintended consequences. Exhibit A is the overuse of antibiotics in doctors’ offices and on farms that encourages the development of drug-resistant bacteria. Researchers suspect a similar situation involving C. auris and agricultural fungicides used on crops. So far the origins of C. auris are unclear, with different clusters arising in different areas of the world.

There’s no need to panic. But vigilance is required to track C. auris and raise awareness in order to combat it. Officials typically are eager to spread the word about potential health crises, from measles to MRSA. In this case, the CDC issued alerts about fungus to health care facilities, but the New York Times encountered an unusual wall of silence while investigating superbugs such as C. auris. Medical facilities didn’t want to scare off patients.

Any attempts to hide the spread of a communicable disease are irresponsible. Knowledge leads to faster prevention and treatment. Patients and their families have a right to know how hospitals and government agencies are responding to a new threat. Medical workers also deserve to be informed of the risks they encounter on the job.

Battling the superbugs requires aggressive responses and, ultimately, scientific advancements. Downplaying outbreaks won’t stop their rise.” (M)

“The rise of C. auris, which may have lurked unnoticed for millennia, owes entirely to human intervention — the massive use of fungicides in agriculture and on farm animals which winnowed away more vulnerable species, giving the last bug standing a free run. Sensitised to clinical fungicides, C. auris has proved to be difficult to extirpate, and culls infected humans who cannot fight diseases very effectively — infants, the old, diabetics, people with immune suppression, either because of diseases like HIV or the use of steroids. The new superfungus has the makings of a future plague, one of several which may cumulatively surpass cancer as a leading killer in a few decades.

The origin of C. auris is known because it broke out in the 21st century, but the plagues from antiquity lack origin stories. Even their spread was understood only retrospectively, in the light of modern science. The father of all plagues, the Black Death, originated in China in the early 14th century and ravaged most of the local population before it began its long journey westwards down the Silk Route, via Samarkand. At the time, the chain of hosts that carried it would have been incomprehensible — the afflicting organism Yersinia pestis, the fleas which it infested, the rats which the fleas in turn infested, which carried it into the homes of humans….” (N)

“WebMD: Most of us know candida from common yeast infections that you might get on your skin or mucous membranes. What makes this one different?

Chiller: It’s not acting like your typical candida. We’re used to seeing those.

Candida — the regular ones — are already a major cause of bloodstream infection in hospitalized patients. When we get invasive infections, for example, bloodstream infections, we think that you sort of auto-infect yourself. You come in with the candida already living in your gut. You’re in the ICU, you’re on a broad spectrum antibiotic. You’re killing off bad bacteria, you’re killing off good bacteria, so what are you left with? Yeast, and it takes over.

What’s new with Candida auris is that it doesn’t act like the typical candida that comes from our gut. This seems to be more of a skin organism. It’s very happy on the skin and on surfaces.

It can survive on surfaces for long periods of time, weeks to months. We know of patients that are colonized [meaning the Candida auris lives on their skin without making them sick] for over a year now.

It is spreading in health care settings, more like bacteria would, so it’s yeast that’s acting like bacteria” (O).