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Explainer: What you need to know about super fungus Candida auris

SINGAPORE — Described as a mysterious and deadly multidrug-resistant fungus, Candida auris was recently in the spotlight after it was dubbed by the United States’ Centers for Disease Control and Prevention(CDC) as a “global emerging threat” that can cause invasive infection and death.

There have been 11 isolated cases of Candida auris infections at public hospitals since 2012, said the Ministry of Health.

There have been 11 isolated cases of Candida auris infections at public hospitals since 2012, said the Ministry of Health.

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SINGAPORE — Described as a mysterious and deadly multidrug-resistant fungus, Candida auris was recently in the spotlight after it was dubbed by the United States’ Centers for Disease Control and Prevention(CDC)  as a “global emerging threat” that can cause invasive infection and death.

While researchers and authorities here have been battling drug-resistant bacteria, the Candida auris has sparked interest and concerns as the super fungus is not killed by common antifungal drugs, which makes infections difficult to treat.

In Singapore, there have been 11 isolated cases of Candida auris infections at public hospitals since 2012, said the Ministry of Health (MOH).

Out of the 11, two patients found to be infected with the antifungal-resistant germ died while the other nine recovered.

WHAT IS CANDIDA AURIS?

Candida auris is a species of fungus, which grows as yeast.

When it enters the bloodstream and spreads throughout the body, it can cause serious invasive infections in the blood, heart and brain, which can be life-threatening.

The fungus can spread through contact with infected patients, or contaminated surfaces and equipment.

The most common symptoms of invasive Candida infection are fever and chills that do not improve after antibiotic treatment for a suspected bacterial infection.

WHO IS AT RISK?  

Most people who get serious Candida auris infections are those who are severely ill, or have compromised immunity.

For example, patients with weakened immune systems, severe underlying diseases and those exposed to medical procedures and devices such as urinary catheters and surgery are more susceptible.

WHEN DID IT FIRST EMERGE?

Scientists first encountered the fungi in 2009, when doctors swabbed the ear of an infected elderly woman in Japan.

Auris is the Latin word for ear, while Candida refers to a type of yeast.

Despite its name, Candida auris can also affect many other regions of the body and can cause invasive infections, including bloodstream and wound infections.

Since then, it has found its way around the world. The first large outbreak of 72 cases occurred in Europe between 2015 and 2016.

In the United States, there have been at least 587 cases of Candida auris infections since 2013, with most occurring in nursing home patients in New York City, Chicago and New Jersey.

WHAT MAKES IT SO DANGEROUS

There are three main reasons why Candida auris is so dangerous: It is hard to identify, hard to treat and hard to remove.

1. Candida auris can be misidentified as other types of fungi, unless specialised laboratory technology is used

“The problem with Candida auris is that our ability to identify and diagnose Candida auris accurately and rapidly may not be ideal. Some currently used laboratory techniques cannot readily distinguish Candida auris from other candida species. Most of these standard protocols may not have the molecular sequence to be able to identify Candida auris,” said Dr Nicholas Chew, an infectious disease specialist practising at Mount Elizabeth Novena Hospital.

Using current techniques, Candida auris is “often misidentified” and misdiagnosed as Candida haemulonii (another type of multidrug-resistant species) and this could lead to a patient getting the wrong treatment, he added.

2. The Candida auris is also resistant to major antifungal medications and is considered one of the most drug-resistant infections

According to the CDC, the leading national public health institute in the US, 90 per cent of Candida auris infections are resistant to at least one antifungal drug, while 30 per cent are resistant to two or more major drugs.

3. It is hard to remove

Candida auris can persist on surfaces in healthcare environments, including bedside tables, bedrails and even on medical equipment such as ultrasound machines, said the CDC.

WHY HAVE WE NOT HEARD OF IT?

While the drug-resistant fungus has been recognised within the medical and infectious diseases community, it has been in the news recently in part due to the rising number of cases of Candida auris, said Dr Chew.

However, a New York Times article highlighted that hospitals and governments are reluctant to disclose outbreaks for fear for being seeing as infection hubs.

Dr Leong Hoe Nam, an infectious diseases expert at Mount Elizabeth Novena Hospital, said that it was only a “matter of time” before Candida auris would find its way into the spotlight.

“Germs will always mutate to try to overcome the pre-existing antibiotics out there. For the longest time we’ve been talking about multidrug-resistant bacteria, but we’ve been using antifungal agents in animal and vegetable farming,” he said.

“Because of the abuse, we’re breeding the ultimate terrorist in fungus and this is Candida auris.”

HOW DID IT GET TO SINGAPORE?

The MOH said that there have been 11 “isolated” and “sporadic” cases of Candida auris infections at public hospitals in Singapore since 2012.

Three patients, including one of the two patients who died, were treated at the Singapore General Hospital between 2012 and 2017.

The first case of Candida auris infection was detected in the right thigh bone of a 52-year-old Singapore-born woman in 2012. She had suffered several limb fractures in a traffic incident in India before returning to Singapore and was later discharged.

Another case involved a 69-year-old American man who suffered an infection that exacerbated his lung disease while he touring Bangladesh in late 2016. He was admitted to the intensive care unit of a hospital there and then transferred to Singapore, where he suffered further complications, including cardiac arrest. Candida auris was later found in his blood. He was given palliative care and eventually died.

The MOH said that the patients “were immediately isolated” and the hospitals did not identify any spread of the infection.

“The patients’ rooms were thoroughly cleaned and disinfected to remove the fungus,” a MOH spokesperson added.

While Candida auris is not legally notifiable in Singapore, healthcare institutions are required to report any outbreak of healthcare-associated infections — including Candida auris — to MOH.

Candida auris has been included in the updated list of pathogens for the public health laboratory surveillance programme since 2018 to “enable a coordinated and broad-based response to infectious threats of public health importance”, said the MOH.

SHOULD WE BE WORRIED?    

While there is “cause for concern”, Dr Chew said that there is no reason to panic.

The risk of Candida auris infection to a “healthy individual” is low.

“A lot of people who are healthy may end up carrying it, but it is not going to be of medical risk to them, it only becomes a problem when they have surgical procedures, or if they are immunocompromised, for example, (if they are) on chemotherapy or have had an organ transplant,” he said.

MOH said that healthcare institutions in Singapore have infection prevention and control measures in place to prevent and control any healthcare-associated infections, including Candida auris.

All public hospitals also have facilities to isolate infected patients when necessary.

They are also required to adequately disinfect equipment and the environment of infected patients.

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