Transmission of Pan-resistant and Echinocandin-resistant Candida Auris Between Healthcare Facilities During the COVID-19 Pandemic

BACKGROUND: Candida auris is a Texas notifiable condition requiring isolate submission to the state public health laboratory. C. auris spreads in healthcare through contact with contaminated surfaces and unclean hands. During the COVID-19 pandemic, pan-resistant and echinocandin-resistant C. auris were identified in Texas for the first time. METHODS: In January 2021, a long-term acute care hospital patient's isolate was identified as C. auris. Retrospective surveillance identified a 2020 case. Remote and onsite infection control assessments (ICARs) were conducted at healthcare facilities (HCFs) where the cases received care. Colonization screenings were conducted until the HCFs achieved two rounds of negative results. Cases and those pending screening results were placed on contact precautions. Epidemiologists provided education and resources to HCFs to mitigate identified infection prevention gaps. Antifungal susceptibility testing (AST) was performed at the Antibiotic Resistance (AR) Laboratory Network laboratory. Whole genome sequencing (WGS) was performed by the Centers for Disease Control and Prevention (CDC) Laboratory. RESULTS: There were 47 C. auris cases with collection dates from November 20, 2020, to September 27, 2021, including 15 clinical and 32 colonized cases from 22 years to 89 years old with a mean age of 63. Sixty-six percent (n=31) were males. Common gaps from the 46 ICARs conducted at 42 HCFs included using ineffective disinfectants, not following manufacturer's instructions, reusing disposable personal protective equipment, and not conducting audits. There were 59 colonization screenings at 20 HCFs. AST revealed two pan-resistant, seven echinocandin-resistant, and thirty-one fluconazole resistant cases. CDC performed WGS on 16 isolates, revealing clusters within and between HCFs, including a cluster of resistant cases. CONCLUSIONS: WGS supported transmission of pan-resistant or echinocandin-resistant C. auris for the first time in the United States. The pandemic presented new infection control risks. Rapid surveillance detection, colonization screenings, infection control assessments, and education are instrumental to outbreak containment.