Welcome to the inaugural post of the TR pearl series – Consultant Collaboration!

If you’ve been watching or reading the news, you probably saw headlines about the new emerging superbug: multidrug-resistant (MDR) Candida auris.

But did you know that the first isolate of this MDR fungus to be prospectively identified in the United States was actually here at Mount Sinai?! Dr. Camille Hamula, Director of Microbiology at Sinai, notes it was discovered incidentally from an ear swab, and likely thought to be colonization, not pathogenic. You can read more about that here.

Last month, the CDC published their Morbidity and Mortality Weekly Report that warned about institutional spread of this superbug. Over a nine month period, the number of cases of multidrug-resistant Candida auris in the US grew from 7 to 122. It seems to spread in hospitals and other care facilities. Many of these cases were colonization. NYC has had the most isolates in the country, and Sinai has had about 5.

So now we know that it is present in our institution, but what does that mean for us in the ED?

If you think back to any resus shift, you inevitably took care of at least one patient from a nursing home or other long term care facility, who had multiple hospitalizations, and then presented to the ED with sepsis.

We all know to check their previous culture sensitivities and empirically cover them with broad-spectrum antibiotics. But how often do you consider antifungal coverage?

I spoke with Dr. Sarah Schaefer, assistant professor of Infectious Diseases here at Mount Sinai, for some guidance.

For the most part, she recommends we continue with how we always treat our patients – antibiotics when indicated. Though this MDR Candida can cause invasive infections, the biggest concern right now is its colonization of patients and environmental surfaces in hospitals and healthcare facilities, where it leads to further spread. That being said, it is still quite rare, so the news of this new superbug should not change our current empiric treatment strategies.

So who should get empiric antifungal therapy?

The 2016 Infectious Diseases Society of America guidelines recommend empiric antifungal therapy be considered in “critically ill patients who are at risk for invasive candidiasis and no other known cause of fever; the decision … should be based upon clinical assessment of risk factors.”

Consider these risk factors:

  • Neutropenic fever
  • Indwelling lines / ports
  • Total parenteral nutrition
  • Recent surgery
  • Liver or kidney failure

Dr. Hamula told me that Sinai has seen resistance to azoles. If you do choose an empiric antifungal in a critically ill patient, Dr. Schaefer recommends an echinocandin. Dosing per UpToDate:

  • Caspofungin – 70 mg initial dose (reduce dose if hepatic dysfunction)
  • Anidulafungin – 200 mg initial dose
  • Micafungin – 100 mg

If the patient is known to be colonized with Candida auris, definitely call ID and Infection Prevention early to mitigate its spread.

And as both Drs. Hamula and Schaefer point out, don’t forget the things YOU can do to reduce the spread of germs – diligent hand hygiene before and after every patient encounter, and appropriate contact precautions when indicated.

A huge thank you to Dr. Camille Hamula and Dr. Sarah Schaefer for their time and expertise.