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Candida auris: Drug-resistant and all but unknown

A major threat that has been making headlines worldwide because of its enigmatic and drug-resistant nature is making its presence known in India.
Documentation of global Candida auris cases: Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), Division of Foodborne, Waterborne, and Environmental Diseases (DFWED)

Drug-resistant infections are already widely known about. Malaria, tuberculosis and numerous other diseases are becoming more difficult to treat year after year as drug resistance becomes more commonplace. However, one infection — Candida auris, a type of yeast, — has swept the globe with very little media attention until very recently.

Despite only being widely publicised recently, the infection is occurring across the entirety of the globe, India being no exception to this. If anything, India may be one of the more at-risk countries due to its excessive rate of hospital-acquired infections (HAIs).

In India, HAIs occur at the alarming rate of one infection per four hospital visits. This is compared to one in ten in European countries and one in twenty in the United States. This makes India an ideal breeding ground for Candida auris. Already, the disease seems to have made landfall in India. Just days after it was reported that there was no clinical evidence to suggest the presence of Candida auris in India, doctors in Kolkata are identifying vulnerable patients and seeking advice on the condition.

It is worth appraising Candida auris – its potential threat and the risk it poses to India’s public health system and patients.


Compromised immune systems can result in the infection being lethal

The sheer resilience of this fungus is best demonstrated by a report from The New York Times. In it, they describe the admission of an elderly man to the Brooklyn branch of Mount Sinai Hospital for abdominal surgery. Blood tests revealed that he was infected with a pathogen as deadly as it was mysterious. After investigation, this was revealed to be Candida auris.

The man was swiftly isolated in an intensive care unit where the doctors could minimise the risk of him passing on the infection to others. Candida has since been observed far more frequently, predominantly in those with weakened immune systems. In these individuals, the fungus is often lethal.

The man at Mount Sinai died after ninety days in the hospital. This is not an unusual situation; further outbreaks have shown notable mortality rates. In the case of a larger outbreak that occurred in Valencia, Spain, 372 people were found with the germ in their bodies. Of these infected individuals, 85 of them developed bloodstream infections, of whom 41 percent died within thirty days.

Dr Lynn Sosa, an expert on epidemiology, said she sees Candida auris as the most serious and significant threat among drug-resistant infections. “It’s invincible and hard to diagnose,” said Dr. Sosa. She notes that almost half of patients who die, may die as quickly as within 90 days.


High mortality rates are not the only concern

While the elderly man in the Mount Sinai case died within ninety days, this was not the case for the infection. Candida auris is a tremendously difficult infection to be rid of, not least because of its resistance to antifungals.

“Everything was positive [for Candida auris] — 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.”

Tests confirmed the fungus was everywhere in his room. The hospital needed special cleaning equipment and had to rip out some of the ceiling and floor tiles to eradicate it. Such an act is costly, and takes a considerable amount of time. This is an extreme precaution needed where only a single case of the disease was detected.

In countries such as India, many hospitals — particularly public hospitals which face considerable strain due to shortages of personnel and resources — will not be able to cope with such a burden to isolate individual cases of the disease.

Candida auris threatens public health on a global scale. Due to the current situation in which HAIs are more prevalent in middle-income and lower-income nations, it is these regions in which the fungus may begin to wear down health systems at a swifter pace.

Drug-resistant infections typically cause more harm in developing nations due to the higher comparative expense of the second-line therapies required to treat them. In many instances supply chains for these medications are all but non-existent, meaning the infections may spread unchecked.


A global phenomenon

Though developing nations may eventually bear the brunt of the disease burden, current epidemiology of the disease indicates it is present the world over. Experts have so far been unable to pinpoint exactly where the drug-resistant strain of Candida auris emerged. Tests have shown positive results from the US to Australia.

The nature of modern travel — in which just a single infected individual in an airport could spread a disease to a global level within a 24-hour time scale — is posed to couple with Candida auris’s ability to survive both medications and the most thorough of sanitation protocols for elongated periods of time. This makes it a considerable threat to global healthcare.

India, already known to be a hotbed of drug-resistant diseases, could well act as a breeding ground for the fungus. Without considerable precautions and financial commitment, the disease could well spiral out of control as hospitals are simply unable to manage the condition.


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