Two NYC fatalities Had Nation’s First Cases of ‘Pan-Resistant’ Fungus

Jon Hurdle | April 22, 2019 | Healthcare
Deaths fuel fears of an outbreak of Candida auris that can resist many, or all, medications; no reports of pan-resistant C. auris in New Jersey

Credit: Wikimedia Commons
Surgical gloves
Two patients who died in New York City hospitals within the last month were confirmed as the nation’s first cases of a kind of fungus that’s resistant to all classes of anti-fungal medication, the Centers for Disease Control and Prevention has said.

It’s unclear whether the “pan-resistant” strain of the Candida auris fungus was the cause of their deaths, or whether they were caused by unrelated infections, but the appearance of the new strain in the United States has fueled fears about the recent spread of a fungus that can survive many kinds of medications.

In New Jersey, there have been no reports of pan-resistant C. auris so far but 115 cases of other strains of the fungus have been confirmed — representing an increase of 11 cases since the end of February, said Nicole Kirgan, a spokeswoman for the state’s Department of Health. In addition, there are currently 22 “probable” cases, she said.

Credit: CDC
A strain of Candida auris cultured in a petri dish
In the current outbreak of C. auris, most cases have been in New York, New Jersey and Illinois, according to the CDC which reported a total of 587 cases nationwide by February 28. In New York, 309 cases were confirmed by the end of February, according to the CDC.

Kirgan declined to say whether any of the New Jersey patients have died from the fungus, noting that many are already weakened by other conditions that required hospitalization to begin with.

“Given those most at risk include people with compromised immune systems with other underlying conditions, it is difficult to determine underlying cause of death,” she said.

Patients with ‘underlying medical conditions’

“In general, nearly all patients infected or colonized with C. auris have had multiple underlying medical conditions and extensive stays in healthcare facilities, especially long-term acute care hospitals and post-acute care facilities and nursing homes that take care of patients on ventilators,” Kirgan said.

She also declined to identify New Jersey hospitals that are or were treating patients with any strain of the fungus, saying that patients frequently get transferred between hospitals and other healthcare facilities, and that the fungus may be present at one facility but diagnosed in another.

The health department is closely monitoring the fungus and its resistance to medication, and requires that every newly identified case is tested for resistance at a public health laboratory, Kirgan said. “These efforts ensure that should the more resistant organism be introduced to NJ, we would be aware.”

But Dr. Ted Louie, an infectious disease specialist with Robert Wood Johnson University Hospital in New Brunswick, and a spokesman for the Medical Society of New Jersey, said there have been some deaths in New Jersey among patients infected with types of C. auris other than the pan-resistant strain, but he was unable to say how many.

C. auris ‘probably at most larger hospitals’ in NJ

He said he knew of two cases in central Jersey hospitals but said the outbreak of C. auris is likely widespread across New Jersey. “Most likely, this is statewide, and probably at most larger hospitals,” he said.

Of the two cases he had seen, one patient had been infected with the fungus but survived, and the other had been “colonized,” meaning that the patient was carrying the fungus but it had not made the patient ill, although that patient died from other causes, Dr. Louie said.

Both had many existing illnesses and had been hospitalized for long periods, making them more susceptible to hospital-acquired infections such as C. auris.

“These were very, very ill patients to start with, they can’t fight infections off, they have been in the hospital for long periods of time, and they get many antibiotics, and that’s the type of person who will tend to get Candida auris,” Dr. Louie said.

He said he is alarmed by the government’s confirmation of the pan-resistant strain, and predicted there will likely be a high mortality rate among infected patients, especially those with a blood infection, because there is no known treatment for it.

Still, hospitals can work to prevent its spread by isolating patients, requiring staff to wear gloves and gowns when coming into contact with the patient, and using certain disinfectants that are known to kill the fungus even though different strains resist many or all medications, Dr. Louie said.

What works in the lab may not work in patients

But Dr. Tom Chiller, the chief of CDC’s Mycotic Diseases Branch, said there may be a difference between whether a medication works in the lab, and whether it can overcome fungal resistance in a patient.

“Sometimes you can use these drugs in a patient because the patient is an ecosystem where the body is helping fight the infection,” Dr. Chiller said in an interview.

The two patients who died in New York developed a resistance to medication that appeared to be the right way of treating the fungal infection but turned out to be ineffective because the fungus evolved during treatment, he said.

“We have to be vigilant when we are treating these patients … knowing these organisms can change and evolve even while we’re treating them,” Dr. Chiller said. “This kind of resistance can develop on what we think is appropriate therapy.”

In New York, the state’s department of health said there is “no risk” to the general public, and that the “vast majority” of patients have serious underlying conditions.

Most of New York’s cases are in New York City, with additional cases in Nassau, Westchester, Suffolk, Orange, and Monroe counties, the department said in a statement.

If a case is identified or suspected, the department said it requires hospital staff to isolate the patient or patients in a single room, wear protective equipment such as gloves and gowns, and use EPA-approved disinfectant to clean the room.

Of the two patients who died in New York City, it is “difficult to say” whether or how much the fungus contributed to their deaths because they were already seriously ill, the statement said.

The New Jersey Hospital Association, a trade group, is taking seriously the warnings about C. auris, and last week held a conference on how to respond to emerging infections. The conference was scheduled before the fungus warnings and was originally focused on the Ebola virus, but shows that officials are alert to new threats to public health, said Kerry McKean, a spokeswoman for the group.