On top of everything else during this pandemic, drug-resistant infections are threatening the most vulnerable patients in COVID-19 ICUs
New study by researchers at the University of Minnesota highlights the continuing need for microbiologists and clinical laboratories to stay alert for COVID-19 patients with drug-resistant infections. In their study, researchers highlighted CDC statistics about the number of Candida auris (C. auris) infections reported in the United States during 2020, for example.
In a paper, titled, “Three Cases of Worrisome Pan-Resistant C Auris Found in New York,” the Center for Infectious Disease Research and Policy (CIDRAP) at the University of Minnesota reported that “As of Dec 11, the CDC said 941 confirmed and probable C. auris cases have been reported in 13 states, and an additional 1,830 patients have been found to be colonized with the multidrug-resistant fungus. Most of the cases have been detected in the New York City area, New Jersey, and the Chicago area.”
Candida auris is a particularly nasty fungus. It spreads easily, is difficult to remove from surfaces, and can kill. Worst of all, modern drugs designed to combat this potentially deadly fungus are becoming less effective at eradicating it, and COVID-19 ICU patients appear especially vulnerable to C. auris infections.
COVID-19 and C. auris a Potentially Devastating Combination
Hospitals in many areas are at a critical capacity. Thus, hospital-acquired infections such as sepsis can be particularly dangerous for COVID-19 patients. Adding to the problem, C. auris requires special equipment to identify, and standard medical laboratory methods are not always enough. Misidentification is possible, even probable.
A paper in the Journal of Global Antimicrobial Resistance (JGAR), titled, “The Lurking Scourge of Multidrug Resistant Candida Auris in Times of COVID-19 Pandemic,” notes that “A particularly disturbing feature of COVID-19 patients is their tendency to develop acute respiratory distress syndrome that requires ICU admission, mechanical ventilation, and/or extracorporeal membrane oxygenation. … This haunting facet of COVID-19 pandemic has severely challenged even the most advanced hospital settings. Yet one potential confounder, not in the immediate attention of most healthcare professionals, is the secondary transmission of multidrug resistant organisms like the fungus Candida auris in COVID-19 ICUs. … C. auris outbreaks occur in critically ill hospitalized patients and can result in mortalities rates ranging from 30% to 72%. … Both C. auris and SARS-CoV-2 have been found on hospital surfaces including on bedrails, IV poles, beds, air conditioner ducts, windows and hospital floors. Therefore, the standard COVID-19 critical care of mechanical ventilation and protracted ventilator-assisted management makes these patients potentially susceptible to colonization and infections by C. auris.”
One study mentioned in the JGAR paper conducted in New Delhi, India, looked at 596 cases where patients were admitted to the ICU with COVID-19. Fifteen of them had infections caused by C. auris. Eight of those patients died. “Of note, four patients who died experienced persistent fungemia and despite five days of micafungin therapy, C. auris again grew in blood culture,” according to reporting on the study in Infection Control Today (ICT).
Some C. auris mortality rates are as high as 72%. And patients with weakened immune systems are at particular risk, “making it an even more serious concern when 8% to 9% of roughly 530,000 ICU patients in the United States have COVID-19,” ICT reported.
Apparently, the COVID-19 pandemic has created circumstances that are particularly suited for C. auris to spread. “Given the nosocomial transmission of SARS-CoV-2 by those infected, many hospital environments may serve as venues for C. auris transmission as it is a known environmental colonizer of ICUs,” wrote the JGAR paper authors.
CDC Reports and Recommendations
Along with being especially dangerous for people with weakened immune systems, C. auris infections also produce symptoms similar to those of COVID-19, “including fever, cough, and shortness of breath,” according to the CDC’s website. People admitted to ICUs with COVID-19 are especially vulnerable to bacterial and fungal co-infections. “These fungal co-infections are reported with increasing frequency and can be associated with severe illness and death,” says the CDC.
C. auris outbreaks in the United States have mostly been in long-term care facilities, but the pandemic seems to be changing that and more outbreaks have been detected in acute care facilities, the CDC reported. The lack of appropriate personal protective equipment (PPE), changes in infection control routines, and other factors could be to blame for the increase.
Just as community spread is an issue with COVID-19 variants, so too is it a concern with C. auris infections. “New C. auris cases without links to known cases or healthcare abroad have been identified recently in multiple states, suggesting an increase in undetected transmission,” the CDC noted.
As of January 19, 2021, according to the CDC the case count of C. auris infections in the US was 1,625, with California, Florida, Illinois, New Jersey, and New York having more than 100 cases each.
According to a CDC report, “Candida auris (C. auris) is an emerging multidrug-resistant yeast (a type of fungus). It can cause severe infections and spreads easily between hospitalized patients and nursing home residents.” The graphic above, taken from the report, illustrates how “C. auris began spreading in the United States in 2015. Reported cases increased 318% in 2018 when compared to the average number of cases reported in 2015 to 2017.” (Graphic copyright: Centers for Disease Control and Prevention.)
Using Clinical Laboratory Tests to Identify C. Auris
One of the big concerns about C. auris is that it is so difficult to detect, and that medical laboratories in some countries simply do not have the technology and resources to identify and tackle the infection.
“As C. auris diagnostics in resource-limited countries is yet another challenge, we feel that alerting the global medical community about the potential of C. auris as a confounding factor in COVID-19 is a necessity,” wrote the authors of the paper published in the Journal of Global Antimicrobial Resistance.
As if the COVID-19 pandemic has not been enough, drug resistant bacteria, viruses, and deadly fungi are threatening to wreak havoc among SARS-CoV-2 infected patients. Microbiologists and medical laboratory scientists know that testing for all types of infections is vitally important, but especially when it comes to infections caused by antibiotic-resistant bacteria (ARB) and other dangerous organisms that demonstrate antimicrobial resistance (AMR).
Microbiologists and clinical laboratory professionals will want to stay informed about the number of C. auris cases identified in the US and the locations and settings where the fungus was detected. They will want to be on the alert within their hospitals and health networks, as well as with the doctor’s offices served by their labs.
AccuWeather interviewed experts, including pathologists who have analyzed the virus, who say SARS-CoV-2 is susceptible to heat, light, and humidity, while others study weather patterns for their predictions
AccuWeather, as it watched the outbreak of SARS-CoV-2, the novel coronavirus that causes COVID-19, wanted to know what effect that warmer spring temperatures might have on curbing the spread of the virus. There is a good reason to ask this question. As microbiologists, infectious disease doctors, and primary care physicians know, the typical start and end to every flu season is well-documented and closely watched.
As SARS-CoV-2 ravages countries around the world, clinical pathologists and microbiologists debate whether it will subside as temperatures rise in Spring and Summer. Recent analyses suggest it may indeed be a seasonal phenomenon. However, some infectious disease specialists have expressed skepticism.
CNN reported that Nicholls was part of a research team which reproduced the virus in January to study its behavior and evaluate diagnostic tests. Nicholls was also involved in an early effort to analyze the coronavirus associated with the 2003 SARS outbreak involving SARS-CoV, another coronavirus that originated in Asia.
“Sunlight will cut the virus’ ability to grow in half, so the half-life will be 2.5 minutes and in the dark it’s about 13 to 20,” Nicholls told AccuWeather. “Sunlight is really good at killing viruses.” And that, “In cold environments, there is longer virus survival than warm ones.” He added, “I think it will burn itself out in about six months.”
The graphic above, created by John Nicholls, MBBS Adel, FRCPA, FHKCPath, FHKAM (Pathology), Clinical Professor of Pathology at the University of Hong Kong, shows “the temperate zone where the major SARS-CoV-2 hotspots have appeared so far. The variation from year to year, in this case, is minimal; however, meteorologists would typically use the 30-year normal data for this type of analysis.” (Caption and graphic copyright: AccuWeather/John Nicholls.)
Can Weather Predict the Spread of COVID-19?
Other researchers have analyzed regional weather data to see if there’s a correlation with incidence of COVID-19. A team at the Massachusetts Institute of Technology (MIT) found that the number of cases has been relatively low in areas with warm, humid conditions and higher in more northerly regions. They published their findings in SSRN (formerly Social Science Research Network), an open-access journal and repository for early-stage research, titled “Will Coronavirus Pandemic Diminish by Summer?”
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The MIT researchers found that as of March 22, 90% of the
transmissions of SARS-CoV-2 occurred within a temperature range of three to 17
degrees Celsius (37.4 to 62.6 degrees Fahrenheit) and an absolute humidity
range of four to nine grams per cubic meter. Fewer than 6% of the transmissions
have been in warmer climates further south, they wrote.
“Based on the current data on the spread of [SARS-CoV-2], we
hypothesize that the lower number of cases in tropical countries might be due
to warm humid conditions, under which the spread of the virus might be slower
as has been observed for other viruses,” they wrote.
In the US, “the outbreak also shows a north-south divide,”
with higher incidence in northern states, they wrote. The outliers are Oregon,
with fewer than 200 cases, and Louisiana, where, as of March 22, approximately
1,000 had been reported.
There’s been a recent spike in reported cases from warmer
regions in Asia, South America, and Africa, but the MIT researchers attribute
this largely to increased testing.
Still, “there may be several caveats to our work,” they
wrote in their published study. For example, South Korea has been engaged in
widespread testing that includes asymptomatic individuals, whereas other
countries, including the US, have limited testing to a narrower range of
people, which could mean that more cases are going undetected. “Further, the
rate of outdoor transmission versus indoor and direct versus indirect
transmission are also not well understood and environmental related impacts are
mostly applicable to outdoor transmissions,” the MIT researchers wrote.
Even in warmer, more humid regions, they advocate “proper
quarantine measures” to limit the spread of the virus.
The New York Times (NYT) reported that other recent studies have shown a correlation between weather conditions and the incidence of COVID-19 outbreaks as well, though none of this research has been peer reviewed.
Why the Correlation? It’s Unclear, MIT Says
Though the MIT researchers found a strong relation between
the number of cases and weather conditions, “the underlying reasoning behind
this relationship is still not clear,” they wrote. “Similarly, we do not know
which environmental factor is more important. It could be that either
temperature or absolute humidity is more important, or both may be equally or
not important at all in the transmission of [SARS-CoV-2].”
Some experts have looked at older coronaviruses for clues. “The coronavirus is surrounded by a lipid layer, in other words, a layer of fat,” said molecular virologist Thomas Pietschmann, PhD, Director of the Department for Experimental Virology at the Helmholtz Center for Infection Research in Hanover, Germany, in a story from German news service Deutsche Welle. This makes it susceptible to temperature increases, he suggested.
However, Pietschmann cautioned that because it’s a new
virus, scientists cannot say if it will behave like older viruses. “Honestly
speaking, we do not know the virus yet,” he concluded.
Epidemiologist and virologist Joseph Fair, PhD, MPH (above), Special Advisor for Ebola, USAID, and Research Professor at Texas A&M University, said that sunlight might be a bigger factor than temperature or humidity. “It really doesn’t have anything to do with the warmth, but it has to do with the length of the day and the exposure to sunlight which inactivates the virus through UV light,” he told NBC News. “The science is still out,” he said. “We can assume this will follow typical other coronavirus cases,” but “everyone in the scientific and public health community expect it to be back in the fall and we expect to be in this for quite some time.” (Photo copyright: Texas A&M University.)
Marc Lipsitch, DPhil, Professor of Epidemiology and Director of the Center for Communicable Disease Dynamics at the Harvard T.H. Chan School of Public Health, is skeptical that warmer weather will put the brakes on COVID-19. “While we may expect modest declines in the contagiousness of SARS-CoV-2 in warmer, wetter weather, and perhaps with the closing of schools in temperate regions of the Northern Hemisphere, it is not reasonable to expect these declines alone to slow transmission enough to make a big dent,” he wrote in a commentary for the center.
How should pathologists and clinical laboratories in this country prepare for COVID-19? Lipsitch wrote that Influenza does tend to be seasonal, in part because cold, dry air is highly conducive to flu transmission. However, “for coronaviruses, the relevance of this factor is unknown.” And “new viruses have a temporary but important advantage—few or no individuals in the population are immune to them,” which means they are not as susceptible to the factors that constrain older viruses in warmer, more humid months.
So, we may not yet know enough to adequately prepare for
what’s coming. Nevertheless, monitoring the rapidly changing data on COVID-19
should be part of every lab’s daily agenda.
These genetic tests cut time to answer from days to a few hours, reducing the risk of exposing non-infected patients and improving outcomes for Ebola patients
In response to the continuing outbreak of Ebola in the West African countries of Guinea, Liberia, and Sierra Leone, more attention has been given to medical laboratory testing in these countries, along with a rush to develop diagnostic tests that can detect Ebola faster and more accurately without the need for state-of-the art clinical laboratories that are uncommon in those nations.The lack of even limited basic services in the region, such as electricity, hinders any attempt to install modern diagnostic facilities and clinical laboratories essential to controlling and preventing further spread of the disease. Another issue is the lack of trained pathologists, Ph.Ds., and clinical laboratory scientists to staff such labs in those nations.
One solution to this challenge, however, is for developed nations to provide mobile medical laboratories and hospital facilities. Such resources have been contributed by the United States, Canada, and several European countries. (more…)
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If validated by additional research, microbiologists, pathologists, and medical laboratory professionals might soon find analysis of the human microbiome to be a useful marker in screening for colon cancer
Microbiologists may play a greater role in the early detection of colorectal cancer, if the findings of a research study at the University of Michigan (UMich) are confirmed with additional clinical studies.
Combining gut microbiome analysis with traditional risk factors for colorectal cancer—such as body mass index (BMI), age, and race—significantly improved the ability of pathologists to distinguish healthy people from those with precancerous or cancerous lesions, wrote researchers from the UMich in a scholarly paper published in the November 2014 issue in Cancer Prevention Research.
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