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Rise of deadly fungus spotlights hospital infection-control challenges

Nurse Lydia Mauney disinfects her powered air-purifying respirator after tending to a patient in a covid-19 unit at Mission Hospital in Mission Viejo, Calif., in December 2020. (Jae C. Hong/AP)
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A deadly fungus spreading at an alarming rate in U.S. health facilities has exposed the broader problem of how patient safety is jeopardized by underfunded and understaffed infection-prevention efforts, experts say.

On any given day, 1 in 31 hospital patients and 1 in 43 nursing home residents has an infection acquired while seeking medical care, according to the Centers for Disease Control and Prevention.

Candida auris, the fungus spreading primarily in long-term acute-care hospitals and skilled-nursing facilities, is considered a serious global public health threat because it can be difficult to detect and resists some antifungal drugs and disinfectants.

It’s just one of the infections acquired in health-care settings that are ripe for transmission because patients are on invasive devices and are susceptible to infections healthy people do not contract. There’s a wide range of other pathogens — from methicillin-resistant Staphylococcus aureus to E. coli bacteria that cause urinary tract infections — that are more rampant.

“Infection control within health care is extremely neglected,” said Saskia Popescu, an assistant professor at George Mason University who is an expert in infection prevention. “We expect hospitals to continuously respond to growing and emerging infectious-disease threats but don’t give them the resources to do so.”

What you need to know about Candida auris

In 2021, the CDC recorded more than 27,000 infections from intravenous lines, more than 24,000 from catheters and more than 50,000 from ventilators across thousands of acute-care hospitals. An additional 4,000 infections were identified at long-term care hospitals.

Exposure is inevitable. Invasive devices break the skin, a natural barrier against pathogens, and open a path for bacteria and fungi to enter the body. And patients at long-term facilities are often elderly, severely ill or immunocompromised.

“Often their immune system is not the same as ours. They can’t fight it off the way we can,” said William J. Pesce, chief medical officer at the Hospital for Special Care, a long-term acute-care facility in Connecticut.

But the risk can be mitigated with infection-prevention protocols that include regular surveillance, isolation of infected patients, protective equipment, proper hand hygiene and deep cleaning.

The coronavirus pandemic upended those efforts as hospitals scrambled to keep up with a deluge of covid patients, often amid staff and supply shortages in the pandemic’s early months. Ventilator use soared. As a result, CDC scientists found that infections from invasive devices surged alongside covid hospitalizations in the winter and summer of 2021.

The pandemic also disrupted the nation’s progress against antimicrobial-resistant pathogens, with Candida auris being just one of eight showing alarming increases from 2019 to 2020. The CDC estimates that more than 29,400 people died of such infections in the first year of the pandemic, and that nearly 40 percent were infected in a hospital.

Some experts say the coronavirus exacerbated problems that predated the pandemic.

The health system faces financial challenges and severe staffing shortages that make infection control more difficult, said Akin Demehin, senior director of policy at the American Hospital Association. “That is why we continue to advocate for needed financial support to hospitals, and for supportive workforce resources and policies across all levels of government,” Demehin said in a statement.

Hospital accreditation organizations and federal regulators require infection-prevention specialists at acute-care hospitals, experts say, but do not set standards for staffing or funding. And the rules are looser in other health-care settings.

“That’s what’s a little bit scary about Candida auris — we know that the majority of these infections happen in long-term care and nursing homes, and the infrastructure in infection prevention in those settings is not that strong,” said Patricia Jackson, president of the Association for Professionals in Infection Control and Epidemiology.

Deadly fungal infection rapidly spreading in U.S. health facilities

That organization has advocated for federal regulations to mandate full-time infection-prevention specialists at long-term care facilities. “This wasn’t always required in acute care either,” Jackson said. “When regulatory speakers speak, the administrators listen.”

Facilities that do have full-time infection-prevention staff, including Connecticut’s Hospital for Special Care, have more capacity to screen patients for risk factors and to isolate those who are contagious.

But there can be gaps — such as staff and visitors failing to properly wash their hands.

“That’s such a simple thing to do, but sometimes people forget,” said Vivian Almario, an infection preventionist at the Hospital for Special Care, which has not had cases of Candida auris.

Miscommunication can also contribute to the spread of infections in health-care settings.

The American Health Care Association, which represents nursing homes, said the fungus is primarily spreading into their facilities from patients discharged from acute- and long-term care hospitals. “It is critical that hospitals follow enhanced barrier precautions and inform nursing homes of colonization so, together, we can mitigate the spread,” said David Gifford, the association’s chief medical officer.

The havoc Candida auris could inflict on hospitals came on Shaunte Walton’s radar in 2019 when she read about facilities that had to tear down pipes and replace contaminated flooring and ceiling tiles. Walton, who oversees infection control for UCLA Health in Los Angeles, said a new electronic records system to identify high risk patients for testing and target their rooms for intense disinfecting was crucial to preventing an outbreak when 11 patients tested positive in 2021.

Los Angeles County identified four outbreaks of Candida auris that started because health-care facilities failed to communicate that patients had tested positive before transferring them to other facilities.

Zachary Rubin, a Los Angeles health official who works on the issue, said some health-care facilities forget to screen patients or communicate their results before transferring them, despite their legal requirements. He also suspects that some facilities are deliberately withholding this information to avoid the hassles of isolating and caring for a patient carrying a deadly fungus.

“That is, unfortunately, an incentive for facilities that are sending the patient to not let receiving facilities know right up front because then they’ll get refused,” said Rubin, chief of the health-care outreach unit of the Los Angeles County Department of Public Health. “You have Candida auris transmitting between patients before you even know a patient is positive.”

Rubin said only 5 to 10 percent of patients who have Candida auris on their bodies develop deadly infections. Most strains in the United States are still treatable by some drugs.

Experts note that most infections acquired at health facilities are not catastrophic — and that it’s a risk that comes with seeking medical care.

“Being in hospitals is not the safest place to be. The safest place is to be home,” said John Votto, a former president of the National Association of Long Term Hospitals. “What we do in every hospital is try to prevent. You can’t prevent 100 percent. There’s no way.”