JAN DYER is a writer and editor specializing in clinical topics. She lives in Suffern, New York.

Jan Dyer

Picture a busy outpatient clinic: physical therapy, oncology, cardiac, dental, urgent care. Over the course of a day, dozens of people—even amid COVID-19—may pass through its rooms: staff, patients, parents, caregivers, delivery people. In the US, outpatient visits have climbed steadily, to nearly a 

. According to the CDC’s “Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care,” the past several decades have seen a “significant shift” in health care delivery from the acute, inpatient hospital setting to a variety of outpatient and community-based settings. More than three-fourths of all operations in the US are performed in settings 

But although they have the same main players—health care providers, other staff, patients—outpatient settings are not like inpatient settings. They have unique requirements and circumstances, including those related to infection prevention and control.

Epidemiologist Joe Perz, DrPH, who works for the CDC’s Prevention and Response Branch, told 

) that “compared with inpatient care in a hospital setting or congregate care in long-term care settings like nursing homes, the outpatient environment has a ton more variety, in terms of the types of care provided. While core practices like hand hygiene and environmental cleaning apply to all patient encounters, outpatient settings also provide more specialized forms of care that come with more specialized infection control requirements. Plus, the volume of patient encounters is staggering, and this is spread across an enormous number of individually operated facilities, many of which do not have clear lines of oversight for infection control. These distinctions present significant challenges.”

If Perz had to list the top 3 of those challenges, here’s what he would choose: “Broadly speaking, I’d cite awareness, attention, and consistency. Traditionally, many outpatient settings had infection control quite low on their list of priorities and concerns. Too often it was out of sight and out of mind. Not surprisingly, knowledge of even the basics of infection control was lacking and we saw many gaps in terms of things like hand hygiene, injection safety, cleaning, and even device reprocessing. There were attention deficits and a lot of inconsistencies in terms of how outpatient providers practiced infection control.”

The result? The CDC says data similar to those for hospital-acquired infections are lacking for most outpatient settings, but “numerous outbreak reports have described transmission of gram-negative and gram-positive bacteria, mycobacteria, viruses, and parasites. In many instances, outbreaks and other adverse events were associated with breakdowns in basic infection prevention procedures.”

Case in point: In 2015, a CDC research team reviewed investigations of health care-associated infection outbreaks in Los Angeles outpatient settings between 

. Of the 28 investigations, 79% revealed more than 1 infection control breach.

Lapses in infection control were suspected as the source for 16 (57%) of the investigations, such as using single-use medications multiple times or reusing fingerstick blood glucose meters. Bacterial agents were implicated in half of the identified outbreak investigations. Breaches were frequently associated with injection safety, equipment processing and sterilization, and environmental cleaning. An investigation of a urology office, for instance, revealed that the facility had been improperly cleaning and disinfecting cystoscopes for more than 10 years.

The investigators were perturbed by their findings. “The lack of change in 5 decades related to outbreak source and infections resulting from preventable unsafe behaviors is alarming,” they wrote in their report for 

, “Most outbreaks documented could have been prevented by using standard precautions and practicing basic infection control. These findings highlight a need for more infection control oversight of outpatient settings, as well as better reporting from outpatient settings.”

That was 6 years ago. Has time made a difference? Time that has included COVID-19? Things have changed, after all. A 2020 data analysis found visits to ambulatory practices declined nearly 60% by early April 2020. Even after a rebound (across all specialties), numbers were still roughly one-third lower than 

And in a 2021 study, investigators tallied outpatient visits between January 1, 2020, and June 15, 2020, among 16,740,365 

. They found in-person visits from January 1 to June 10 dropped from 102.7 to 76.3 (a decrease of 26.4 or –30.0% change). By the last 4 weeks, the percent change from baseline ranged from –73.2% in Hawaii to –16.0% in Alaska.

No matter how few the visits, though, the basic problems remain. Kelsey OYong, MPH, CIC, supervising epidemiologist at Los Angeles County Department of Public Health and lead author on the investigation review, tells 

 that “other than COVID-19 in the past 2 years, lapses in infection control continue to be the most common source of outbreaks.”

Though this varies by outpatient setting type, says OYong, her department continues to see reuse of single-dose vials and equipment as outbreak sources. Culprits also include environmental contamination and improper cleaning and disinfection of equipment.

“In a way,” says OYong, “the COVID-19 pandemic has highlighted the importance of infection prevention generally, and specifically in the realms of respiratory hygiene, personal protective equipment, source control, and employee health. Many outpatient settings are improving infection control practices and knowledge as it relates to respiratory diseases. We hope that this knowledge translates to other diseases, spread by contact or procedures, as well.”

The ultimate goal in all this is not only good health care, but safe health care (take another look at the title of the CDC guide, however; it sets the bar for safe care with “minimum expectations”). Many vulnerable patient populations rely on “frequent and intensive use of outpatient care to maintain or improve their health,” the guide says. Each year, for instance, more than 1 million cancer patients receive outpatient chemotherapy, radiation therapy, or both. But according to CDC data, since 2002, at least 9 serious infectious disease outbreaks, including unsafe injection practices, have occurred in cancer clinics. Hundreds of patients were infected; thousands more required notification and testing for 

Obviously, building—or reinforcing—a stronger foundation for infection control would help. Compared with inpatient acute care settings, the CDC says, outpatient settings have traditionally lacked infrastructure and resources to support infection prevention and surveillance activities. And, to restate more of the obvious, outpatient settings are not like inpatient settings.

“In the broader context of all the hardships we’ve experienced, on the provider and patient sides of ambulatory care, there is greater appreciation of infection risk,” says Perz. “And we are seeing this across the spectrum, from primary care to specialized outpatient settings.” But, he adds, “to maintain effective outpatient care, there needs to be a foundation of protections, for both patients and health care workers.

OYong agrees. “The pandemic has stretched health care workers to their professional and emotional limit. For many settings, the majority of staff time is now spent on COVID-19 response efforts, taking away especially from surveillance and adherence monitoring activities. Stress and burnout are serious concerns for the health care workforce.”

They’re not only worn out; they’re also being stretched intolerably thin.“For infection preventionists in the outpatient setting,” she says, “juggling many different roles is a big challenge. They often play the role of infection preventionist, employee health director, risk manager, health educator, and health care epidemiologist, plus their normal nursing and clinical roles.”

Moreover, she points out that “sometimes designated infection preventionists [Ips] in outpatient settings don’t have the same access to resources or community that inpatient IPs have. They often work independently if they’re not part of a larger health care system or network and may not have access to community best practices or policies.”

That’s beginning to change, though, Perz says. “One very positive development I’d like to highlight is 

, CDC’s national infection control training collaborative. Project Firstline’s content is designed so that, regardless of a health care worker’s previous training or educational background, they can understand and apply the infection control principles and protocols needed to protect themselves, their facility, and their patients from all infectious disease threats, such as COVID-19.” (“The COVID-19 pandemic has underscored gaps in infection control knowledge and practice in healthcare settings nationwide,” the 

Project Firstline teams up a coalition of academic, public health, and health care partners plus 64 state, local, and territorial health departments through the Epidemiology and Laboratory Capacity for Prevention and Control of Emerging Infectious Diseases Cooperative Agreement. One of the initiatives integrates “enhanced infection control content” into community college classrooms. The program designers say they chose community colleges because they educate a significant portion of the US nursing and allied health care workforce; know how to meet the unique training needs of a diverse, intergenerational health care workforce; and are equipped to tailor training and educational resources to fill critical gaps in underserved communities.

While those up-and-coming health care providers are being trained, what to do about the ones with boots already on the ground? OYong has some suggestions for how to handle the persistent challenges she and the other investigators identified in 2015. For instance: Make it a group effort. The pandemic naturally changed practice. It also may have changed attitudes about “my job” vs “their job”; we’re truly all in this together.

“Building an infection prevention team helps mitigate all of those responsibilities falling to a single person,” she says. “Creating a facility-wide culture of safety helps all staff take accountability for infection control. Empowering all staff to speak up when they see issues with PPE, injection safety, etc. helps stop lapses at their source.”

Perz says “thepandemic experience taught us a lot about keeping our guards up to keep infection risks down. This begins when patients enter—or even approach—an outpatient facility. We are now all much more sensitive to the needs for things like screening, triage, and source control. We have been forced to be more mindful of the needs for worker protections, which were often taken for granted. These needs were all present prior to the pandemic but were vastly underappreciated.”

In the meantime, here’s his best evidence- and experience-based advice: “Remember that your efforts to stem the spread of infections are making a real difference. As health care providers, your mission has always been to protect health and promote quality of life. More than ever, infection control is central to this mission.”

Jan Dyer is a writer and editor specializing in clinical topics. She lives in Suffern, New York.

Articles

Outpatient settings are not like inpatient settings. They have unique requirements and circumstances, including those related to infection prevention and control.

Infection Control in Outpatient Settings: Old Challenges, New Realities

Bacteria love surfaces. They need them to survive and thrive. Through adhesion to surfaces, they can form biofilm, a slimy extracellular matrix, that makes them hundreds of times more effective in resisting antibiotics.

Viruses also love to cling to things. That’s why one of the first responses to SARS-CoV-2 was to find out just where and how long it survived outside the body.

And early research duly alarmed the world. Laboratory studies suggested that the virus could last anywhere from hours on clothing to 3 days on paper money to 6 days on hard surfaces such as plastic and stainless steel. In early 2020, scientists identified RNA of SARS-CoV-2 on a variety of surfaces in the cabins of both symptomatic and asymptomatic infected passengers aboard the 

up to 17 days after the cabins were vacated but before disinfection procedures were conducted.

 They could not at the time determine whether there was any transmission from surfaces.

More recently, investigators have found that surfaces can be positive for the COVID-19 virus but that the viral material isn’t actually able to infect cells. Transmission of COVID-19 via surfaces is rare. Emanuel Goldman, PhD, a professor of microbiology at Rutgers New Jersey Medical School, became irritated by the way COVID-19’s viability on fomites (inanimate surfaces or objects) was being tested. In a comment letter to 

in August 2020, Goldman wrote that the risk was being exaggerated.

 Although investigators were claiming virus survival of up to 6 days, he said, they were placing very large initial virus titer samples on the surface being tested.

“None of these studies present scenarios akin to real-life situations,” he said. In an interview with 

 published in January 2021, he said, “The viral RNA is the equivalent of the corpse of the virus. It’s not infectious.”

So how to deep-clean contaminated surfaces? One relatively new way is with electrostatic sprayers (ESSs). The method has been used for more than 50 years in agriculture to reduce spray drift when applying pesticides to crops, but it has been used only in the past 10 years or so in health care settings. Thanks to COVID-19, the past 2 years have been profitable for disinfectant manufacturers. By the end of 2020, global sales of surface disinfectant totaled $4.5 billion—a jump of more than 30% over the previous year.

 To give that context: In 2019, the market size was expected to cross just $1.9 billion by 2025.

The COVID-19 virus does not last long on surfaces that have a lot of holes or microscopic grooves, nooks, or crannies, said Frank Esper, MD, in an article for Cleveland Clinic’s website—but those areas are where ESS shines.

 Most pathogens love complex surfaces and, given the chance, will settle right in. Norovirus, for instance, which can infect with minute amounts, can stay transmissible on objects and surfaces for days or weeks. Moreover, it can survive some disinfectants.

ESS offers a fast way to clear out pathogens from wide areas. EvaClean, which is certified by the Occupational Safety and Health Administration, has an ESS that uses disinfecting tablets registered with the Environmental Protection Agency (EPA). EvaClean states it takes approximately 30 to 45 minutes to clean and disinfect a hospital room using traditional methods but its ESS can reduce those times by 40%.

 Moreover, depending on the disinfectants used, the ESS can kill 99.99% of bacteria found in biofilm, 

, and other viral and fungal infections, EvaClean states.

An ESS is based on the universal interaction between positive and negative forces. (Remember rubbing a balloon to create static and then sticking the balloon to a wall or your head? Same general principle.) Most surfaces have a (grounded) negative surface charge. The sprayer positively charges the disinfectant as it passes through the sprayer nozzle, and the charged disinfectant droplets seek out and stick to negatively charged surfaces—that is, they produce static.

Like magnets that shoot away from each other when held rear to rear, the positively charged particles in the droplets repel each other and spread out—at many times the force of gravity—looking for exposed surface. The spray droplets can also reverse direction, moving against gravity and coating all sides of the target object. Thus, one of the advantages of electrostatic spraying is that it offers “wraparound” coverage, meaning it can quickly coat high-touch surfaces that may be time consuming to clean such as pens, light switches, faucets, and keyboards.

Because the solution comes out in a thin mist, it covers the targeted area evenly. Sprayers with smaller droplet sizes may be safer for sensitive equipment. Surfaces that are already covered will repel the charged droplets, which redistributes them, making the task that much more efficient and reducing the chance of overapplication.

In addition to time savings, the ESS offers cost savings. Used properly, the ESS can save on disinfectant and cut cleaning time by 50% or more, compared with spray-and-wipe methods. Moreover, according to an EPA decontamination study, because an ESS provides more uniform distribution, using a minimal amount of solution, it significantly reduces waste streams and costs associated with liquid hazardous waste disposal. Compared with a backpack sprayer, the ESS generated almost 75 times less liquid waste.

A downside is that although the droplets give the disinfectant sustained contact with the contaminated surface, the protection doesn’t last forever. The sprayer’s ability to deposit smaller amounts of disinfectant over a wide area may be both an advantage and disadvantage, according to the EPA. With less disinfectant applied, disinfection efficacy may diminish if the surface does not remain wet for the required contact time.

The required time often is specific to the pathogen. One study, for instance, found a 5-minute contact time was required for 

spores were reduced but not eliminated completely after a single spray application of the disinfectant. The investigators say that failure to eliminate the spores is partly because curved or vertical surfaces typically had drying times of approximately 2 minutes. Thus, in settings where 

 is a concern, they say, repeated application may be required to maintain 5 minutes of wet contact time. Moreover, left intact, the solution will last long enough for the pathogen to be deactivated, but only until the surface is touched again.

Some of the advantages of ESSs depend on the components.

A team of EPA investigators compared several spray parameters for 6 electrostatic sprayers, 2 foggers, and 1 hand-pumped garden sprayer.

 “The electrostatic spray process is complicated and involves multiple physical phenomena,” they wrote in 

 One on November 30, 2021. Parameters that might affect a disinfectant’s ability to inactivate the virus on surfaces include spray droplet size distribution, electrostatic charge, ability of the spray to wrap around objects, and loss of disinfectant chemical active ingredient due to the spray process. Also, not all electrostatic sprays carry the same charges. In this study, 2 ESSs that used alternating current had a negative charge, whereas the battery-powered ESS carried a positive charge.

The investigators tested the sprays on a variety of surfaces, including a metal trashcan and other surfaces such as a stepladder, a clip-on lamp, and a fold-out chair.

For all the devices evaluated, “[w]e were surprised to find there was not much of a ‘wrap-around’ effect of the spray from ESS, a claim that some ESS suppliers use for marketing—albeit this is just based on the limited tests we did,” Joseph Wood, senior research engineer with the EPA’s Center for Environmental Solutions and Emergency Response, and primary author on the study, told 

. For instance, the deposition was greatest at the front of the trashcan, with some minor amounts of spray deposited on the sides and only minimal amounts deposited on the back of the can.

Due to the range in recommended ESS surface coverage, types of surfaces and materials, varying disinfectant chemistries and parameters such as droplet charge, and site-specific environmental conditions, surfaces may not remain wet for the required contact time of the disinfectant. Wood’s top recommendation for using ESS: “Ensure that the surface you are disinfecting remains wet for the required contact time of the disinfectant you are using, and follow all label directions, including use of PPE [personal protective equipment].”

On the plus side, the investigators found that little of the active ingredient in dichlor- and hydrogen peroxide–based disinfectants was lost to the air (ie, below occupational health levels of concern) and the active ingredient concentrations collected 3 feet away from the nozzle did not decrease.

Those are serious considerations. For one, although ESSs allow for contactless cleaning, aerosolized disinfectant can hang in the air for long periods of time, especially if the area is not well ventilated. Aerosolized disinfectant can irritate skin, eyes, and airways.

The Centers for Disease Control and Prevention and EPA advise extreme caution when using ESSs, stating that they should be used only:

by a trained professional wearing appropriate PPE and who is alone in the room;

with disinfectants approved for this method of application (if the label doesn’t include directions for use with electrostatic spraying, the EPA has not reviewed any data on safety and effectiveness; see 

EPA’s List N: Disinfectants for Use Against SARS-CoV-2

according to manufacturer instructions for safety, use, and contact time.

Other advice from experts about ESS includes as follows:

wipe surfaces physically clean prior to disinfection because ESS solution only kills pathogens, it does not remove surface grime;

stay out of the area for the time indicated in the product label and specified by the application device (usually around 40 minutes);

open windows and doors after use, if possible, to air out the space;

remove chemical residue, which can pose health risks, before others enter the room;

follow product label directions for wiping or rinsing residue after the appropriate contact time has been achieved; and

An ESS does indeed kill nearly 100% of pathogens. It also kills the COVID-19 virus. But is that last function overkill? Fomite transmission of COVID-19 is a “ghost problem,” according to Joseph Allen, associate professor and director of the Healthy Buildings program at the T.H. Chan School of Public Health at Harvard University; Charles Haas, professor of environmental engineering at Drexel University; and Linsey Marr, professor of civil and environmental engineering at Virginia Tech.

in December 2020, they advised that it’s much better, when dealing with an airborne virus, to “shift our effort toward cleaning shared air, not shared surfaces.”

They wrote, “We don’t have a single documented case of COVID-19 transmission from surfaces. Not one….When we look at [the] entire causal chain, it’s easy to see that if fomite transmission is happening, it’s minor and certainly not driving the pandemic.”

Investigators, though, are still not saying definitively that COVID-19 is never spread by surface contact. Fomite transmission is difficult to prove, in part because respiratory transmission from asymptomatic individuals cannot be ruled out. Furthermore, in hospital settings, COVID-19 is still not the only infectious threat. Bacteria and viruses and more still linger on bed frames, bedside tables, monitors, and wheelchairs.

One of the lessons learned from this pandemic has been that handwashing is a primary preventive of infection. One investigative team says that even with low adherence to handwashing—with just 1 in 4 individuals disinfecting their hands after surface contact—median infection risks from fomite contact were reduced by 0.16 to 2.2 log. With high adherence—3 of 4 individuals disinfecting—median risks decreased by 3.4 to 4.0 log.

Enhanced cleaning is “hygiene theater,” the authors wrote in 

article. But because surface transmission is still—although remotely—possible, Marr told 

, handwashing is still crucial. Despite the efficiency of ESSs, the oldest disinfecting tool—handwashing—may be the best.

Jan Dyer is a writer and editor, specializing in clinical topics. She lives in Suffern, New York.

Busscher HJ, van der Mei HC. How do bacteria know they are on a surface and regulate their response to an adhering state? 

. Published online January 26, 2012.doi.org/10.1371/journal.ppat.1002440

Moriarty LF, Plucinski MM, Marston BJ, et al. Public health responses to COVID-19 outbreaks on cruise ships - worldwide, February-March 2020. 

. 2020;69(12):347-352. doi:10.15585/mmwr.mm6912e3

Goldman E. Exaggerated risk of transmission of COVID-19 by fomites. 

. 2020;20(8):892-893. doi:10.1016/S1473-3099(20)30561-2

Lewis D. COVID-19 rarely spreads through surfaces. So why are we still deep cleaning? 

. 2021;590(7844):26-28. doi:10.1038/d41586-021-00251-4

Electrostatic disinfectant sprayer market - global outlook and forecast 2020-2025. September 2020. Accessed November 29, 2021. 

https://www.marketresearch.com/Arizton-v4150/Electrostatic-Disinfectant-Sprayer-Global-Outlook-13546626/

How long will coronavirus survive on surfaces?Cleveland Clinic. Updated August 5, 2020. Accessed November 29, 2021. 

https://health.clevelandclinic.org/how-long-will-coronavirus-survive-on-surfaces

Norovirus illness: key facts. CDC. January 2015. Accessed November 29, 2021. 

https://www.cdc.gov/norovirus/downloads/keyfacts.pdf

Gomes A. Frequently asked questions about electrostatic disinfection. February 27, 2020. Accessed November 29, 2021. 

https://octoclean.com/blog/frequently-asked-questions-about-electrostatic-disinfection

Archer J, Karnik M, Touati A, Aslett D, Abdel-Hady A. Evaluation of electrostatic sprayers for use in a personnel decontamination line protocol for biological contamination incident response operations. EPA. October 9, 2018. Accessed November 29, 2021. 

https://cfpub.epa.gov/si/si_public_record_report.cfm?dirEntryId=342750&Lab=NHSRC&fed_org_id=1253&subject=Homeland%20Security%20Research&view=desc&sortBy=pubDateYear&showCriteria=1&count=25&searchall=%27indoor%20outdoor%20decontamination%27%20AND%20%27biological%27

Evaluating electrostatic sprayers for disinfectant application. EPA. Accessed November 29, 2021. 

https://www.epa.gov/covid19-research/evaluating-electrostatic-sprayers-disinfectant-application

Cadnum JL, Jencson AL, Livingston SH, et al. Evaluation of an electrostatic spray disinfectant technology for rapid decontamination of portable equipment and large open areas in the era of SARS-CoV-2. 

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The electrostatic sprayer method kills nearly 100% of pathogens. It also kills the COVID-19 virus. But is that overkill?

Going Deep: Cleaning Potential of Electrostatic Sprayers

What’s the most important thing to know about 

 today? Mainly that it’s a clear present and future danger. The Centers for Disease Control and Prevention (CDC) classifies


 as an “urgent threat”—the highest level of concern.

 is 1 of only 5 pathogens to fall into that category, and it is the first fungal pathogen.

 is a public health concern due to high rates of antifungal resistance and a unique ability to spread easily and cause outbreaks in health care settings, especially long-term care facilities,” said Joe Sexton, acting laboratory team lead at the CDC’s mycotic diseases branch, in an interview with 

®. “It’s a high priority not only for our group but also at the agency as a whole.”

According to the CDC’s tracking, the cumulative number of 

 cases so far this year is 161. In 2020, the cumulative total was 178, so it’s likely that 2021 will surpass that number.

 The number of clinical cases may seem small, but add to that the nearly 3000 people who have been identified through screening as colonized with the extremely transmissible fungus.

 was first reported in 2009, although retrospective review suggests earlier strains date to 1996. One of the most disturbing features of 

 is that, in its relatively short life, it has rapidly developed resistance to the few available treatment options. Approximately 85% of 

 isolates in the US are resistant to azoles, 33% to amphotericin B, and 1% to echinocandins—making echinocandins critical.5 But since 2019, cases of “pan-resistance” have been appearing; that is, patients for whom echinocandins don’t work. CDC investigators reported on 5 cases (3 in Washington, DC, and 2 in Texas). All 5 were clustered within facilities. Perplexingly, none of the patients had been treated with antifungal drugs prior to the diagnosis, which is a first, according to the investigators.

 incidence has taken a back seat to the COVID-19 pandemic, like many health care concerns. “News about 

 outbreaks has been overshadowed over the past year and a half by coverage of COVID-19,” said Cornelius (Neil) Clancy, MD, an associate professor of medicine and director of the mycology program at the University of Pittsburgh. “However, it hasn’t gone away, and the threat it poses worldwide to health care systems, long-term care facilities, and the public health has not diminished.”

Clancy said it’s hard to know precisely how the pandemic has affected the incidence of 

 infections. “What is clear, however, is that outbreaks of infections, including 

 outbreaks and increased incidence of health care-acquired infections, in general, are major features of the pandemic,” he said.

The pandemic has essentially put a match to a combustible situation. “We tend to see transmission and see cases among patients who are in these high-acuity, long-term care facilities…that have very sick patients, like ones who are on ventilators or have tracheostomy or other invasive medical devices,” said Meghan Lyman, MD, a medical officer in the CDC’s mycotic diseases branch and lead author on the study of pan-resistance, in an interview with 

. “Getting COVID-19 and having these complications puts them at higher risk for acquiring 

 infections has added pressure to what health care facilities are dealing with. The infection prevention challenges likely stem from pressures the pandemic placed on infection preventionists (IPs) and health care resources and personnel, Clancy said. “Even under the best of circumstances, IP teams typically operate at the extremes of their capacity. When an unprecedented public health challenge like COVID-19 emerges, there is limited overflow capacity, and attention and resources normally given to routine IP practices run the risk of being diverted. Moreover, staff become overwhelmed and fatigued, which makes adherence to strict IP practices more difficult to sustain,” he said.

Not only that, “many COVID-19 patients, particularly those who are hospitalized, are at increased risk for secondary infections due to risk factors like [intravenous] lines, urinary catheters, and mechanical ventilation. With this background, facilities are vulnerable to 

If it does arrive in a facility, it’s toward the top of the danger list, given the bad outcomes among infected patients, Clancy warned. Death is 1 of those possible outcomes. A systematic review of nearly 5000 cases worldwide reported an overall crude mortality rate of 39%.2 Among the patients with pan-resistance detailed in the CDC report, 30-day mortality in both outbreaks combined was 30%, although the relative contribution of 

 outbreak takes its toll throughout the facility. Eradicating, or simply controlling, outbreaks commands “massive and sustained IP efforts,” Clancy said. “Clearly, devoting these efforts is much more difficult with COVID-19 and the IP challenges imposed by the pandemic.”

“Unfortunately, we have seen increased spread of 

 during the pandemic. Typically, it’s most problematic in long-term care settings, which have also been heavily burdened by the pandemic. However, during the pandemic, we’ve seen outbreaks in COVID-19 specialty care units, ICUs, and other acute care settings where we typically don’t see spread of 

,” Sexton said. He cites a case reported in the CDC’s 

: In July 2020, the Florida Department of Health was alerted to 3 

 bloodstream infections and 1 urinary tract infection in 4 patients with COVID-19, who received care in the same dedicated COVID-19 unit of an acute care hospital.

“We’ve also seen unusual cases pop up without epidemiologic links to other cases,” Sexton said. “Which tells us there is additional undetected transmission happening. The reasons for increased spread during the pandemic are not fully clear but may be related to changes in routine infection control practices.”

In the CDC study of pan-resistance, the investigators observed multiple opportunities for contamination of the base layer of gowns and gloves during doffing and through direct contact with the patient care environment or potentially contaminated surfaces, such as mobile computers. Mobile computers and medical equipment were not always disinfected between uses, and medical supplies (eg, oxygen tubing and gauze) were stored in open bins in hallways and accessed by health care providers wearing the base personal protective equipment (PPE) layer. The investigators also observed missed opportunities for performing hand hygiene.

Those lapses likely contributed to widespread 

 transmission, the investigators concluded. After the hospital removed supplies from hallways, enhanced cleaning and disinfection practices, and ceased base PPE layer practices, the investigators detected no further 

? At the moment, the answer is…possibly. “Our ability to respond to 

 has improved substantially,” Sexton said. “Due to enhanced diagnostic capacity, improved understanding of risk factors, and advancements in disinfectant and infection prevention and control [IPC] guidance.” And of course, increased awareness and adherence to essential IPC practices are also critical to improved control.

But the fact that the fungus continues to spread within and between facilities, as demonstrated by an increase in the number and geographic spread of cases in recent years, means “we need to improve our understanding of how colonization relates to environmental contamination, and how to disrupt transmission pathways,” Sexton said. Shedding from colonized patients’ skin into the health care environment (calculated to occur at a rate of a million microbes per hour) creates an environmental reservoir and source of ongoing nosocomial transmission, said the research team (including Sexton), who studied residents of a skilled nursing facility (SNF) with endemic 

Investigators are coming up with a variety of plans of attack. At the CDC, Sexton’s group is actively engaged in numerous applied scientific studies, including collaborations with external partners and other government agencies, to improve public health guidance for 

“In the beginning of 2019, there were still no hospital disinfectants approved for 

, leaving a gap in practical guidance for health care facilities. We generated data in our laboratory, which reinforced concerns that many common disinfectants could not kill 

. However, we also found several chemistries that worked quite well. We worked with the Environmental Protection Agency [EPA] to improve temporary guidance based on this data, which helped pave the way for the private sector to get engaged,” Sexton said. “Now, just 2 years later, over 25 hospital disinfectants have been approved specifically for 

, giving health care facilities a wide selection of products they can be confident are effective.” The EPA has organized these approved products into an easy-to-use reference, “List P,” which is regularly updated.

, they can spread the fungus to others while not getting an active infection. However, about 5% to 10% of those carrying 

 will go on to have invasive infections later, according to the CDC investigators. The CDC is actively pursuing studies that add to the understanding of colonization patterns and the positive relationship between skin colonization burden and environmental contamination. For instance, data from the SNF study suggest “highly personalized patterns” of 

 The site-to-site variability in colonization limits infection control strategies predicated on targeting only patients known to be colonized, the investigators said. Facility or unit-wide infection control approaches may be more effective.

At the University of Pittsburgh, Clancy said, “We are not researching 

 per se in the lab, but we do a lot of work on antifungal resistance among 

 species. Of course, antifungal resistance is a hallmark feature of 

. Antifungal resistance, poor outcomes among infected patients, capacity for nosocomial spread, and environmental persistence are the constellation of features that make 

 a major threat. We also do whole genome sequencing of 

clinical strains from our health care system, so we are confident we will identify any strains, should they arrive, and that we have not missed any strains in the past.”

Both Clancy and Sexton stress we still have a lot to learn about how 

 spreads and how to stop transmission. “Raising awareness about 

 is critical because early detection is key to control,” Sexton said. He also noted that the CDC made resources publicly available on its website that provide useful information and guidance for patients, health care providers, public health professionals, laboratorians, and more.

 has not arrived, then there is potential for danger if it does arrive. Facilities need to have detailed plans in place to detect and respond promptly, and IP programs, the clinical microbiology lab, and other services need to maintain vigilance,” Clancy said.

“We’re really encouraging health departments and facilities to be more proactive instead of reactive to identifying 

. “We’ve found that controlling the situation and containing spread is easiest when it’s identified early before there’s widespread transmission.”

Antibiotic resistance threats in the United States. Centers for Disease Control and Prevention. December 2019. Accessed October 12, 2021. 

https://www.cdc.gov/drugresistance/pdf/threats-report/2019-ar-threats-report-508.pdf

Proctor DM, Dangana T, Sexton DJ, et al. Integrated genomic, epidemiologic investigation of Candida auris skin colonization in a skilled nursing facility. 

. 2021;27(8):1401-1409. doi:10.1038/s41591-021-01383-w

Drug-resistant Candida auris (C. auris). Centers for Disease Control and Prevention. November 24, 2019. Accessed October 18, 2021. 

. Centers for Disease Control and Prevention. Updated September 2, 2021. Accessed October 12, 2021. 

https://www.cdc.gov/fungal/candida-auris/tracking-c-auris.html

Lyman M, Forsberg K, Reuben J, et al. Notes from the field: transmission of pan-resistant and echinocandin-resistant Candida auris in health care facilities - Texas and the District of Columbia, January-April 2021. 

 2021;70(29):1022-1023. doi:10.15585/mmwr.mm7029a2

Branswell H. U.S. sees first cases of dangerous fungus resistant to all drugs in untreated people. 

July 22, 2021. Accessed October 11, 2021. 

https://www.statnews.com/2021/07/22/first-cases-candida-auris-resistant-to-all-drugs-untreated-people/

Prestel C, Anderson E, Forsberg K, et al. Candida auris outbreak in a COVID-19 specialty care unit - Florida, July-August 2020. 

. 2021;70(2):56-57. doi:10.15585/mmwr.mm7002e3

List P: antimicrobial products registered with EPA for claims against Candida Auris. United States Environmental Protection Agency. Updated September 1, 2021. Accessed October 12, 2021. 

One of the most disturbing features of C auris is that, in its relatively short life, it has rapidly developed resistance to the few available treatment options.

IP Strategies for Mitigating Spread of Candida auris

The patient’s room may be a sanctuary of cleanliness, but what about outside? Outpatient clinics, radiology, physical therapy, and other such areas may be “underappreciated sources” of transmission of multidrug-resistant organisms, according to investigators from the Louis Stokes Cleveland VA Medical Center in Ohio. In a 6-month observational study, they found environmental shedding of methicillin-resistant 

 (MRSA) during 45% of appointments outside hospital rooms or during outpatient clinic visits.

Patients were screened for MRSA or multidrug-resistant gram-negative bacilli (MDR-GNB) upon admission, ward transfer, and discharge. Those with MRSA colonization or infection were placed in contact precautions (as were any patients with cultures positive for extended-spectrum β-lactamase–producing gram-negative bacilli or carbapenem-resistant gram-negative bacilli). For appointments outside patient rooms, staff at the appointment locations were alerted that the patient was in contact precautions. Clinical staff in subspecialty clinics, radiology, hemodialysis, and physical therapy were responsible for cleaning surfaces between patient visits.

Of 50 enrolled patients, 39 were colonized with MRSA and evaluated for shedding during 53 procedures. Eleven MDR-GNB carriers were evaluated during 14 procedures. Patients were classified as shedding if 1 or more environmental cultures were positive during 1 or more procedures. All preprocedure cultures collected after cleaning and disinfection of surfaces were negative for the pathogens. The investigators performed χ2 tests to identify patient-level factors associated with shedding.

No MDR-GNB were recovered from surfaces during 14 appointments. “We probably recovered more MRSA because it tends to be [hardier] and more able to survive on surfaces than multidrug-resistant gram-negative bacilli,” says Curtis Donskey, MD, director of infection control at Louis Stokes Cleveland VA Medical Center, chair of the Infection Control Committee at the Cleveland Department of Veterans Affairs, and an author of the study. He adds that conclusions that can be drawn about shedding of MDR-GNB are limited by the small number of colonized patients studied.

Preliminary data for the last quarter of 2020 revealed a jump of 34% in methicillin-resistant Staphylococcus aureus (MRSA) compared with the same quarter in 2019. Several states had much higher increases. In Arizona, for instance, rates leapt 80%; in New Jersey, that figure was 99%.

Jan Dyer

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