Elizabeth Jefferson, PhD, CIC: “You have to really pay attention and make sure that it [Candida auris] stays contained so that you don’t have an outbreak. It just takes one case.”
The last thing an infection preventionist wants to see when she’s in the midst of a COVID-19 pandemic is the appearance of another deadly pathogen such as Candida auris. But that’s exactly what Elizabeth Jefferson, PhD, CIC, faced in March 2020 when a patient tested positive for C. auris. Jefferson is an infection preventionist in the infection prevention and clinical epidemiology department at Scripps Memorial Hospital La Jolla. C. auris has mortality rates of anywhere from 30% to 60% and this fungal pathogen can, as Jefferson puts it, “spread like wildfire through a unit.” Just how she and other health care professionals at Scripps Memorial Hospital La Jolla—in concert with clinicians with the San Diego country department of public health—prevented this single case of C. auris from becoming a full-blown outbreak is the subject of a study unveiled today at the annual conference of the Association for Professionals in Infection Control and Epidemiology (APIC). Jefferson gives Infection Control Today® the blow-by-blow account.
Infection Control Today®:I read the study and you did react fast, even with all the COVID-19 pandemonium going on. How did you manage to pull that off?
Elizabeth Jefferson, PhD, CIC: Well, it was a team effort, first of all. It was pulled off because number one, the patient was put in isolation very quickly because of health care abroad. And number two is that we were able to detect Candida auris quickly through screening with the help of the local public health department. And then Washington State laboratories. As well as it was identified in a wound culture by our microbiology lab, using MALDI-TOF. And then third was the amazing collaboration with [San Diego County Health & Human Services] providing guidance. And fourth is just the commitment to infection control practices by the frontline staff and through our education.
ICT®: You used the phrase “health care abroad.” What does that mean?
Jefferson: The patient had an accident in South Africa and required hospitalization for the treatment of those injuries. So as soon as a patient is identified as having health care abroad, they’re considered high risk. In our case, we screened for a carbapenemase-producing organism.
So immediately they’re put in isolation because they’re high risk for that organism. And that organism often shows up with Candida auris. That’s why that patient was ultimately screened for Candida auris. [That was done by] the department of public health. And we worked closely with a senior public health nurse one-on-one with her throughout this Candida auris containment.
ICT®: Did the ties between your hospital’s infection prevention and control department and the state department of public health get stronger because of COVID-19 or did it just basically stay the same?
Jefferson: Probably stronger because there were more meetings during COVID-19. It was stronger. But we missed the face-to-face interaction. Because the infection preventionists at least once a month go down to the public health department and listen to talks by the San Diego public health. This case took place in March of 2020. It was just at the beginning of the pandemic, and there was a lot of unknowns about COVID. And there were shortages in PPE and what kind of personal protective equipment is needed. It was all very new. And it caused a lot of strain on staff. It was just getting figured out what to do about COVID.
ICT®: How was that patient treated?
Jefferson: That patient had a lot of orthopedic injuries. That’s why the patient required hospitalization for so long. The patient actually had to go to surgery six times. The ID physicians were able to treat Candida auris with antifungals that were [effective against] this strain of Candida auris. Candida auris was also detected in a wound. And that was identified by our microbiology lab. If it’s a culture, we were able to detect it in a wound. But just through colonization, like on the skin, we weren’t able to detect it. It had to be sent out to the [country public health] lab.
ICT®: What was your role in in caring for this patient?
Jefferson: I was the infection preventionist who was the lead on this whole Candida auris containment. And then interacting with department of public health.
ICT®: You acted like a liaison between the hospital and department of public health, right?
Jefferson: Yes. At that time, the [hospital’s infection control department] manager was working in the command center for COVID. Our resources were limited.
ICT®: And what do you do about the limited resources? How do you work around that?
Jefferson: At that time, we were fortunate to have a nurse who was on modified duty to help out. She helped out with the education of the nurses on the unit, and also the health care workers on the unit about Candida auris. And was also involved in the audits and the direct observation of the cleaning and disinfecting.
ICT®: Were you concerned about it traveling to other patients? And how would that happen?
Jefferson: Candida auris is different than other Candida species. Candida auris can colonize the skin indefinitely for some patients, and it contaminates the surface, so it acts more like a bacteria. It contaminates the surface and then it can be transferred to others in the room. Also, if there’s any shared patient equipment, if it’s not cleaned and disinfected properly, it can be transferred to another patient. And there have been studies showing that there could be a prevalence of Candida auris of something like 2% and then 10 months later, it’s up near 50%. It can spread like wildfire through a unit.
ICT®: Was part of your job educating your fellow health care professionals about what to do and how to handle this?
Jefferson: Yes. The CDC [Centers for Disease Control and Prevention] website has a plethora of great information guidelines on Candida auris. Using that resource and then being on the unit and then talking with the health care workers, the environmental services staff. And then I did talks at the infection prevention meetings.
ICT®: What are the techniques for preventing spread or contamination for health care workers when it comes to Candida auris?
Jefferson: Gown and gloves, and then also meticulous hand hygiene. And the preferred method is alcohol-based hand gel. And then also, the rooms. The high-touch surfaces in the room are cleaned twice a day, too.
ICT®: And who does that?
Jefferson: That’s the environmental services staff. You have to use disinfectant against Candida auris. And that is a chlorine-based disinfectant. Something that is effective against Clostridium difficile. And then also we use UV disinfection when the room was vacated by the patient.
ICT®: And how do you make sure that a room is cleaned properly?
Jefferson: Talking to the [EVS] supervisors, and also observing the cleaning process. Making sure that they’re cleaning the surfaces and that they’re using the proper disinfectant. And also going back to that room. Doing rounds on the room, and speaking to the staff. The surgeries were scheduled at the end of the day. So then after that the room was cleaned and disinfected, and then you’ll be disinfected. Terminally cleaned at the end of the day.
ICT®: I remember reading in your study that six other patients were tested for Candida auris.
Jefferson: They were neighbors of the patient with the Candida auris that had a stay in the room more than 48 hours and that had invasive lines that were considered high risk.
ICT®: No health care workers were infected.
Jefferson: Studies have shown that health care workers do not become colonized with Candida auris [for the most part]. That it’s insignificant.
ICT®: Why is that? Is it one of those diseases that attacks somebody whose immune system is already weakened?
Jefferson: Candida auris is primarily found…. Where the outbreaks occur are in ventilators in SNFs [skilled nursing facilities]. Where it can really spread. And then so for COVID, those are high-risk patients too, because they’re on ventilators and they get transferred to skilled nursing facilities.
ICT®: Is there anything that I neglected to ask you about your study that you think infection preventionists should know?
Jefferson: Well, it’s really important to know that it just takes like one single case. You have to really pay attention and make sure that it stays contained so that you don’t have an outbreak. It just takes one case. And it’s so important to pay attention to patients’ travel histories. Well, before this, I’m really interested in microbiology, so I was very interested in Candida auris even before this patient showed up. Just because of COVID … you have to remember all the other pathogens are out there.
\This interview has been edited for clarity and length.