An azole-resistant C. parapsilosis outbreak in a Spanish hospital: An emerging challenge during the COVID-19 pandemic

Puig-Asensio, M.; Jiménez, E.; Aguilar, M.; Ayats, J.; Zaragoza, O.; Gavaldà, L.; Gutiérrez, C.; Alcázar-Fuoli, L.; Ardanuy, C.; Padullés, A.; Carratalà, J.; Pujol, M.

ABSTRACT

Introduction:

Candida parapsilosis is the second leading cause of candidemia and fluconazole is the treatment of choice. In July 2020, an outbreak caused by azole-resistant C. parapsilosis (ARCP) strains was detected in the Intensive Care Unit (ICU) of a tertiary-care center in Spain.

Objectives:

This study aims to describe an ongoing ARCP outbreak that started during the COVID-19 pandemic.

Methods:

We implemented a package of

interventions:

1) collection of surveillance cultures (throat, axilla, and groin) on patient admission and weekly thereafter;2) daily chlorhexidine bathing of patients;3) change of daily routine cleaning from 1% sodium hypochlorite to hydrogen peroxide. The presence of ERG11 mutations and the genotyping of 17 random ARCP isolates were performed by microsatellite analysis. Changes in annual defined daily doses (DDD) of antifungals/ 100 patient-days from 2019 to 2020 were reported to assess antifungal overuse. Cultures from the environment and gowns were obtained with a sterile gauze soaked in saline solution.

Results:

Between April 2020-May 2021, 239 patients (2 retrospectively identified) were found to be colonized or infected with an ARCP. Patients were initially identified in a COVID-19 ICU ward, but other units were affected after transferring colonized patients. Microbiological

analysis:

15/17 (88.2%) strains had the Y132F mutation in the ERG11 gene, 1 had the K143R mutation, and 1 did not have any mutations. Most ARCP isolates belonged to the same genotype III. The use of antifungals increased 1.4-fold from 2019 to 2020 (2.7 to 3.7 DDD/100 patient-days). Environmental cultures obtained before daily routine cleaning were positive for ARCP strains in 34/88 (38.6%). Patient care equipment, surfaces in close contact to the patient, and high-touch surfaces were frequently contaminated. Two out of 3 reusable gowns (99% polyester), cultured after patient care, and 1 sink were contaminated with ARCP.

Conclusion:

The frequent contamination of the environment coupled with suboptimal infection prevention practices during the COVID-19 pandemic (shared gowns between patients) have been important challenges to control an ARCP outbreak.