What we know about the Valencia candida outbreak: we need to include society in the fight against multi-resistance

On April 6, the New York Times published a long story on how the Candida auris it is expanding "throughout the world in a climate of secrecy." The text is very interesting, but there is something that has particularly caught the attention of the Spanish public: it talks about an outbreak of Candida at the Hospital de La Fe in Valencia that colonized 372 people and developed bloodstream infections in 85 of them.

With a death rate of 41%, that would mean that, according to the New York Times, 40 people "have died of candida in Spain and we have not found out." Is this possible? What do we know and what do we not know about the outbreak of the Hospital de La Fe and about the Candida auris usually? we have talked to

What is the Candida auris?

A fungus. Specifically, it is one of the few candida species capable of infecting humans. It is what we call an "opportunistic infection"; that is, one of those infections that preys on people with immature or compromised immune systems (from babies to the elderly, from smokers to newly operated people). This is why these types of pathogens live in hospitals: because they only thrive in patients who are already serious. They are vultures waiting for their chance.

There are so many of these infections. Interesting thing about the Candida auris is that it is relatively new (it was first described in 2009 in the ear of a Japanese patient) and most of its strains are resistant to most of the known antifungals. It is, therefore, a "superbug" that is spreading around the world at full speed, jumping from hospital to hospital.

And, in this context, that of the Hospital de La Fe was one of the first major outbreaks of this dimension of which we have evidence. What we know about him, we know from some isolated and partial news, from the NYT report and, above all, from a work published a year ago in the scientific magazine Mycoses. In this, the cases related to candida between April 2016 and January 2017 are analyzed in detail. However, as reflected in the article, the outbreak was still active in March 2018.

What do we know about the outbreak?

Xataka has contacted the center and explained the details of the outbreak. "The first cases of Candida auris At La Fe Hospital they were detected in April 2016. "" From the start, the outbreak has affected 409 patients, of whom 87 developed the infection by invasive candidiasis. [...] Currently, the outbreak is under control and only one new case of colonized patient (carrier patient) has been detected in March 2019, and a single candidemia (infection) since June 2018. "

"Since the detection of this outbreak, it was communicated to the general direction of Public Health of the Ministry of Universal Health and Public Health." "The measures taken consisted mainly of extreme and increased cleaning and hygiene with special products, reinforcement of the professional ratios when necessary, constant microbiological control of patients and their environment, specific training sessions with professionals, contact isolation in the patients, among others. In addition, the Hospital makes a daily report with the number of patients carrying multidrug-resistant germs and the measures carried out. "

Why did we know so little until now?

One of the authors of the article and a La Fe doctor explained to the New York Times that the center's management did not want anyone to speak to journalists because "he is concerned about the hospital's public image." This may sound outrageous, but it is standard practice: authorities are informed and proceeded according to procedure. In fact, the same report explains how English or North American centers opt for the same non-dissemination policy.

Why? Because nosocomial or in-hospital diseases are a huge health problem, yes; but a very common one. These are "infections contracted during a hospital stay that had not manifested or were not incubating at the time the patient was admitted." Today, they affect 5% of all hospitalized patients. What, in 2005, were more than 50,000 people in Spain alone.

Furthermore, we are talking about a specific type of infection that "carries a high morbidity and mortality and a higher economic cost", but which are really only problematic in patients who already had a very poor state of health. Public health experts, therefore, often recommend treating these outbreaks with discretion. From a health point of view (especially in health systems where there is no option to choose a hospital), it is traditionally understood that the advertising of outbreaks of nosocomial diseases is related to a reduction in the care burden: even if they need it, patients visit the doctor less and defer operations more often.

That's a problem because, except for optional operations (which are usually postponed during outbreaks like this anyway), delaying treatments has a negative impact on the patient's health. An impact that is usually greater than the risk of infection. Let us remember that, as they also point out from the same Hospital, it is not that dozens of people have died from candidiasis: "we have no official record of the mortality related to candidemia due to C. auris, since it is very difficult to discern if patients die from the pathogen or with it, since they are patients with many underlying diseases and in a very serious general condition. In fact, so far, no studies have provided related mortality figures in outbreaks published in other countries. "

How did we find out?

La Fe doctors considered it appropriate to share with other hospitals how they had tried to combat the C. auris in Valencia. It is such a new and unknown species that we have not yet developed clear protocols. Therefore, despite the discretion policy, an analysis of the outbreak was published in April 2018 with the aim of providing all the information available with the international medical community. It is necessary.

According to the US CDC, almost half of patients who become infected with C. auris they die within 90 days. It is true that, as I have already explained, to develop the infection the immune system has to be previously compromised, but the problem is still serious and cannot be postponed. In somewhat more general terms: Current estimates estimate that some 700,000 people die from drug-resistant infections each year. And this has only just begun.

According to a British government report, if policies are not put in place to curb the rise in drug resistance, by 2050 some 10 million people will die each year. Today, to give us an idea of ​​the size of the threat, about eight million people die each year from cancer.

We talk a lot about superbugs, but cases like La Fe remind us that the great analyzes of multi-resistant fungi paint a terrible and perhaps less visible scenario. While the role of livestock farming in the development of antibiotic resistance is constantly denounced, we often forget the role of agriculture in the loss of effectiveness of antifungals. That is to say, we need to talk about "the fungal threat", but without unnecessary alarm.

Does that mean that everything has been done well?

From a strictly communicative point of view, the behavior of the Hospital is usual. There is no point in talking about "silenced problems" or similar concepts. However, it does seem clear that we should review the protocols. And it is that, although there are public health reasons to treat these types of outbreaks with discretion, if something shows all this is that we did not live in the 80s. We live in a radically different world.

And we must think about how to adapt to it because in an ecosystem taken over by social networks where information is not only super abundant, but also very difficult to control, "hiding" information is a time bomb. The UN itself no longer recommends it. Beyond the demands of transparency and oversight, current medicine must rethink its relationship with a society that increasingly has more information, although it is not very clear what to do with it.

The best example is that, at the time of the end of the article, no one has clarified all the doubts that have arisen about the outbreak despite having been around the social media for days. Perhaps the great challenge of contemporary medicine is to include the whole of society in the battle against serious health problems. Because in times of misinformation, credibility and trust once lost are difficult to regain.

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