Infection Prevention and Control for Candida auris

In addition to these key points, considerations that are setting-specific are listed below:

The mainstay of infection control measures for C. auris in acute care hospitals and high acuity post-acute care settings is as follows:

Transmission-based precautions

Patients with C. auris should be placed in single rooms and managed using Standard and Contact Precautions. If a limited number of single rooms are available, they should be reserved for patients who may be at highest risk of transmitting C. auris, particularly patients requiring higher levels of care (e.g., bed-bound). Patients with C. auris could be placed in rooms with other patients with C. auris. Patients colonized with C. auris and other multidrug-resistant organisms (MDROs) should be placed in rooms with patients colonized with the same MDROs. CDC does not recommend placing patients with C. auris in rooms with patients with other types of MDROs.

To the extent possible, minimize the number of staff who care for the C. auris patient. If multiple C. auris patients are present in a facility, consider cohorting staff who care for these patients.

Duration of contact precautions

CDC currently recommends continuing Contact Precautions for as long as the person is colonized with C. auris. Information is limited on the duration of C. auris colonization; however, evidence suggests that patients remain colonized for many months, perhaps indefinitely.

Periodic reassessments for presence of C. auris colonization (e.g., every 3 months) for a patient with known C. auris colonization could help inform duration of infection control measures. Assessments of colonization should involve testing of, at minimum, swabs of the axilla and groin and sites yielding C. auris on previous cultures (e.g., urine and sputum). The patient should not be on antifungal medications active against C. auris at the time of these assessments. The optimal time between last receipt of antifungal medications and testing for C. auris colonization has not been established, but it is reasonable to wait one week. Wait at least 48 hours after administration of topical antiseptic (e.g., chlorhexidine), if such products are being used, before performing any testing for C. auris colonization.

  • If a patient’s swab is positive, there is no need to repeat sampling for at least another three months.
  • If a patient’s swab is negative, then at least one more assessment at least one week later is needed before discontinuing C. auris specific-infection control precautions.

Note that decisions to discharge the patient from one level of care to another should be based on clinical criteria and the ability of the accepting facility to provide care, and not on the presence or absence of colonization.

Hand hygiene

Increased emphasis on hand hygiene is needed on the unit where a patient with C. auris resides.

When caring for patients for C. auris, healthcare personnel should follow standard hand hygiene practices, which include alcohol-based hand sanitizer use or, if hands are visibly soiled, washing with soap and water. Wearing gloves is not a substitute for hand hygiene.

As part of Contact Precautions, healthcare personnel should:

  • Always wear gloves to reduce hand contamination.
  • Avoid touching surfaces outside the immediate patient care environment while wearing gloves.
  • Perform hand hygiene before donning gloves and following glove removal.

Environmental disinfection

C. auris can persist on surfaces in healthcare environments. C. auris has been cultured from multiple locations in patient rooms, including both high touch surfaces, such as bedside tables and bedrails, and locations further away from the patient, such as windowsills. C. auris has also been identified on mobile equipment, such as glucometers, temperature probes, blood pressure cuffs, ultrasound machines, nursing carts, and crash carts. Meticulous cleaning and disinfection of both patient rooms and mobile equipment is necessary to reduce the risk of transmission.

Quaternary ammonium compounds (QACs) that are routinely used for disinfection may not be effective against C. auris.  Data on hands-free disinfection methods, like germicidal UV irradiation, are limited, and these methods may require cycle times similar to those used to inactivate bacterial spores (e.g., Clostridioides difficile) when used for C. auris (Cadnum et al., 2018External)Until further information is available for C. auris, CDC recommends use of an Environmental Protection Agency (EPA)-registered hospital-grade disinfectant effective against Clostridioides difficile spores (List KExternal). It is important to follow all manufacturers’ directions for use of the surface disinfectant, including applying the product for the correct contact time.

When use of products on List K is not feasible, published research found that the following products led to a substantial reduction (≥4 log reduction) of C. auris in laboratory testing (Cadnum et al., 2018External; Rutala, et al., 2017External):

  • Oxivir Tb
  • Clorox Healthcare Hydrogen Peroxide Cleaner Disinfectant
  • Prime Sani-Cloth Wipe
  • Super Sani-Cloth Wipe

Details on contact time and testing parameters are included in the references. This does not constitute an endorsement of a specific company or disinfectant. More research is needed to evaluate which disinfectants, including others not listed here, are effective against C. auris.

Thorough daily and terminal cleaning and disinfection of patients’ rooms and cleaning and disinfection of areas outside of their rooms where they receive care (e.g., radiology, physical therapy) is necessary. Shared equipment (e.g., ventilators, physical therapy equipment) should also be cleaned and disinfected before being used by another patient.

Patient transfer between healthcare facilities

When patients are transferred to other healthcare facilities, receiving facilities should receive notification of the patient’s C. auris infection or colonization recommended infection control precautions. Examples of infection control transfer forms to aid this communication can be found at the top of the Healthcare-associated Infections Prevention Toolkits webpage.

Screening

Screening patients to identify C. auris colonization is an important part of infection prevention and control. Click here to learn more about screening and for screening-related resources.

Prospective surveillance

Prospective laboratory surveillance can help identify other C. auris cases in facilities that have had new cases identified or have seen C. auris transmission. Identify the species of all Candida isolates from any specimen source (normally sterile and non-sterile sites) from the facility or unit where C. auris was detected for at least one month until no evidence exists of C. auris transmission.

Identify prior healthcare exposures

Review patient records to identify healthcare exposures before and after the positive culture, particularly overnight stays in healthcare facilities in the month prior to the patient’s positive culture, unless there is information to suggest another time of C. auris acquisition. Facilities that are identified as part of this review should be targeted for contact investigation and a review of clinical microbiology records to identify other cases at the facility.  At a minimum, targeted facilities should include the:

  • Patient’s current facility
  • Facilities at which the patient stayed in the month prior to their positive culture.

Facilities with longer length of stays (e.g., long-term acute care, nursing homes) at which the patient stayed within the past 3 months may also be considered for this review, especially if the patient’s length of stay was longer than 7 days.

State or local health department involvement will be necessary to coordinate activities at other facilities.

Facilitating adherence to infection control measures

Preventing C. auris transmission requires diligent adherence to infection control recommendations by all healthcare personnel who care for the patient. In order to enhance adherence to infection control measures, consider the following steps:

  • Educate all healthcare personnel, including staff who work with environmental cleaning services about C. auris and need for appropriate precautions.
  • Ensure adequate supplies are available to implement infection control measures.
  • Monitor adherence to infection control practices and implement supervised cleaning of the patient care areas.
  • “Flag” the patient’s record to institute recommended infection control measures in case of re-admission.

Considerations for specific settings

Nursing homes should follow all of the same recommendations listed for general acute care hospitals and high acuity post-acute care settings. Additional considerations are as follows:

  • In general, nursing home residents should be placed on Standard and Contact Precautions.
  • Functional nursing home residents without wounds or indwelling medical devices (e.g., urinary and intravenous catheters and gastrostomy tubes) who can perform hand hygiene might be at lower risk of transmitting C. auris. Facilities could consider relaxing the requirement for Contact Precautions for these residents. However, in these instances, healthcare personnel should still use gowns and gloves when performing tasks that put them at higher risk of contaminating their hands or clothing. These tasks include changing wound dressings and linens and assisting with bathing, toileting, and dressing in the morning and evening.
  • Nursing home residents with C. auris can leave their rooms as long as secretions and bodily fluids can be contained and the patient can perform hand hygiene prior to leaving their room.
  • If residents with C. auris receive physical therapy or other shared services (e.g., physical therapy equipment, recreational resources), staff should not work with other patients while working with the affected patient. They should use a gown and gloves when they anticipate touching the patient or potentially contaminated equipment. Ideally, affected patients should be the last to receive therapy on a given day. Shared equipment should be thoroughly cleaned and disinfected after use.

Some patients with C. auris have required dialysis care. Recommendations for dialysis clinics are similar to infection control precautions for acute care hospitals and high acuity post-acute care settings and include the following:

  • Standard Precautions should be used with strict adherence to hand hygiene.
  • A mask and eye protection or face shield should be worn if performing procedures likely to generate splash or splatter (e.g., wound manipulation, suctioning) of contaminated material (e.g., blood, body fluids, secretions, excretions).
  • Hand hygiene should be performed using an appropriate agent (e.g., alcohol-based hand sanitizer or hand washing with soap and water).
  • Disposable gowns and gloves should be worn when caring for patients or touching equipment at the dialysis station. Gowns and gloves should be removed and disposed of carefully, and hand hygiene should be performed when leaving the patient’s station.
  • If available, use a separate room that is not in use as a hepatitis B isolation room (in the case of dialysis clinics) for patient treatment. If a separate room is not available, dialyze the patient at a station with as few adjacent stations as possible (e.g., at the end or corner of the unit) and consider dialyzing the patient on the last shift of the day.
  • Ensure any reusable equipment brought to the dialysis station properly cleaned and disinfected before use with another patient. Items that cannot be disinfected should be discarded.
  • The dialysis station (e.g., chairs, beds, tables, machines) should be thoroughly cleaned and disinfected between patients. Information specific to disinfection in dialysis facilities is available on CDC’s dialysis safety page Cdc-pdf[PDF – 2 pages]. Until further information about the efficacy of disinfectants against C. auris is available, environmental surface disinfection should be performed with an Environmental Protection Agency (EPA)-registered hospital-grade disinfectant effective against Clostridioides difficile spores (List KExternal).
  • To the extent possible, the number of persons who care for the C. auris patient should be minimized. Appropriate personnel should be educated and informed about the presence of a patient with C. auris and the need for special precautions.
  • If the patient needs to be admitted or referred to another facility, the receiving facility should be informed of the patient’s C. auris status.

Recommendations for outpatient settings are similar to infection control precautions for acute care hospitals and high acuity post-acute care settings and include the following:

  • Standard Precautions should be used with strict adherence to hand hygiene.
  • A mask and eye protection or face shield should be worn if performing procedures likely to generate splash or splatter (e.g., wound manipulation, suctioning) of contaminated material (e.g., blood, body fluids, secretions, excretions).
  • Hand hygiene should be performed using an appropriate agent (e.g., alcohol-based hand sanitizer or hand washing with soap and water).
  • Disposable gown and gloves should be used if extensive patient contact is anticipated or contact with infected areas is planned (e.g. debridement or dressing of colonized or infected wound). Gowns and gloves should be removed and disposed of carefully, and hand hygiene should be performed when leaving the patient’s room.
  • Ensure any reusable equipment brought into the patient room is properly cleaned and disinfected before use with another patient.
  • Meticulous cleaning and disinfection of the room/care area should be performed with an Environmental Protection Agency (EPA)-registered hospital-grade disinfectant effective against Clostridioides difficile spores (List KExternal) at the end of each visit until further information on the efficacy of disinfectants against C. auris is available.
  • To the extent possible, the number of persons who care for the C. auris patient should be minimized (e.g., dedicate a single staff person).
  • Appropriate personnel should be educated and informed about the presence of a patient with C. auris and the need for special precautions.
  • If the patient needs to be admitted or referred to another facility, the receiving facility should be informed of the patient’s C. auris status.

Recommendations for home healthcare settings are similar to infection control precautions for inpatient settings and include the following:

  • Standard Precautions should be used with strict adherence to hand hygiene.
  • A mask and eye protection or face shield should be worn if performing procedures likely to generate splash or splatter (e.g., wound manipulation, suctioning) of contaminated material (e.g., blood, body fluids, secretions, excretions).
  • Hand hygiene should be performed using an appropriate agent (e.g., alcohol-based hand sanitizer or hand washing with plain or antibacterial soap and water).
  • Disposable gown and gloves should be worn upon entering the area of house where the patient care will be provided. Gowns and gloves should be removed and disposed of carefully, and hand hygiene should be performed when leaving the patient care area.
  • Ensure any reusable equipment is properly cleaned and disinfected before use with another patient.
  • If the patient needs to be admitted or referred to another facility, the receiving facility should be informed of the patient’s C. auris status.

The risk of C. auris infection for otherwise healthy household members, even those with extensive contact, is believed to be low. Household members should practice good hand hygiene (frequent hand washing with soap and water or use of alcohol-based hand rubs). If household members are providing extensive care to a patient with C. auris (such as changing the dressing on an infected wound), these persons could consider wearing disposable gloves while providing this level of care.