Infection Prevention and Control for Candida auris

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

The primary infection control measures for prevention of C. auris transmission in healthcare settings are:

Hand hygiene

Alcohol-based hand sanitizer

When caring for patients with C. auris, healthcare personnel should follow standard hand hygiene practices. Alcohol-based hand sanitizer (ABHS) is effective against C. auris and is the preferred method for cleaning hands when they are not visibly soiled. If hands are visibly soiled, wash with soap and water. Wearing gloves is not a substitute for hand hygiene.

Increase hand hygiene audits on units where patients with C. auris reside. Consider re-educating healthcare personnel on hand hygiene through an in-service or retraining, especially if audits demonstrate low adherence to recommended hand hygiene practices.

Transmission-based precautions & room placement

Recommended transmission-based precautions, by setting

Patients with C. auris in acute care hospitals and long-term acute care hospitals should be managed using contact precautions. Residents with C. auris in nursing homes, including skilled nursing facilities with ventilator units, should be managed using either contact precautions or enhanced barrier precautions, depending on the situation. Refer to the CDC Guidance on enhanced barrier precautions for more details about when contact precautions vs. enhanced barrier precautions would apply.

Implementation of transmission-based precautions for C. auris is similar to its use for other multidrug-resistant organisms (MDROs). In most instances, facilities that care for patients with other MDROs or Clostridioides difficile can also care for patients with C. auris. Facilities may contact their state or local health department if they need additional guidance on caring for patients with C. auris. 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—not on the presence or absence of colonization.

Contact precautions: Considerations for single rooms and roommate pairings

Patients or residents on contact precautions should be placed in a single room whenever possible. If a limited number of single rooms are available, they should be prioritized for people at higher risk of pathogen transmission (e.g., those with uncontained secretions or excretions, acute diarrhea). When single rooms are not available, people with the same MDROs may be housed together in the same room. However, since people are often colonized with different combinations of resistant pathogens, assigning rooms by MDROs may not be feasible. Room assignments for people on contact precautions might be considered based on a single pathogen (e.g., C. auris) without regard to co-colonizing organisms as a measure to control transmission during an acute outbreak.

Recommended practices to reduce transmission in shared rooms

In circumstances when patients or residents colonized with C. auris or other MDROs are placed in shared rooms, facilities must implement strategies to help minimize transmission between roommates. These strategies include:

  • Maintaining spatial separation of at least 3 feet between roommates.
  • Using privacy curtains to limit direct contact.
  • Cleaning and disinfecting any shared reusable equipment.
  • Cleaning and disinfecting environmental surfaces on a more frequent schedule.
  • Having healthcare personnel change personal protective equipment (if worn) and performing hand hygiene when moving between roommates.
Additional cohorting considerations

If multiple patients or residents with C. auris are present in the same facility, consider cohorting them together in one wing or unit (even if in single rooms) to decrease the direct movement of healthcare personnel and equipment from those colonized or infected with C. auris to those without. Facilities could also consider cohorting healthcare personnel who provide the most regular care to these patients or residents (e.g., nurses, nursing assistants) during a shift.

Duration of precautions

Patients and residents in healthcare facilities often remain colonized with C. auris for many months, perhaps indefinitely, even after acute infection (if present) has been treated and resolves.

CDC recommends continuing setting appropriate transmission-based precautions for the entire duration of the patient’s stay in the facility.

Reassessment of colonization

CDC does not recommend routine reassessments for C. auris colonization. Long-term follow-up of colonized patients in healthcare facilities, especially those patients who continue to require complex medical care, such as ventilator support, suggests that colonization persists for a long time and the results of repeat colonization swabs may alternate between C. auris being detected and not detected.  A considerable number of patients have had a positive C. auris specimen after multiple negative swabs.   Additional information is being collected to understand the duration of colonization and the role of colonization in spread of C. auris.

If a patient’s clinical status improves significantly (e.g., patient is weaned off a ventilator and is being transferred to a lower level of care), reassessment of colonization may be considered in consultation with the relevant state or local public health department. Reassessments should not be performed during the 3 months after the patient’s last test result positive for C. auris. Reassessments should involve testing of, at minimum, swabs of the axilla and groin and sites yielding C. auris on previous specimens (e.g., urine and sputum). The patient should not be receiving 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 1 week. Testing for C. auris colonization should also be performed at least 48 hours after administration of topical antiseptic (e.g., chlorhexidine), if such products are being used. When reassessment is considered appropriate, CDC recommends that C. auris–specific infection control precautions be discontinued only if a patient or resident has two negative colonization tests at least 1 week apart. However, because colonization may continue despite negative testing, ongoing use of transmission-based precautions may be warranted in specific situations. 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–not on the presence or absence of colonization.

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 general environmental surfaces farther away from the patient, such as windowsills. C. auris has also been identified on mobile equipment that is shared between patients, such as glucometers, temperature probes, blood pressure cuffs, ultrasound machines, nursing carts, and crash carts.

Perform thorough daily and terminal cleaning and disinfection of patients’ or residents’ rooms and other areas where they receive care (e.g., radiology, physical therapy) using an appropriate disinfectant. Shared equipment (e.g., ventilators, physical therapy equipment) should also be cleaned and disinfected before being used by another patient.

It is important to follow all manufacturers’ directions for use of surface disinfectants and applying the product for the correct contact time. Some products with C. albicans or fungicidal claims may not be effective against C. auris, and accumulating data indicate that products solely dependent on quaternary ammonia compounds (QACs) are NOT effective. [1, 2].

Products with EPA-registered claims for C. auris or Clostridioides difficile (List K)

CDC recommends use of an Environmental Protection Agency (EPA)–registered hospital-grade disinfectant effective against C. auris. It is important to follow all manufacturers’ directions for use of surface disinfectants, including applying the product for the correct contact time. Currently, products with C. auris claims include:

Products with EPA-registered claims for C. auris or Clostridioides difficile
Product Name EPA Regulatory Number
Clorox Healthcare Hydrogen Peroxide Cleaner Disinfectant1 pdf icon[PDF – 20 pages]external icon 67619-24
Clorox Healthcare Original Scent Hydrogen Peroxide Cleaner Disinfectant Wipes1 pdf icon[PDF – 19 pages]external icon 67619-25
Medline Micro-Kill Bleach Germicidal Bleach Wipes2 pdf icon[PDF – 37 pages]external icon 37549-1
Diversey Oxivir 1 Spray1 pdf icon[PDF – 20 pages]external icon 70627-74
Diversey Oxivir 1 Wipes1 pdf icon[PDF – 18 pages]external icon 70627-74
Diversey Oxivir Wipes1 pdf icon[PDF – 24 pages]external icon 70627-77
Diversey Avert Sporicidal Disinfectant Cleaner2 pdf icon[PDF – 17 pages]external icon 70627-72
Ecolab OxyCide Daily Disinfectant Cleaner3 pdf icon[PDF – 16 pages]external icon 1677-237
PDI Sani-Cloth Prime4 pdf icon[PDF – 22 pages]external icon 9480-12
PDI Sani-Prime Spray4 pdf icon[PDF – 18 pages]external icon 9480-10
Ecolab Virasept5 pdf icon[PDF – 18 pages]external icon 1677-226

1 Active ingredient: hydrogen peroxide
2 Active ingredient: sodium hypochlorite
3 Active ingredient: hydrogen peroxide, peroxyacetic acid
4 Active ingredient: quaternary ammonium compounds, ethanol, and isopropanol
5 Active ingredient: hydrogen peroxide, octanoic acid, and peroxyacetic acid

Because there are few products with C. auris claims at this time, CDC and EPA have identified additional products that are effective against C. auris. Although these products do not yet have formal EPA-registered claims for C. auris, testing at CDC has confirmed they are effective against C. auris pdf icon[PDF – 2 pages]. The label on the product will not include instructions for C. auris. Please follow the instructions provided for C. albicans, if included, or else follow those for fungicidal activity. These products include:

  • Oxivir TB Spray
  • Oxivir TB Wipes
  • PDI Super Sani-Cloth

If none of the above products are available, CDC recommends use of an EPA-registered hospital-grade disinfectant effective against Clostridioides difficile spores (List Kexternal icon).

Additional resources from the literature

Research about disinfection effective against C. auris is ongoing. Data on “no-touch” devices, such as germicidal UV irradiation and vaporized hydrogen peroxide, are limited, and the parameters required for effective disinfection are not yet well understood [1, 3-6].

Patient transfer between healthcare facilities

When transferring a patient or resident with C. auris colonization or infection to another healthcare facility, make sure to notify the receiving facility of patient’s C. auris infection or colonization status, including recommended infection control precautions. An example of an infection control transfer form to aid this communication can be found at the top of the Healthcare-associated Infections Prevention Toolkits web page.

Facilitating adherence to infection control measures

Ensuring that all healthcare personnel adhere to infection control recommendations is critical to preventing C. auris transmission. Consider taking the following steps to enhance adherence:

  • Educate all healthcare personnel, including healthcare personnel who work with environmental cleaning services, about C. auris and the need for appropriate precautions. Follow-up education may be needed to reinforce concepts and to account for healthcare personnel turnover and guidance updates.
  • Ensure adequate supplies are available to implement infection control measures.
  • Monitor adherence to infection control practices, and implement supervised cleaning of patient care areas.
  • “Flag” the patient’s record to alert healthcare personnel to institute recommended infection control measures in case of readmission.

Screening

Screening patients to identify C. auris colonization is essential for implementing appropriate infection prevention and control practices. Click here to learn more about screening and find screening-related resources.

Prospective surveillance

In facilities that have had new cases identified or have seen C. auris transmission, prospective laboratory surveillance can help identify other C. auris cases. For facilities or units where C. auris was detected, identify the species of all Candida isolates from any specimen source (normally sterile and nonsterile sites) for at least 1 month until there is no evidence of C. auris transmission.

Identify prior healthcare exposures for patients with newly identified infection or colonization

When a patient is newly found to be colonized or infected with C. auris, the state or local health department should follow the CDC Interim Guidance for a Public Health Response to Contain Novel or Targeted Multidrug-resistant Organisms (MDROs) to evaluate for transmission and prevent further spread of C. auris.

Health departments should consider reviewing the patient’s records to identify all healthcare exposures before and after C. auris was identified, particularly overnight stays in healthcare facilities in the month prior to the patient’s positive specimen, unless there is information to suggest when C. auris was acquired (e.g., an overnight stay in a healthcare facility outside the United States). Public health officials should consider investigating contacts and reviewing clinical microbiology records at these facilities to look for other cases. At a minimum, perform these investigations at:

  • Patient’s current facility
  • Facilities at which the patient stayed in the month before their positive specimen

Health departments should also conduct surveillance at facilities with longer length of stays (e.g., long-term acute care, nursing homes) where the patient stayed in the 3 months before C. auris detection, especially if the patient stayed longer than 7 days.

Considerations for specific settings

The following is interim guidance for patients with C. auris who require hemodialysis care. Further updates will be provided as additional information becomes available.

In addition to following standard precautions and infection control practices routinely recommended for the care of all hemodialysis patients, facilities and healthcare personnel at dialysis centers should do the following:

  • Inform and educate appropriate personnel about the presence of a patient with C. auris and the need for infection control measures outlined below.
  • Use alcohol-based hand sanitizer as the preferred method for cleaning hands when they are not visibly soiled. If hands are visibly soiled, wash with soap and water. Wearing gloves is not a substitute for hand hygiene.
  • Wear disposable gowns and gloves when caring for patients with C. auris or touching items 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.
  • 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.
  • Environmental contamination of surfaces and equipment is common with C. auris and can lead to transmission of the fungus. Thoroughly clean and disinfect the dialysis station (e.g., chairs, side tables, machines) between patients by using a disinfectant active against C. auris.
  • Ensure any reusable equipment brought to the dialysis station is properly cleaned and disinfected before use with another patient.
  • If the patient is transferred to another healthcare facility, inform the receiving facility of the patient’s C. auris status.

In addition to following standard precautions and infection control practices routinely recommended for care of all patients in outpatient settings, facilities and healthcare personnel should do the following:

  • Inform and educate appropriate personnel about the presence of a patient with C. auris and the need for infection control measures outlined below.
  • Use alcohol-based hand sanitizer as the preferred method for cleaning hands when they are not visibly soiled. If hands are visibly soiled, wash with soap and water. Wearing gloves is not a substitute for hand hygiene.
  • Use disposable gown and gloves 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.
  • Environmental contamination of surfaces and equipment is common with C. auris and can lead to transmission. Thoroughly clean and disinfect the areas in the facility the patient came into contact with (e.g., chairs, exam tables) by using a disinfectant active against C. auris.
  • Ensure any reusable equipment (e.g., blood pressure cuffs) used in the care of the patient is properly cleaned and disinfected before use with another patient.
  • If the patient needs to be admitted or referred to another facility, inform the receiving facility of the patient’s C. auris status.

In addition to following standard precautions and infection control practices routinely recommended in home healthcare settings, personnel should do the following:

  • Use alcohol-based hand sanitizer as the preferred method for cleaning hands when they are not visibly soiled. If hands are visibly soiled, wash with soap and water. Wearing gloves is not a substitute for hand hygiene.
  • Wear disposable gown and gloves when entering the area of house where providing patient care. 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 brought to the home is properly cleaned and disinfected with a disinfectant that is effective against C. auris before use with another patient.
  • If the patient needs to be admitted or referred to another facility, inform the receiving facility of the patient’s C. auris status.

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

Environmental disinfectant references
  1. Cadnum, J.L., et al., Relative resistance of the emerging fungal pathogen Candida auris and other Candida species to killing by ultraviolet light. Infect Control Hosp Epidemiol, 2018. 39(1): p. 94-96.
  2. Rutala, W.A., et al., Susceptibility of Candida auris and Candida albicans to 21 germicides used in healthcare facilities. Infect Control Hosp Epidemiol, 2019. 40(3): p. 380-382.
  3. Abdolrasouli, A., et al., In vitro efficacy of disinfectants utilised for skin decolonisation and environmental decontamination during a hospital outbreak with Candida auris. Mycoses, 2017. 60(11): p. 758-763.
  4. de Groot, T., et al., Killing of Candida auris by UV-C: Importance of exposure time and distance. Mycoses, 2019. 62(5): p. 408-412.
  5. Maslo, C., M. du Plooy, and J. Coetzee, The efficacy of pulsed-xenon ultraviolet light technology on Candida auris. BMC Infect Dis, 2019. 19(1): p. 540.
  6. Lemons, A., et al., Susceptibility of Candida auris to ultraviolet germicidal irradiation (UVGI) correlates with drug resistance to common antifungal agents. American Journal of Infection Control, 2019. 47(6): p. S18.