Infection Prevention and Control for Candida auris
The primary infection control measures for prevention of C. auris transmission in healthcare settings are:
- Adherence to hand hygiene.
- Appropriate use of Transmission-Based Precautions based on setting.
- Cleaning and disinfecting the patient care environment (daily and terminal cleaning) and reusable equipment with recommended products, including focus on shared mobile equipment (e.g., glucometers, blood pressure cuffs).
- Communication about patient’s C. auris status when patient is transferred.
- Screening contacts of newly identified case patients to identify C. auris colonization.
- Laboratory surveillance of clinical specimens to detect additional cases.
On this page, the term “patient” refers to both patients of healthcare facilities and residents of nursing homes.
In addition to these key points, setting-specific considerations are listed below:
When caring for patients with C. auris, healthcare personnel should follow standard hand hygiene practices. Alcohol-based hand sanitizer (ABHS) is the preferred hand hygiene method for C. auris when hands are not visibly soiled. If hands are visibly soiled, wash with soap and water. Wearing gloves is not a substitute for hand hygiene.
Recommended Transmission Based Precautions, by setting
Healthcare providers should use Contact Precautions to manage patients with C. auris in acute care hospitals and long-term acute care hospitals. Manage residents with C. auris in nursing homes, including skilled nursing facilities, using either Contact Precautions or Enhanced Barrier Precautions, depending on the situation and local or state jurisdiction recommendations. Refer to the CDC Guidance on Enhanced Barrier Precautions for more details about when Contact Precautions versus Enhanced Barrier Precautions would apply.
The Transmission-Based Precautions and Enhanced Barrier Precautions for C. auris is similar to their 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 infection or colonization.
Patient placement: Considerations for private rooms and cohorting of patients in shared rooms
Patients on Contact Precautions should be placed in a single-patient room whenever possible. If a limited number of single-patient 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, draining wounds).
In nursing homes, although single-patient rooms are not required for residents with C. auris, facilities with the capacity to offer single-patient rooms for these individuals may choose to do so. Healthcare providers can find recommendations about patient placement in nursing homes using Enhanced Barrier Precautions in CDC’s FAQs about Enhanced Barrier Precautions in Nursing Homes.
When single rooms are not available, facilities may choose to cohort patients with C. auris together in the same room. While it is preferable to cohort patients with the same MDROs together, facilities may assign rooms based on single (or a limited number of) high-concern MDROs (e.g., C. auris or carbapenemase-producing Enterobacterales) without regard to co-colonizing organisms.
Facilities also can place patients with C. auris together in a dedicated unit or part of a unit to decrease movement of healthcare personnel and equipment from those colonized or infected with C. auris to those who are not. Facilities could also consider dedicating healthcare personnel (e.g., nurses, nursing assistants) who provide regular care to these patients during a shift.
Please see Considerations for specific settings for additional considerations about patient placement.
Recommended practices to reduce transmission in all shared rooms
When patients are placed in shared rooms, facilities must implement strategies to help minimize transmission between roommates. These strategies apply for all shared rooms, regardless of patient colonization or infection status:
- Maintain separation of at least 3 feet between beds.
- Use privacy curtains to limit direct contact.
- Clean and disinfect as if each bed area were a different room. For example:
- Clean and disinfect any shared or reusable equipment.
- Change mopheads, cleaning cloths, and other cleaning equipment between bed areas.
- Clean and disinfect environmental surfaces on a more frequent schedule.
- Have healthcare personnel change personal protective equipment (if worn), including gloves, and perform hand hygiene before and after interaction with each roommate.
Additional considerations for placement of patients with C. auris colonization or infection
Before making decisions to cohort patients according to C. auris or other high-concern MDROs by room or place them together in a dedicated unit or area within a facility, facilities should consider the following to ensure that these practices are implemented without increasing the risk of pathogen spread:
Benefits: Placing patients with C. auris or other high-concern MDROs in the same room, or in a dedicated unit, wing, or area (even if in single-patient rooms), and/or dedicating staff to their care can decrease movement of healthcare personnel and equipment from those colonized or infected with C. auris to those who are not. This strategy may be best used for initial room assignments in facilities performing admission screening for select MDROs or for a single MDRO in facilities with an acute outbreak.
Drawbacks: Increasing patient movement to place patients in the same room, unit, or area based on MDROs might, in some circumstances, increase C. auris transmission—for example, if there are gaps in environmental cleaning. Facilities choosing to implement this strategy should do so in a way that reduces overall exposures throughout the facility (e.g., avoiding frequent room changes that lead to environmental contamination in more areas and more healthcare contacts that could be exposed).
Duration of precautions
Patients in healthcare facilities often remain colonized with C. auris for many months, perhaps indefinitely, even after an acute infection (if present) has been treated and resolves.
CDC recommends continuing Contact Precautions or Enhanced Barrier Precautions, depending on the healthcare setting, for the entire duration of all inpatient healthcare stays, including those in long-term healthcare facilities.
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 colonization persists for a prolonged period of time. Repeat colonization swabs may alternate between detecting and not detecting C. auris. Surveillance has identified patients that remained colonized for longer than 2 years. It is likely that colonization may even persist longer as we learn more about colonized patients. A considerable number of patients have had a positive C. auris specimen after multiple negative swabs. In a publication by Pacilli et al. (Clin Infect Dis 2020), among patients who had a positive C. auris screening result followed by one or more negative screening results, more than 50% had a subsequent positive screening result. Additional information is being collected to understand the duration of colonization and the role of colonization in spread of C. auris.
The decision to discharge a 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 infection or colonization.
Reducing or eliminating C. auris colonization (decolonization)
At this time, no specific intervention is known to reduce or eliminate C. auris colonization. Laboratory evidence suggests that high levels of chlorhexidine are active against C. auris. However, the effects of chlorhexidine on reducing C. auris skin burden or infection have not been systematically assessed. C. auris outbreaks and transmission have been observed in facilities routinely using chlorhexidine bathing.
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 surfaces farther away from the patient, such as windowsills. C. auris has also been identified on mobile or reusable equipment that is shared between patients, such as glucometers, temperature probes, blood pressure cuffs, ultrasound machines, nursing carts, and crash carts.
Perform thorough routine (at least daily) and terminal cleaning and disinfection of patients’ rooms and other areas where patients receive care (e.g., radiology, physical therapy) using an appropriate disinfectant. Clean and disinfect shared or reusable equipment (e.g., ventilators, physical therapy equipment) after each use. Label cleaned and disinfected equipment as such and store it away from dirty equipment.
All healthcare personnel providing patient care should be trained on which mobile and reusable equipment they are responsible for cleaning and how to clean the equipment properly. Numerous CDC and health department investigations have found that healthcare personnel are often unclear on who is responsible for cleaning mobile or reusable equipment and how it should be cleaned. Because equipment moves from room to room, often several times per day in the case of vital signs monitors and glucometers, mobile or reusable equipment is likely an important source of C. auris spread.
Follow all manufacturer’s directions for use of surface disinfectants, and apply 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.
CDC recommends using an Environmental Protection Agency (EPA)–registered hospital-grade disinfectant effective against C. auris. See EPA’s List P for a current list of EPA-approved products for C. auris. If the products on List P are not accessible or otherwise suitable, facilities may use an EPA-registered hospital-grade disinfectant effective against C. difficile spores (List K) for the disinfection of C. auris. Regardless of the product selected, it is important to follow all manufacturer’s directions for use, including applying the product for the correct contact time.
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. If these methods are used, they should be used only as a supplement to standard cleaning and disinfection methods.
Disinfection and reprocessing of medical devices
The U.S. Food and Drug Administration (FDA) regulates products used for the reprocessing of medical devices based on device classification, and EPA’s List P should not be referenced for this purpose. When selecting a product for the reprocessing of medical devices, please refer to the current list of FDA-cleared liquid chemical sterilant for critical devices and high-level disinfectants for semi-critical devices. Products should be used according to the FDA-cleared label claim and device manufacturer’s instructions.
Environmental sampling is generally not recommended to assess cleaning and disinfection processes and cannot be used to confirm absence of C. auris. In some limited scenarios, environmental sampling may be useful to support outbreak investigations, special studies, or environmental surveillance, especially when epidemiologic evidence implicates an environmental reservoir in ongoing transmission. Consultation with public health is recommended for facilities considering environmental sampling.
Environmental sampling is not recommended for routine assessment of cleaning and disinfection practices. For facilities that want to evaluate environmental cleaning practices, many tools are available (see Facilitating adherence to infection control measures) to assess practices and provide feedback.
When transferring a patient with C. auris colonization or infection to another healthcare facility or to another unit within a facility, notify the receiving facility or unit of the patient’s C. auris infection or colonization status, including recommended Transmission-Based 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.
Ensuring that all healthcare personnel adhere to infection control recommendations is critical to preventing transmission of C. auris, as well as other MDROs and communicable diseases. Consider taking the following steps to enhance adherence:
- Educate all healthcare personnel about C. auris and the need for appropriate precautions. Given the potential for environmental spread of this fungus, include personnel involved in environmental services, activity programs, and dietary services, as well as other healthcare personnel without routine direct patient contact. Follow-up education may be needed to reinforce concepts and to account for healthcare personnel changes and guidance updates.
- Ensure that adequate supplies (i.e., alcohol-based hand sanitizer, gowns and gloves, and cleaning and disinfection agents) are available to implement and maintain appropriate infection control measures.
- Monitor for adherence to appropriate infection control practices by performing audits and providing feedback on hand hygiene practices, donning and doffing of gowns and gloves, and environmental cleaning and disinfection. Consider increasing the number of audits performed on units with C. auris cases.
- Ensure that an appropriate sign is present on the patient’s door to alert healthcare personnel and visitors of recommended precautions.
- Flag the patient’s record to alert healthcare personnel to institute recommended infection control measures in case of readmission.
Screening patients to identify C. auris colonization is another important component for preventing spread of C. auris. Infection control measures described above also apply to patients found to be colonized through screening. Learn more about screening and find screening-related resources.
The principles of C. auris infection control are similar across settings. The following sections provide guidance specific to each setting.
The following is interim guidance for patients with C. auris who require dialysis 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 specific infection control measures.
- As in other settings, 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 gowns and gloves using proper donning and doffing techniques when caring for patients with C. auris or touching items at the dialysis station. Remove gowns and gloves, dispose of them carefully, and perform hand hygiene when leaving the patient’s station.
- Minimize exposure to other patients by dialyzing 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. Thoroughly clean and disinfect the dialysis station (e.g., chairs, side tables, machines) between patients by using products approved for use against C. auris (see above for more information about these disinfectant products and List P).
- Properly clean and disinfect reusable equipment brought to the dialysis station after each use.
- If the patient is transferred to another healthcare facility, inform the receiving facility of the patient’s C. auris status. Communication tools can be found in Healthcare-Associated Infections Prevention Toolkits.
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 healthcare 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. As always, perform hand hygiene when entering and leaving the patient’s room.
- Wear gown and gloves using proper donning and doffing techniques if extensive patient contact is anticipated or contact with infected areas is planned (e.g., debridement or dressing of colonized or infected wound). Remove gowns and gloves, dispose of them carefully, and perform hand hygiene when leaving the patient’s room.
- Thoroughly clean and disinfect the areas in the facility the patient came into contact with (e.g., chairs, exam tables) by using products with EPA-registered claims for C. auris (List P).
- Properly clean and disinfect reusable equipment (e.g., blood pressure cuffs) used in the care of the patient after each use.
- 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:
- If possible, schedule patients with C. auris as the last visit of the day.
- 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. As always, perform hand hygiene when entering and leaving the patient care area.
- Wear gown and gloves using proper donning and doffing techniques when entering the area of the house where providing patient care. Remove gowns and gloves and dispose of them carefully when leaving the area.
- Properly clean any reusable equipment (e.g., blood pressure cuffs) brought to the home after each use.
- 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. Nearly all cases of C. auris colonization detected to date have been associated with admission to a healthcare facility. Household members should practice good hand hygiene (i.e., use of alcohol-based hand sanitizers or frequent handwashing with soap and water). Household members could consider wearing disposable gloves while providing high-touch care to a person with C. auris, such as changing the dressing on an infected wound, and perform hand hygiene after glove removal.
Although the risk of C. auris colonization among healthy household members is thought to be very low, household members who require admission to a healthcare facility can inform healthcare providers that they live with someone colonized with C. auris so that colonization testing can be considered.
- Candum JL, Shaik AA, Piedrahita CT, Jencson AL, Larkin EL, Ghannoum MA, 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 Jan.
- Rutala WA, Kanamori J, Gergen MF, Sickbert-Bennett EE, Weber DJ. Susceptibility of Candida auris and Candida albicans to 21 germicides used in healthcare facilities. Infect Control Hosp Epidemiol. 2019 Mar.
- Abdolrasouli A, Armstrong-James D, Ryan L, Schelenz S. In vitro efficacy of disinfectants utilised for skin decolonisation and environmental decontamination during a hospital outbreak with Candida auris. 2017 Nov.
- de Groot T, Chowdhary A, Meis JF, Voss A. Killing of Candida auris by UV-C: Importance of exposure time and distance. 2019 May.
- Maslo C, du Plooy M, Coetzee J. The efficacy of pulsed-xenon ultraviolet light technology on Candida auris. BMC Infect Dis. 2019.
- Lemons A, McClelland T, Martin Jr. SB, Lindsley WG, Green BJ. Susceptibility of Candida auris to ultraviolet germicidal irradiation (UVGI) correlates with drug resistance to common antifungal agents. Am J Infect Control. 2019 Jun.
- Sexton D, Welsh R, Bentz M, Forsberg K, Jackson B, Berkow E, et al. (2020). Evaluation of nine surface disinfectants against Candida auris using a quantitative disk carrier method: EPA SOP-MB-35 Infect Con & Hosp Epi. 2020 June.