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Candida auris Interim Recommendations for Healthcare Facilities and Laboratories

Candida auris is an emerging pathogen, and understanding of this organism continues to evolve rapidly. This guidance is based on review of currently available information developed from investigations inside and outside the United States and on input from national and international experts. These recommendations will be updated as new information becomes available.

Reporting

Healthcare facilities that suspect they have a patient with C. auris infection should contact state or local public health authorities and CDC (candidaauris@cdc.gov).

Laboratory Diagnosis

When should C. auris infection be suspected?

C. auris can be misidentified as a number of different organisms when using traditional biochemical methods for yeast identification. C. auris should be suspected when an isolate is identified as Candida haemulonii, because C. auris is most commonly misidentified as this species, including by the BD Phoenix yeast identification system, as well as by some Vitek-2 and matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) systems. DNA sequencing and MALDI-TOF using certain databases can distinguish C. auris and other related species (e.g., C. duobushaemulonii and C. pseudohaemulonii) from C. haemulonii.

C. auris should also be suspected when an isolate is identified as follows:

  • Simply reported as Candida spp. after a validated method of Candida species identification was attempted, especially when an infection is not responding to antifungal therapy
  • As Rhodotorula glutinis by API 20C, and the characteristic red color of R. glutinis is not present
  • As Candida sake by API 20C
  • As Candida catenulata by BD Phoenix
  • As Candida catenulata, Candida famata, Candida guilliermondii, or Candida lusitaniae by MicroScan
  • Please note that Saccharomyces cerevisiae no longer appears to be a frequent misidentification for C. auris

An increase of unidentified Candida species infections in a patient care unit, including increases in isolation of Candida from urine specimens, should also prompt suspicion for C. auris, since C. auris can be transmitted in healthcare settings.

Identification of any of the species listed above should prompt further characterization using appropriate methodology (see below). Laboratories with capability to characterize these isolates further are encouraged to do so; CDC and some state public health laboratories can also assist with characterizations when local capacity does not exist. All confirmed and suspected C. auris isolates should be forwarded to CDC through state public health laboratories.

How can C. auris be identified?

Diagnostic devices based on MALDI-TOF can differentiate C. auris from other Candida species, but not all devices currently include C. auris in the reference database to allow for detection. Molecular methods based on sequencing the D1-D2 region of the 28s rDNA also can identify C. auris. As C. auris continues to gain recognition, updated versions of other yeast identification platforms may be able to identify C. auris; please consult the instrument manufacturer for more information. When in doubt, please forward suspected C.auris specimens to CDC through state public health laboratories for further characterization.

When should antifungal susceptibility testing for C. auris be performed and how should results be interpreted?

All C. auris isolates should undergo antifungal susceptibility testing. Because no C. auris-specific susceptibility breakpoints have been established, breakpoints are defined based on those established for closely related Candida species and on expert opinion. Correlation between microbiologic breakpoints and clinical outcomes is not known at this time. For this reason, the information below should be considered a general guide and not as definitive susceptibility breakpoints. Please note that a finding of an elevated minimum inhibitory concentration (MIC) for an antifungal drug should not necessarily preclude its use, especially if the use of other antifungal drugs for the patient has been ineffective.

Class/Drug Tentative MIC Breakpoints (µg/mL) Comment
Triazoles
Fluconazole ≥32 Modal minimum inhibitory concentration (MIC) to fluconazole among isolates tested at CDC was ≥256; isolates with MICs ≥32 were shown to have a resistance mutation in the Erg11 gene, making them unlikely to respond to fluconazole.
Voriconazole and other second generation triazoles N/A Consider using fluconazole susceptibility as a surrogate for second generation triazole susceptibility assessment. However, isolates that are resistant to fluconazole may respond to other triazoles occasionally. The decision to treat with another triazole will need to be made on case-by-case basis.
Polyenes
Amphotericin B >2 Isolates with MICs >2 for any Candida species are generally considered unlikely to be clinically susceptible to amphotericin B.
Echinocandins
Anidulafungin ≥ 4 Tentative breakpoints are based on the modal distribution of echinocandin MICs of approximately 100 isolates from diverse geographic locations.
Caspofungin ≥ 2
Micafungin ≥ 4

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Treatment

What are the suggested treatment regimens for invasive C. auris infections (e.g., bloodstream infections, intra-abdominal infections) in adults?

Based on the limited data available to date, an echinocandin drug at a dose listed below is recommended initial therapy for treatment of C. auris infections.

  • anidulafungin: loading dose 200 mg, then 100 mg daily
  • caspofungin: loading dose 70 mg, then 50 mg daily
  • micafungin: 100 mg daily

Although echinocandin-resistant C. auris isolates have been reported, most strains found in the United States have been susceptible to echinocandins. Because this organism appears to develop resistance quickly, patients on antifungal treatment should be carefully monitored with follow-up cultures. Both recurrent and persistent C. auris bloodstream infections have been documented.

Switching to a lipid formulation of amphotericin B (3–5 mg/kg daily) could be considered if the patient is clinically unresponsive to echinocandin treatment or has persistent fungemia >5 days.

All other considerations for management of C. auris are similar to other types of Candida infections. Please refer to the 2016 IDSA Clinical Practice Guideline for the Management of Candidiasis for details.

Consultation of an infectious disease specialist is highly recommended when caring for patients with C. auris infection.

Should C. auris isolated from in noninvasive sites (e.g., urine, external ear, wounds, and respiratory specimens) be treated?

CDC does not recommend treatment of C. auris cultured from noninvasive sites but not judged to be causing infection. Similar to recommendations for other Candida species, treatment is generally only indicated if clinical disease is present. There are currently no data on the efficacy of decolonization for patients with C. auris, such as the use of chlorhexidine or topical antifungals.

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Infection Control Measures

What infection control measures should be used for patients with C. auris infection and for patients colonized with C. auris?

In acute-care settings, such as acute-care hospitals, providers should place patients with C. auris infection or colonization in single rooms on Standard and Contact Precautions [PDF - 226 pages].

In general, residents in nursing homes who are colonized or infected with C. auris should be housed in single rooms when available and placed on Contact Precautions. Residents do not need to be restricted to their rooms, but they should perform hand hygiene before exiting their rooms. If residents colonized or infected with C. auris use shared equipment (e.g., physical therapy equipment, recreational resources), items that residents handle extensively should be cleaned and disinfected after use.

Highly 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 may 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.

When patients are transferred to other healthcare facilities, receiving facilities should receive notification of C. auris infection or colonization and the level of precautions recommended.

In addition, state or local health authorities and CDC should be consulted about the need for additional interventions to prevent transmission.

How long should infected or colonized patients remain on infection control precautions?

The optimal duration for use of infection control precautions in healthcare settings (acute-care hospitals, long-term acute-care hospitals, and nursing homes) is unclear since the typical duration of C. auris colonization is unknown. Periodic reassessments for presence of C. auris colonization (e.g., every 1–3 months) might be needed to inform duration of infection control measures. Assessments of colonization should involve testing of axilla and groin swabs for C. auris. Two or more assessments performed at least one week apart with negative results are needed before discontinuing infection control precautions is considered; the patient or resident should not be on antifungal medications active against C. auris at the time of these assessments. 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.

How should rooms of patients with C. auris be cleaned?

C. auris can persist on surfaces in healthcare environments. Healthcare facilities that have patients with C. auris infection or colonization should ensure thorough daily and terminal cleaning and disinfection of these patients’ rooms. CDC recommends use of an Environmental Protection Agency (EPA)-registered hospital-grade disinfectant effective against Clostridium difficile spores (List K). This is a change from the original recommended for use of a disinfectant with a fungal claim. CDC’s interim disinfection recommendation for C. auris will continue to be updated as new information becomes available.

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