CDC Warns Health Care Facilities of Rapid Increase in Candida auris Infections

The Centers for Disease Control and Prevention (CDC) is concerned about Candida auris (C. auris) for three main reasons. It is often multidrug-resistant, is difficult to identify with standard laboratory methods, and can be misidentified in labs without specific technology. It has increasingly been the cause of outbreaks in health care settings. For these reasons, it is important for health care facilities to quickly identify C. auris so that they can take special precautions to stop its spread.

Health care facilities in several countries have reported that C. auris has been causing severe illness. In some, this yeast can enter the bloodstream and spread throughout the body, causing serious invasive infections. Unlike Candida infections in the mouth and throat (also called “thrush”) or vaginal “yeast infections,” invasive candidiasis is a serious infection that can affect the blood, heart, brain, eyes, bones, and other parts of the body.

This yeast often does not respond to commonly used antifungal drugs, making infections difficult to treat. Those who seem at highest risk for invasive C. auris infections are those who have been hospitalized in a health care facility for an extended period of time, those who have received antibiotics or antifungal medications, and those with indwelling medical devices such as catheters, g-tubes, and intravenous lines.

Surveillance and Screening for C. auris

Some may be asymptomatically colonized with C. auris on skin, nares, oropharynx, rectum, and other body sites. Those colonized with C. auris can transmit C. auris to other patients within health care facilities and may be at risk for invasive C. auris infections. Screening patients for C. auris colonization allows facilities to identify those with C. auris colonization and implement infection prevention and control measures. Screening for C. auris colonization is an important component of surveillance. Information on whom to screen and how to screen for C. auris colonization can be found here.

Reporting

Health care facilities or laboratories that suspect they have a patient with C. auris infection should contact state or local public health authorities and the CDC immediately for guidance.

Treatment and Management of C. auris Infections and Colonization

Consultation with an infectious disease specialist is highly recommended when caring for patients with C. auris infection. Even after treatment for invasive infections, patients generally remain colonized with C. auris for long periods, and perhaps indefinitely. Therefore, all recommended infection control measures should be followed during and after treatment for C. auris infection.

Infection Prevention and Control for C. auris

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

Adherence to hand hygiene. 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.
Appropriate use of Transmission-Based Precautions (TBP). Manage residents with C. auris in nursing homes, including skilled nursing facilities (SNFs), using either Contact Precautions or Enhanced Barrier Precautions (EBP), depending on the situation and local or state jurisdiction recommendations. Refer to the CDC guidance on EBP for more details about when Contact Precautions versus EBP would apply.
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 cases to identify C. auris colonization.

TBP and Room Placement

Contact Precautions should be used and those with C. auris 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. 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 multidrug-resistant organisms (MDROs) together, facilities may assign rooms based on single (or a limited number of) high-concern MDROs 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 health care personnel (HCP) and equipment from those colonized or infected with C. auris to those who are not. Facilities could also consider dedicating HCP (e.g., nurses, nursing assistants) who provide regular care to these patients during a shift.

Recommended Practices to Reduce Transmission in All Shared Rooms

Maintain separation of at least three 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 HCP change personal protective equipment (if worn), including gloves, and perform hand hygiene before and after interaction with each roommate.

Duration of Precautions

Patients in health care facilities often remain colonized with C. auris for many months, perhaps indefinitely, even after an acute infection (if present) has been treated and resolved. The CDC recommends continuing Contact Precautions or EBP, depending on the health care setting, for the entire duration of all inpatient health care stays, including those in long term care facilities.

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.

Products with EPA-Registered Claims for C. auris

The CDC recommends using an Environmental Protection Agency (EPA)-registered hospital-grade disinfectant effective against C. auris. The EPA’s current approved list can be found here. 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 found here. Regardless of the product selected, it is important to follow all manufacturers' directions for use, including applying the product for the correct contact time.

Facilitating Adherence to Infection Control Measures

Educate all HCP 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 HCP without routine direct patient contact. Follow-up education may be needed to reinforce concepts and to account for HCP changes and guidance updates.
Ensure that adequate supplies (e.g., ABHS, gowns and gloves, cleaning and disinfection agents) are available to implement and maintain appropriate infection control measures.
Monitor 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 HCP and visitors of recommended precautions.
Flag the patient’s record to alert HCP to institute recommended infection control measures in case of readmission.

Additional resources are available below:

Tips for Infection Preventionists can be found here.
CDC fact sheets on C. auris can be found here and here.
LeadingAge National's Infection Control Toolkit with EBP policies and procedures can be found here.

Contact: Carrie Mosley, cmosley@leadingageny.org, 518-867-8383 ext. 147