Recommendations for Infection Control for Candida auris

Infection control recommendations for inpatient settings (acute care hospitals, long-term acute care hospitals, and nursing homes)

The mainstay of infection control measures for C. auris in inpatient settings is as follows:

• Placing the patient with C. auris in a single-patient room and using Standard and Contact Precautions.
• Emphasizing adherence to hand hygiene.
• Cleaning and disinfecting the patient care environment (daily and terminal cleaning) with recommended products.
• Screening contacts of newly identified case patients to identify C. auris colonization. Because patients colonized with C. auris can be a source of C. auris transmission, these patients should be managed using the same infection control measures as for patients with C. auris infection.

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.

Special Considerations for Nursing Home Residents

• 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.

Duration of Infection Control 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. Quaternary ammonia products that are routinely used for disinfection may not be effective against C. auris. Until further information is available for C. auris, CDC recommends use of an Environmental Protection Agency (EPA)-registered hospital-grade disinfectant effective against Clostridium difficile spores (List K). It is important to follow all manufacturers’ directions for use of the surface disinfectant, including applying the product for the correct contact time.

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.

Screening Close Contacts of Newly Identified Patients with C. auris Infection or Colonization for Presence of Colonization

Because patients with C. auris could have been colonized for months prior to detection of the organism, there is a potential that transmission of C. auris occurred to other patients around the case-patient while specific infection control measures were not in place. Therefore, it is important to identify the patient’s prior healthcare exposures and contacts.

Screening should be performed to identify colonization among potentially epidemiologically-linked patients; at a minimum this should include:

• Current roommates
• Roommates at the current or other facilities in the prior month. Roommates should be identified and screened even if they have been discharged from the facility.

More extensive screening to detect transmission, like point prevalence surveys to identify colonized patients on units or floors on which the index patient currently resides or resided in the past, should be strongly considered. Surveys could initially be limited to the highest risk contacts including those who overlapped on the ward or unit with the index patient for 3 or more days or who require higher levels of care (e.g., mechanical ventilation). Wider surveys are clearly indicated if there is evidence or suspicion of ongoing transmission (e.g., C. auris is detected from multiple patients among those screened).

A “ring” strategy for screening could be employed in which a smaller group of patients with the most extensive contact with the index patient are screened first; screening additional patients can be considered if transmission is documented in this higher risk group.

Screening for C. auris should be done using a composite swab of the patient’s axilla and groin. Patients have also been found to be colonized with C. auris in the nose, external ear canals, oropharynx, urine, wounds, and rectum. However, the axilla and groin appear to be the most common and consistent sites of colonization. Consult with local or state public health department and CDC for more information on assessing patients for colonization. Once a patient is identified as colonized with C. auris, the same infection control precautions are needed as for patients with C. auris infection.

While awaiting screening results, healthcare facilities may consider using contact precautions for high-risk contacts of C. auris patients (i.e., current roommates or roommates within the past month) or patients admitted following recent overnight stays in countries with known C. auris transmission.

CDC has developed a script to help inform patients about why screening is being conducted and a handout with frequently asked questions about screening that can be given to patients.

Additional guidance on screening is available in the Interim Guidance for a Health Response to Contain Novel or Targeted Multidrug-resistant Organisms [PDF – 10 pages].

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. 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 index patient stayed for more than 7 days in the prior 3 months.
• Facilities with longer length of stays (e.g., long-term acute care, nursing homes).

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

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.

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 precautions.
• 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.

Infection control recommendations for dialysis clinics and infusion centers

Some patients with C. auris have required dialysis care. Recommendations for dialysis clinics 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 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 [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 Clostridium difficile spores (List K).
• 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.

Infections control recommendations for outpatient settings (e.g., primary care office, wound clinic, etc.)

Recommendations for outpatient 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 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 Clostridium difficile spores (List K) 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.

Infection control recommendations for home healthcare settings

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.

Infections control recommendations for home and family members

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.

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