Notice: Candida auris interim recommendations for infection prevention and control
Emerging global healthcare-associated fungal pathogen Candida auris (C. auris)
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Candida auris (C. auris) is a fungus that can cause healthcare-associated invasive infections and outbreaks. C. auris is often resistant to multiple antifungal drugs and can be challenging to identify in the laboratory. Mortality rates of invasive C. auris infections are estimated to be greater than 40%, which is similar to other drug-resistant organisms.Footnote 1 The Public Health Agency of Canada (PHAC) has noted the spread of C. auris in hospital and long-term care (LTC) settings across the globe, including Canada. Recently, multiple healthcare-associated C. auris outbreaks and the identification of pan-resistant C. auris isolates internationally have increased concerns about the impacts of C. auris in healthcare settings.
Data from the National Microbiology Laboratory (NML) and Canadian Nosocomial Infection Surveillance Program (CNISP) indicate that 31 cases of C. auris have been isolated from hospitalized patients in 6 Canadian provinces between 2012 and 2021. This includes both infected and colonized cases. The peer-reviewed literature describes the first series of C. auris cases and a small hospital outbreak reported in Canada.Footnote 2Footnote 3Footnote 4 Given a lack of data, the status of C. auris in LTC homes is currently unknown.
The propensity of C. auris to spread can have serious implications for the Canadian healthcare system. Invasive C. auris infections can lead to severe morbidity and mortality, especially among hospitalized patients who are immunocompromised or receiving intensive care.Footnote 5Footnote 6
C. auris can:
- become resistant to all available antifungal drugsFootnote 7Footnote 8
- be transmitted among patients in hospitals and LTC homes
- persist on surfaces and multi-use equipment for extended periods of timeFootnote 9Footnote 10Footnote 11
- extensively contaminate healthcare environments occupied by C. auris positive patientsFootnote 12Footnote 13Footnote 14Footnote 15Footnote 16 and
- be resistant to quaternary ammonium-based hospital disinfectantsFootnote 17Footnote 18
Laboratory challenges in C. auris identification and misidentification using phenotypic and biochemical methods are well documented. However, the situation has improved due to advancements in laboratory technologies (such as updates to MALDI-TOF databases)Footnote 5Footnote 19. Early identification, adherence to infection prevention and control practices, and strict and effective environmental cleaning and disinfection can prevent C. auris spread in healthcare settings.
The following interim guidance is based on the best available evidence, and is an update to the 2017 PHAC C. auris interim recommendations. This guidance will be updated as new information becomes available.
For the purposes of this guidance, the term “patient" will be used to include those receiving healthcare who are traditionally and routinely referred to as patients, clients or residents.
Interim recommendations for C. auris infection prevention and control in hospitals and long-term care homes:
- Routine Practices, including adherence to hand hygiene, are required for the care of all patients at all times.
- Patients being admitted to hospital and LTC homes should be placed on pre-emptive Contact Precautions and screened for C. auris if they have been admitted to a hospital or LTC home outside of Canada (including in the US) within the prior 12 months or transferred from a Canadian healthcare facility with an ongoing C. auris outbreak (if known).
- C. auris screening should include a single bilateral swab of a patient’s axilla and groin. In addition, single swabs of previously colonized or clinically relevant sites may also be indicated (for example: wounds, exit sites of devices, external ear canal).
- Patients suspected or confirmed to be positive for C. auris should be cared for in a private room with a dedicated washroom on Contact Precautions with gowns and gloves. When a dedicated washroom is not available, a dedicated commode may be used.
- When a previously unknown C. auris colonization or infection is identified in a patient not already on Contact Precautions
- All close patient contacts prior to the identification (such as past and present roommates, bathroom mates, or patients who occupied the room immediately before the case patient) should be placed in a private room on pre-emptive Contact Precautions and have specimens collected to test for C. auris. Screened close patient contacts should remain on Contact Precautions until cleared by infection prevention and control.
- Ward or unit mates who are not close contacts should be tested (i.e. point prevalence testing). Consider Contact Precautions until point prevalence results are available. Private rooms are not required for unit or ward mates who are not close contacts while awaiting the results on point prevalence testing.
- When a single case is identified, facilities are encouraged to request species-level identification on all isolates that would normally be reported as Candida for a limited period (for example, 4 to 8 weeks), when a new C. auris infection or colonization is identified in a patient.
- For patients identified as colonized or infected with C. auris, private room accommodation and Contact Precautions should be in place for the duration of the hospital admission as well as any subsequent or future hospital admissions. There are no proven clinical or microbiological criteria that can be used to reliably predict when the colonization/infection has cleared. The duration of Contact Precautions for residents or clients with C. auris in LTC home settings or other healthcare facilities should be determined in conjunction with local and regional epidemiology, facility administration and infection prevention and control professionals.
- Single use and disposable patient care supplies should be used for a patient with C. auris whenever possible. Reusable, non-critical patient care equipment and supplies should be identified and stored in the patient’s room, dedicated to the patient for the duration of their admission and appropriately cleaned and disinfected prior to use on another patient.
- Environmental cleaning and disinfection of a room of a patient with C. auris should be done using Health Canada approved hospital or healthcare disinfectants with claims of efficacy against C. auris (with drug identification numbers (DIN)). Quaternary ammonium compounds should not be used due to reduced activity against C. auris. Manufacturer instructions for use, wet contact time and surface and equipment type should be followed. All horizontal and frequently touched surfaces should be cleaned at a minimum of once daily and when visibly soiled.
- Terminal cleaning of the patient equipment and environment, including the removal and cleaning of hospital linens and privacy curtains, should be done upon patient discharge or transfer. All single use and disposable patient care supplies stored in the patient room should be discarded during terminal clean.
- Transfer of patients colonized or infected with C. auris within or between facilities should be avoided unless medically necessary and for transitions of care (such as acute care to LTC). The receiving unit, department or facility must be notified in advance. All healthcare facilities should be able to manage patients with C. auris and C. auris colonization/infection should not be a reason to refuse the transfer.
- Any transmission of C. auris among patients within a healthcare facility should be considered an outbreak requiring additional infection prevention and control measures. C. auris outbreak response measures should be implemented in consultation with local public health, facility administration, and infection prevention and control professionals.
For more information on general infection prevention and control measures:
- Routine Practices and Additional Precautions for Preventing Transmission of Infection in Healthcare Settings
- Hand Hygiene Practices in Healthcare Settings
As C. auris infections are an emerging issue in Canada, it’s important to:
- collaborate with public health authorities, provincial, territorial and local health laboratories, and
- educate healthcare professionals of the importance of monitoring and preventing the transmission of C. auris
- Footnote 1
Chen J, Tian S, Han X, Chu Y, Wang Q, Zhou B, et al. Is the superbug fungus really so scary? A systematic review and meta-analysis of global epidemiology and mortality of Candida auris. BMC Infectious Diseases. 2020;20(1):827.
- Footnote 2
Eckbo EJ, Wong T, Bharat A, Cameron-Lane M, Hoang L, Dawar M, et al. First reported outbreak of the emerging pathogen Candida auris in Canada. American Journal of Infection Control. 2021.
- Footnote 3
Osbourne Townsend J, Morillo A, Braithwaite LK, Boodoosingh S, Neil A, Widla J, et al. Identification of Candida auris in a foreign repatriated patient to Ontario, Canada and infection control strategies to prevent transmission. Canadian Journal of Infection Control. 2021;36(4).
- Footnote 4
De Luca DG, Alexander DC, Dingle TC, Dufresne PJ, Hoang LM, Kus JV, et al. Four genomic clades of Candida auris identified in Canada, 2012–2019. Medical Mycology. 2022;60(1).
- Footnote 5
Osei Sekyere J. Candida auris: A systematic review and meta-analysis of current updates on an emerging multidrug-resistant pathogen. MicrobiologyOpen. 2018;7(4).
- Footnote 6
Vinayagamoorthy K, Pentapati KC, Prakash HA-OX. Prevalence, risk factors, treatment and outcome of multidrug resistance Candida auris infections in Coronavirus disease (COVID-19) patients: A systematic review. Mycoses. 2022;65(6):613-24.
- Footnote 7
Carolus H, Pierson S, Muñoz JF, Subotić A, Cruz RB, Cuomo CA, et al. Genome-wide analysis of experimentally evolved Candida auris reveals multiple novel mechanisms of multidrug resistance. Mbio. 2021;12(2):e03333-20.
- Footnote 8
Burrack LS, Todd RT, Soisangwan N, Wiederhold NP, Selmecki A. Genomic Diversity across Candida auris Clinical Isolates Shapes Rapid Development of Antifungal Resistance In Vitro and In Vivo. mBio. 2022;13(4):e00842-22.
- Footnote 9
Welsh RM, Bentz ML, Shams A, Houston H, Lyons A, Rose LJ, et al. Survival, persistence, and isolation of the emerging multidrug-resistant pathogenic yeast Candida auris on a plastic health care surface. Journal of clinical microbiology. 2017;55(10):2996.
- Footnote 10
Biswal M, Rudramurthy SM, Jain N, Shamanth AS, Sharma D, Jain K, et al. Controlling a possible outbreak of Candida auris infection: lessons learnt from multiple interventions. Journal of Hospital Infection. 2017;97(4):363.
- Footnote 11
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. Mycoses. 2017;60(11):758.
- Footnote 12
Adams E, Quinn M, Tsay S, Poirot E, Chaturvedi S, Southwick K, et al. Candida auris in healthcare facilities, New York, USA, 2013–2017. Emerging Infectious Diseases. 2018;24(10):1816.
- Footnote 13
Kumar J, Eilertson B, Cadnum JL, Whitlow CS, Jencson AL, Safdar N, et al. Environmental Contamination with Candida Species in Multiple Hospitals Including a Tertiary Care Hospital with a Candida auris Outbreak. Pathogens & immunity. 2019;4(2):260-70.
- Footnote 14
Ruiz-Gaitan A, Martinez H, Moret AM, Calabuig E, Tasias M, Alastruey-Izquierdo A, et al. Detection and treatment of Candida auris in an outbreak situation: risk factors for developing colonization and candidemia by this new species in critically ill patients. Expert review of anti-infective therapy. 2019;17(4):295-305.
- Footnote 15
Eyre DW, Sheppard AE, Madder H, Moir I, Moroney R, Quan TP, et al. A candida auris outbreak and its control in an intensive care setting. NEnglJMed. 2018;379(14):1322.
- Footnote 16
Patterson CA, Wyncoll D, Patel A, Ceesay Y, Newsholme W, Chand M, et al. Cloth Lanyards as a Source of Intermittent Transmission of Candida auris on an ICU. Critical Care Medicine. 2021;49(4).
- Footnote 17
Cadnum JL, Shaikh AA, Piedrahita CT, Sankar T, Jencson AL, Larkin EL, et al. Effectiveness of disinfectants against candida auris and other candida species. Infection Control and Hospital Epidemiology. 2017;38(10):1240.
- Footnote 18
Heaney H, Laing J, Paterson L, Walker AW, Gow NAR, Johnson EM, et al. The environmental stress sensitivities of pathogenic Candida species, including Candida auris, and implications for their spread in the hospital setting. Medical Mycology. 2020.
- Footnote 19
Keighley C, Garnham K, Harch SAJ, Robertson M, Chaw K, Teng JC, et al. Candida auris: Diagnostic Challenges and Emerging Opportunities for the Clinical Microbiology Laboratory. Current fungal infection reports. 2021:1-11.
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