C. auris: What nurses need to know

Submitted by ADonahue on
Strain of C. auris

What is Candida auris?

Candida auris (C. auris) is a type of yeast that is often resistant to antifungal medications and can spread among patients in health care facilities. C. auris was first identified in 2009 and has since emerged as a global health threat, due to its high rates of resistance to anti-fungal drugs and its ability to persist on skin and surfaces and cause a wide range of invasive infections.

C. auris can infect the bloodstream, urinary tract, skin, lower respiratory tract, and more. Approximately one third of patients with an invasive C. auris infection die from the disease. There are several risk factors associated with C. auris infections, including long hospital stays, long-term overuse of antimicrobials, weakened immune systems, and medical conditions that require invasive medical devices like breathing tubes, feeding tubes, or catheters.

What are the symptoms of C. auris infection?

Symptoms associated with C. auris infection depend on the location of the infection in the body (e.g., bloodstream, wound, ears). While symptoms can vary greatly from patient to patient, some symptoms include:

  • Fever and chills
  • Lethargy
  • Low blood pressure
  • High heart rate
  • Low body temperature
  • Ear infections described as pain, pressure, or feeling of fullness in your ear

Patients experiencing C. auris infections are typically not healthy and are already experiencing other health conditions.

Asymptomatic transmission can occur from individuals colonized with C. auris, which is when an individual has the fungus present on their skin but does not experience symptoms. Colonization can remain for years following exposure to C. auris and may last for the rest of a person’s life.

How is C. auris transmitted? 

C. auris is transmitted through contact with contaminated people, surfaces, or objects. C. auris is shed from the skin of infected patients into the environment where it can then spread to other patients and staff. C. auris has been found on hospital room furniture, medical equipment, floors, door handles, windows, sinks, personal items, the hands and clothing of health care personnel, and more. C. auris can survive on a variety of surfaces for several weeks. Research has shown that C. auris can survive on and be cultured from both moist and dry surfaces for over 14 days and from contaminated bedding for up to 7 days. 

Air dispersal of C. auris may also play a role in transmission, though the exact role is still under investigation. Environmental sampling of the area surrounding colonized patients during a 2016 outbreak demonstrated contamination of C. auris in one air sample. Furthermore, a recent 2023 study isolated C. auris samples from two ceiling air vents almost 8 feet high and two passive air samples. A hallway air vent over 32 feet from the C. auris isolation zone was also found to be positive. C. auris may become airborne during aerosol-generating high turbulence activities, such as bed making, which can result in contamination — and the potential for transmission — at longer distances than typically expected for a contact-transmitted pathogen.

What infection prevention and control measures are important to protect nurses and prevent C. auris spread in health care facilities?

Health care employers are responsible for providing a safe work and patient care environment. Multilayered infection prevention measures, as listed below, should be implemented in all health care facilities experiencing C. auris cases.

Identification and screening:

  • Early detection of C. auris cases through active screening of exposed and potentially exposed patients is essential for the timely implementation of infection control measures and reduction of further nosocomial transmission both under normal circumstances and during an outbreak. In addition to screening the contacts of positive cases, it is recommended to screen patients admitted to high-risk units, like the intensive care unit (ICU) or those with ongoing C. auris cases, patients coming from high-risk locations, and patients who have previously been colonized.
  • Environmental sampling is recommended to identify the location of C. auris contamination in the facility, especially when an outbreak is occurring. While C. auris is often found in the general environment, there have been instances where the source of infection during an outbreak was a specific object. For example, the source of a 2018 outbreak was determined to be contaminated patient-monitoring equipment, mainly reusable axillary temperature probes. Despite the implementation of several interventions, the incidence of new cases was reduced only after removal of the contaminated temperature probes.
  • Patient screening and environmental sampling both require the use of laboratories with adequate C. auris testing methods.

Transmission-based precautions:

  • Colonized or infected patients should be isolated in a single room with their own bathroom. In case of an outbreak, all patient cases should be cohorted to a single location or unit within the hospital. Patients who are screened should be isolated until negative results are confirmed.
  • Safe staffing should be maintained at all times. Safe staffing during rest and meal breaks should be planned for. Where staff must wear PPE for multiple patients and/or long periods of time, additional breaks may be necessary.
  • Do not share equipment between patients with C. auris and those without.
  • Single-use items, such as blood pressure cuffs, that can be discarded after use can help minimize spread from contaminated objects. 
  • Reducing the presence of auxiliary, nonessential equipment in C. auris isolation rooms and avoiding storing supplies in open hallways can help limit potential new sources of infection.
  • Introduce a flagging system that indicates an isolated patient and is visible at the entry of the room. Infected and colonized patients should also have an alert on their medical records.
  • Maintain proper hand hygiene before and after entering a patient’s room. Hand washing with soap and water, alcohol-based, or chlorhexidine-based hand soap have all been shown to be effective in eliminating C. auris from hands.
  • PPE should include impermeable gloves and long-sleeved gowns that are donned when entering a patient’s room and discarded before leaving. 
  • Masks and face shields have been recommended during aerosol-generating procedures performed on colonized or infected patients. However, due to the uncertainties regarding the role of air dispersion in the transmission of C. auris and the fact that patients with C. auris may be colonized for life, full-face protection may be prudent during all interactions with C. auris patients, especially if the health care worker and/or their family members are at high risk for colonization or infection. Note that respirators, in conjunction with a face shield, provide a higher level of full-face protection for nurses and other health care workers than surgical or medical masks. At all times, nurses and other health care workers should have access to a range of PPE options, including respirators, masks, faceshields, gloves, and gowns, and the ability to use PPE as they assess it is necessary to protect their health and safety. 
  • Due to the potential long-range air dispersal of C. auris, ventilation and decontamination of out-of-reach high-level surfaces have been proposed to remove C. auris from the environment, prevent reentrainment in the air, and manage outbreaks. We emphasize the need for environmental decontamination that extends beyond high-touch areas to include floors, ceilings, windows, etc.

Disinfection of environmental surfaces:

  • Twice daily and terminal cleaning of environmental surfaces and reusable medical equipment is required to control transmission of C. auris. Some hospitals experiencing outbreaks have increased disinfection to three times daily or every two hours on high-touch surfaces.
  • The CDC recommends using an EPA registered hospital-grade antimicrobial product effective against C. auris during daily and terminal cleaning (List P). If the products on List P are not accessible, health care facilities may use an EPA-registered hospital-grade disinfectant effective against C. difficile spores (List K).
  • A recent review of existing scientific literatures discussed the efficacy of common disinfectants and published the following findings:
    • Chlorine-based products (1000 and 10000 ppm) were found to be effective. Terminal cleaning with chlorine-based products is especially effective when followed by hydrogen peroxide vapor. 
    • Hydrogen peroxide vapor is recommended in addition to other disinfection methods, not in place of. If hydrogen peroxide fumigation of a hospital room is not possible, it is recommended to fumigate moveable equipment in an alternate room. We emphasize the need for adequate controls and PPE for workers who are conducting or who otherwise may be exposed during the fumigation process.
    • Sodium hypochlorite (1000 and 10000 ppm) was also found to be effective, though not on C. auris biofilms.
    • Quaternary ammonium compounds are commonly used disinfectants in health care settings, but the overall evidence regarding their efficacy for C. auris is conflicting, and their use is discouraged. Hospitals experiencing past outbreaks have withdrawn disinfectants wipes or solutions containing quaternary ammonium compounds from their units.

Patient decolonization:

  • Patients can remain colonized despite twice daily 2-4% chlorhexidine washes; however, chlorhexidine wipes are still widely used as they can decrease the bioburden on the skin surface and thereby reduce the risk of transmission.

Visitor restrictions:

  • If visitors are allowed in the hospital or other health care facility, they should follow the same strict transmission-based precautions as listed above when entering rooms where patients colonized or infected with C. auris are isolated. Video calls would reduce transmission risk further.
  • Information regarding C. auris transmission and risks should be given to visitors.

Communication and education:

  • Promptly communicate results of patient surveillance and screening (noting that patients with pending C. auris test results should be isolated until negative results are confirmed).
  • If a colonized or infected patient is transferred, maintain timely communication with the other facility or unit within your hospital. Universal transfer forms that include C. auris colonization status should be utilized and integrated with existing electronic medical records.
  • Ongoing education of all staff about C. auris and the necessary precautions should be incorporated. Schedule regular training sessions for staff in the affected cohort area.