Candida auris in Orange County:
Update for Skilled Nursing Facilities
June 10, 2019
Multiple patients colonized or infected with Candida auris ( C. auris) have been identified in Orange County. This cluster of cases is the first identified in Southern California. 

C. auris is an emerging yeast that is multidrug resistant, can cause serious invasive infections and has a propensity to spread in healthcare settings.  Patients at highest risk are those who have been hospitalized long-term, are ventilated, have a tracheostomy, have an indwelling intravenous catheter, and/or have received multiple rounds of antibiotics.   Early detection of C. auris and rigorous adherence to infection control measures is essential for containing its spread in healthcare facilities.   

Outbreaks have occurred in several states, primarily in the eastern half of the country. In communities experiencing C. auris outbreaks, colonization rates have consistently been highest in residents of adult long term acute care hospitals (LTACs) and skilled nursing facilities that provide ventilator care (vSNFs). Colonization has been identified in residents of skilled nursing facilities that do not provide ventilator care, but rates of colonization and illness are much lower in these settings.  

Point prevalence surveys, with testing of all residents of a facility, have been completed in all LTACs and vSNFs in Orange County. Multiple LTACs and vSNFs were found to have patients who are C. auris colonized; over 60 colonized patients have been identified thus far. Several facilities had no colonized patients identified, and some facilities who initially had colonized patients identified have instituted effective infection control measures and no longer have evidence of ongoing spread of C. auris

OCHCA is working with all facilities with potential ongoing spread of C. auris to assure that receiving facilities are informed of the situation when patients are transferred. Transmission can occur in a variety of healthcare settings, and appropriate infection control measures should be taken by in all settings.
Recommendations:
  • Healthcare facilities should institute empiric Standard and Contact Precautions for all patients admitted from LTACs and adult vSNFs with potential ongoing spread of C. auris.

  • Admission screening for C. auris should be performed by receiving facilities for all patients from the above facilities who may be admitted for a prolonged period (one week or longer).

  • Facility-to-facility communication is critical when transferring a patient who is suspected or confirmed to be colonized or infected with C. auris. Any receiving facility should be made aware of the patient’s status.
Infection Control: 
Appropriate infection control precautions for patients suspected or confirmed to be colonized or infected with C. auris include:

  • Place patient in a single-patient room whenever possible
  • Use Standard and Contact Precautions.
  • Emphasize adherence to hand hygiene.
  • Use dedicated medical equipment.
  • Minimize the number of healthcare staff caring for the patient.
  • Clean and disinfect the patient care environment and reusable equipment (daily and terminal cleaning) with recommended products (see Cleaning Agents section on next page) throughout the unit or facility where patients with C. auris are located.

SNFs could consider relaxing the requirement for Contact Precautions for certain colonized residents who can perform hand hygiene and have no wounds or indwelling medical devices (e.g., urinary and intravenous catheters and gastrostomy tubes). 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.

Patients remain colonized for several months to years, even after an active infection has resolved. There is no treatment for colonization.

Additional infection control recommendations for a variety of healthcare settings can be found at https://www.cdc.gov/fungal/candida-auris/c-auris-infection-control.html .
Admission Screening:
  • Admission screening for C. auris should include a composite swab of the axilla and groin as well as a swab of the nares. The Centers for Disease Control and Prevention (CDC) recommends inclusion of nares swabbing to optimize testing yield.
  • Screening culture testing results are available in 7-21 days.
  • Patients who have been previously screened at a facility with potential C. auris spread should still have admission screening performed at the accepting facility.   
  • SNFs accepting patients from facilities where C. auris-colonized patients have been identified should contact OCHCA at 714-834-8180 to arrange for receipt of screening swabs and to coordinate their transfer to a public health laboratory for testing.
Patient Activities:
  • Patients residing in SNFs who are suspected or confirmed to be colonized with C. auris may leave their rooms as long as secretions and bodily fluids can be contained and they can perform hand hygiene prior to leaving the room.

  • Patients with C. auris can receive physical therapy or other shared services (e.g., physical therapy equipment, recreational resources). Staff providing these services to such a patient should:
  • Not work with other patients while working with the affected patient.
  • Use a gown and gloves when they anticipate touching the patient or potentially contaminated equipment.
  • Whenever possible, see the colonized patient last on a given day.
  • Thoroughly clean and disinfect shared equipment after use.
Laboratory Testing:
C. auris has been identified from many body sites including bloodstream, urine, respiratory tract, biliary fluid, wounds, and external ear canal. The CDC recommends that all yeast isolates obtained from a normally sterile site (e.g., bloodstream, cerebrospinal fluid) be identified to the species level so that appropriate initial treatment can be administered based on the typical, species-specific susceptibility patterns. In addition, yeast isolates obtained from non-sterile sites (e.g., urine, respiratory tract) can be identified to the species level as part of enhanced surveillance for C. auris .
Cleaning Agents:
For environmental cleaning of C. auris , CDC recommends the use of an Environmental Protection Agency (EPA)-registered hospital-grade disinfectant effective against Clostridioides difficile spores (List K, found at https://www.epa.gov/pesticide-registration/list-k-epas-registered-antimicrobial-products-effective-against-clostridium ) . Quaternary ammonium compounds that are routinely used for disinfection may not be effective against C. auris , and data on use of hands-free disinfection methods, like germicidal UV irradiation, are limited. 
Treatment:
Consultation with an infectious disease specialist is highly recommended for patients infected with C. auris . Echinocandins should be used for initial treatment in most cases. Isolates tested in Orange County residents thus far have been susceptible to echinocandins. See CDC's guidance for more detailed treatment information.

For additional information, visit https://www.cdc.gov/fungal/candida-auris/index.html .
Healthcare facilities or laboratories that have questions or have a suspected case of C. auris colonization or infection should contact the Orange County Health Care Agency Epidemiology and Assessment Division immediately at 714-834-8180.
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