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Review

Infection Control Measures against Candidaauris in Healthcare Facilities

by
Wadha A. Alfouzan
1,2,*,
Rita Dhar
1,
Jasim Alabbad
3 and
Ali A. Rabaan
4,5,6
1
Microbiology Unit, Department of Laboratory Medicine, Farwania Hospital, Kuwait City 81004, Kuwait
2
Department of Microbiology, Faculty of Medicine, Kuwait University, Kuwait City 13110, Kuwait
3
Department of Surgery, Faculty of Medicine, Kuwait University, Kuwait City 13110, Kuwait
4
Molecular Diagnostic Laboratory, Johns Hopkins Aramco Healthcare, Dhahran 31311, Saudi Arabia
5
College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia
6
Department of Public Health and Nutrition, The University of Haripur, Haripur 22619, Pakistan
*
Author to whom correspondence should be addressed.
Processes 2022, 10(8), 1625; https://doi.org/10.3390/pr10081625
Submission received: 21 June 2022 / Revised: 11 August 2022 / Accepted: 12 August 2022 / Published: 17 August 2022
(This article belongs to the Special Issue Ways/Opportunities of Decontamination Processes of Surface Moulds and Mycotoxins)
Review Reports Versions Notes

Abstract

:
Candida auris is an emerging multidrug-resistant yeast with high mortality rate, especially in patients with underlying co-morbidities. It has been known to contaminate the environment and colonize human skin for prolonged periods in healthcare settings leading to difficult-to-control outbreaks. However, there is limited literature on the efficacy of different disinfectants/antiseptics, which can effectively decontaminate the environment and decolonize patients to prevent the spread of C. auris. This review highlights recommendations available in the literature for detection and control of C. auris in healthcare settings. Detection of C. auris by biochemical and automated methods has often been misleading. Availability of C. auris-specific PCR can prove to be a more reliable technique for detection of C. auris. Control measures for transmission of C. auris include use of registered hospital grade disinfectant active against Clostridium difficile cleaning the environment and equipment and chlorhexidine for decolonization of patients. Hand hygiene using soap and water, followed by use of alcohol-based hand sanitizer for maximal disinfection, is recommended for healthcare workers.

1. Introduction

Members of the genus Candida can be part of microbiome on human skin, mucous membranes, female genital tract, and gastrointestinal tract. Of the 150 Candida species described in the literature only 10% are known to cause infections (candidiasis), which could be localized and or invasive leading to candidemia [1,2]. Candida infections are among the most common fungal nosocomial infections and are emerging as a serious threat in the hospital-associated outbreaks [3]. Although infections can occur in patients of all ages, extremes of age are more often affected [4]. Invasive candidiasis is emerging in critically ill patients with several risk factors, which include older age, comorbidities, long-term hospitalization, diabetes, recent extensive surgical procedures, broad-spectrum antibiotics, immunosuppression, and presence of medical devices such as endotracheal tubes, feeding tubes, and central venous catheters [3,4,5]. C. albicans has been known to be the most common species causing invasive candidiasis in hospitalized patients. However, in the past decade a wide range of non-albicans species, especially C. glabrata, C. parapsilosis, C. tropicalis, and C. krusei (now Pichia kudriavzevii) have emerged as progressive pathogens [2,3]. The plausible explanation for this switch is an increasing use of fluconazole for prophylaxis or therapy leading to selection of azole-less susceptible/resistant species.
In 2009, C. auris emerged as a novel Candida species isolated from patients with candidemia, wound infections, and otitis. Since then, this multidrug-resistant Candida species is being increasingly identified worldwide and reported to cause outbreaks of invasive infections in healthcare facilities around the world. It is, therefore, imperative to implement robust infection control measures to control C. auris outbreaks, especially in view of the organism having the ability to cause difficult-to-treat life-threatening infections [6]. Transmission-based precautions are required to prevent further spread leading to outbreaks, especially in high dependency units in the healthcare setting. Since the C. auris-colonized/infected patients and the contaminated environment/equipment play an important role in the transmission, it is of utmost importance to decolonize patients and clean the environment and equipment using effective antiseptic and disinfectant, respectively [7]. An update on best practices for control of C. auris transmission in healthcare facilities, based on available information, was recently published by the Infection Prevention and Control working group of the International Society for Antimicrobial Chemotherapy [8].

1.1. Candida auris

In recent years C. auris has been reported from several countries as a new species able to colonize and infect patients with high crude mortality rates (30–72%) [9,10]. Simultaneous global emergence of C. auris associated with healthcare-related infections has been confirmed by whole genome sequencing (WGS) and epidemiological analyses [10,11]. Although reasons for simultaneous emergence of this pathogen are not known, five geographically restricted clades of C. auris have been recognized. C. auris has been reported from six continents causing outbreaks in countries such as India, Colombia, South Africa, United Kingdom, and the United States of America [9].
Biofilm formation has been described as one of the important pathogenicity traits in C. auris. This characteristic can lead the fungus to become resistant to antifungal agents and is also likely to play a role in its ability to persist on various surfaces. The other virulence attributes in C. auris are due to phospholipases and proteinase production, nutrient acquisition, siderophore-based iron acquisition, two-component histidine kinase system, and cell wall modeling. C. auris has also demonstrated ability to evade immune response, especially killing by neutrophils [12].

1.2. Risk Factors

C. auris with multidrug-resistant profile and propensity to spread rapidly in elderly with comorbidities and critically ill patients has emerged as a dominant opportunistic pathogen in these populations. C. auris can often cause outbreaks in ICU setting, especially in patients with central venous catheter and long-term urinary catheter suggesting a potential role for biofilm formation. The risk factors for acquisition of C. auris, which can be as short as four hours, include patients colonized with C. auris or its presence in their environment. Other risk factors include immunosuppressive state, chronic kidney disease, vascular disease, hemodialysis, and prolonged ICU stay [13].
A recent study has described univariable, and multivariable analysis of factors associated with development of C. auris candidemia in colonized patients. The risk factors studied included, age, male gender, Charlson score, diabetes mellitus, chronic obstructive pulmonary disease, chronic kidney disease, previous myocardial infarction, solid cancer, hematological malignancy, hemopoietic stem cell transplant, previous hospitalization, previous abdominal surgery, previous antibiotic treatment, previous antifungal drug use, neutropenia, COVID-19, invasive mechanical ventilation, extracorporeal oxygenation, total parenteral nutrition, and site of C. auris colonization [14].

2. Identification and Antifungal Susceptibility Testing

Until 2009, only four isolates were retrospectively identified as C. auris. Among these isolates three were initially identified as C. haemulonii while one was not identified to the species level [6]. To determine if C. auris had emerged in recent times or if it had existed in the past and had been misidentified, an investigation was conducted to identify Candida spp., included in the SENTRY global collection of Candida spp. collected during 2004–2015 from Asia, Europe, Latin America and North America. A single C. auris isolate was identified from Pakistan dating back to 2008, which had not been previously recognized [11]. Interestingly, even though the first ever case where C. auris was identified in a culture from external ear canal in Japan in 2009, subsequent molecular analysis of a 1996 bloodstream isolate in Korea revealed it to be C. auris [10].
Since C. auris is phylogenetically related to C. haemulonii complex, identifying C. auris in conventional diagnostic laboratories has often been problematic. Using commercial phenotypic and biochemical methods such as API 20C, Vitek 2 (bioMerieux, Marcy-l’Étoile, France), Phoenix (BD, Bregen county, NJ, USA), Microscan (Beckman Coulter, Brea, CA, USA), and MALDI-TOF MS Vitek MS ((bioMerieux, Marcy-l’Étoile, France), C. auris is often misidentified as other Candida species, Rhodotorula species, or Saccharomyces species primarily from lack of organism-specific databases [15,16,17,18]. However, proteomic method such as matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) can identify C. auris accurately and rapidly with more reliable performance than phenotypic systems, although updated version of Vitek2 also identifies it correctly [15]. Molecular techniques may be required to confirm the phenotypic identification of C. auris. Recent development of C. auris-specific PCR may aid in rapid and accurate identification of C. auris.

3. Molecular-Based Identification and Strain Typing

Molecular methods such as polymerase chain reaction (PCR) assays have been found to be rapid and highly accurate [16]. These tests overcome the challenges posed by the inherent characteristics of the organism and limitations of commercial identification systems, which use phenotypic, biochemical, or proteonomic characteristics. C. auris can also be identified by molecular sequencing of the ITS region or D1/D2 region of 28 s rDNA [17]. Magnetic resonance is another modality which has been successfully employed for detection of C. auris directly from blood specimens [18]. Additionally, isolates may be submitted to many commercial reference laboratories for correct and reliable identification of C. auris. Although typing methods such as amplified-length polymorphism or multilocus sequencing have been used for C. auris, WGS remains the best technique for determining the clonality of C. auris isolates [15,19].

4. Antifungal Susceptibility

Multidrug resistance among C. auris strains is a concerning feature, although antifungal resistance may vary across the phylogenetic clades. This characteristic severely limits the treatment options for infected patients resulting in high mortality, especially in patients with serious comorbidities. Although fluconazole-susceptible C. auris strains have been described, most C. auris strains have been reported to be resistant to fluconazole and/or to other azoles including voriconazole, posaconazole, itraconazole, and isavuconazole with most isolates presenting relatively low MIC values against the newer triazoles [11]. Furthermore, C. auris presents variable susceptibility to these azoles among defined geographic clades with MIC values varying from 1–2 µg/mL. Echinocandins remain the cornerstone for the first-line therapy for C. auris whereas erroneous susceptibility results are reported for C. auris against amphotericin B when using VITEK2 (BioMérieux, Marcy-l’Étoile, France) [9]. Molecular methods are also being used to detect resistance in C. auris using allele-specific PCR [6]. Interpretation of susceptibility against antifungal agents is challenging because no breakpoints for C. auris against some of the commonly used antifungal agents have been defined by the Clinical and Laboratory Standards Institute (CLSI) or the European Committee on Antimicrobial Susceptibility Testing (EUCAST) [11]. Generally, breakpoints set for non-species-specific Candida spp. by CLSI and EUCAST are as follows: fluconazole (susceptible, MIC ≤ 2 mg/L; resistant, MIC > 4 mg/L), amphotericin B (susceptible, MIC ≤ 1 mg/L), and echinocandins (resistance, MIC ≥ 4 mg/L) [20].

5. Significance of C. auris Infection in a Healthcare Setting

Besides causing high mortality among vulnerable patient population, C. auris has been recovered from contaminated environmental surfaces in healthcare facilities. In several outbreaks reported in the literature, C. auris was found to be persistently present on the furniture, temperature probes, faucets, beds and other inanimate surfaces of the infected patient’s room [21]. As demonstrated previously, prolonged colonization of C. auris on skin surfaces and medical devices facilitates cross-contamination among patients in the hospital setting [22].

6. Colonization

Often patients admitted to hospital, especially in the intensive care units (ICUs) or high dependency units are likely to get colonized with C. auris at multiple body sites with axilla and groin being the highest yield sites followed by the nares [19,20]. Despite special predilection for the skin, C. auris has also been isolated from urine, respiratory tract, soft tissues, stool, vagina, and rectum, which may more likely represent colonization rather than infection. A colonized patient can lead to contamination of the room, furniture, and equipment with C. auris. Additionally, C. auris can be transmitted to other patients with subsequent colonization, infection, or both. In one of the studies, it was shown that >50% of C. auris infections were preceded by colonization emphasizing the importance of screening to identify such patients in order to adopt measures to prevent an outbreak [13,23]. There is evidence that skin colonization of C. auris can persist for weeks to months and that shedding of this organism from colonized patients and healthcare workers can contaminate environmental surfaces in the hospital setting [24]. Culture-based or molecular-based techniques may be employed for screening patients for colonization with C. auris [25,26]. The ability of the organism to grow in the presence of 10% NaCl and withstand a temperature of 40 °C is exploited in the culture-based method for selection over other Candida species, which are part of the skin microbiome [25]. Molecular-based assays have been recently developed such as PCR, RT-PCR, T2 magnetic resonance or loop-mediated isothermal amplification (LAMP) [26,27,28,29]. These assays have the advantage over culture-based techniques as the overall time to positivity is reduced from days to hours, allowing the rapid implementation of infection control measures. The role of colonized healthcare workers (HCWs) serving as a major source of transmission is contested based on outbreak reports from England [30].

7. Environmental Contamination

Contaminated environmental surfaces play an important role in the transmission of infectious diseases in the healthcare setting [31]. The ability of some organisms to form biofilms protects them from biocidal agents, hostile environmental stressors, and dehydration for extended periods of time [32,33,34]. C. auris can be isolated from environmental surfaces in healthcare facilities where it can survive for at least 14 d [24,35]. The persistence of this pathogen on environmental surfaces presents opportunities to colonize and/or infect hospitalized patients and HCWs. Hence infection control practitioners and healthcare epidemiologists are targeting both colonized patients and contaminated surfaces as part of their infection control measures.

8. Transmission of C. auris

Candida species have not historically been seen to spread and cause outbreaks in the healthcare settings except for C. parapsilosis, which has caused outbreaks in ICUs [23]. In contrast, C. auris has been found to have the ability to readily spread in the healthcare facilities. In studies from the United States and India, 12% and 21% C. auris was found to transmit between patients of close contacts of index patients in long-term healthcare settings who were found to be colonized with C. auris on screening [25,36,37].
Colonization can occur rapidly taking a few hours to a few days of exposure to the index case [37]. Data obtained from screening of healthcare personnel to describe their role in transmitting C. auris from one patient to another have shown that 2.8% of HCWs carried C. auris on the hands, probably due to inadequate hand hygiene. In contrast, of more than 250 HCWs who were screened during an outbreak in the United Kingdom only one nurse was found to be colonized with C. auris [30]. There is dearth of information regarding prevalence of C. auris in the community and from the available reports in the literature it is apparent that C. auris is almost non-existent in the community and is primarily associated with healthcare facilities [27,30].
Spread from the environment: C. auris shed by colonized and or infected patients appear to contaminate the surfaces and fomites within the hospital environment where it may persist for long periods. Contaminated environment contributes to the transmission of C. auris to other patients in the ward [21,35,38]. The ability of C. auris to remain culturable on surfaces has been shown to be higher than that of C. albicans probably because of C. auris being able to form dry surface biofilm on surfaces although it has not yet been established [39].
Improved infection control interventions are, therefore, urgently required to limit the spread of C. auris to mitigate the mortality rate among the infected patients.

9. Infection Control

Candida species are considered commensal organisms, and generally infection occurs because of autoinoculation or translocation as opposed to patient-to-patient transmission. However, C. auris is highly transmissible among patients, perhaps due to its proclivity for persistence on skin and environment and has emerged as a formidable pathogen considering its virulence factors, high resistance to multiple anti-fungal agents, the ability to colonize patients, as well as contaminate environmental surfaces and produce outbreaks with increased mortality rate [23].
Hence, implementation of infection control measures plays a crucial role in controlling C. auris outbreaks and reduce mortality rate in healthcare settings [8,9]. It is therefore imperative to select appropriate agents with antifungal activity (Table 1) for disinfections and decontaminations of the healthcare environment, hand hygiene of HCWs, and decolonization of patients as part of a robust and effective infection control measures against C. auris (Table 2).

9.1. Contact Precautions and Hand Hygiene

Patients, in healthcare facilities and long-term care infirmary, who are infected or colonized with C. auris should be isolated in a single room and placed on contact precautions. In the event of non-availability of a single room, patients colonized or infected with C. auris could also be cohorted in a room with other C. auris patients [40,41,42,43]. Cohorting may prove difficult or impractical if C. auris patients are found to be co-colonized with other MDR organisms [37]. Transmission-based precautions are continued as long as a patient remains colonized or infected with C. auris. Generally, colonization appears to be protracted among patients in the healthcare setting especially because of non-availability of methods for decolonization. Since the typical duration of C. auris colonization remains unknown, the most conservative strategy to prevent spread of infection would be to continue transmission-based precautions for the duration of present or future hospital stay [37]. Enhanced barrier precautions such as use of personal protective equipment (PPE) have been recommended by the Centers for Disease Control and Prevention (CDC) for patients from whom body fluid exposure is anticipated or high contact activities such as performing invasive procedure, dressing, device care etc., are performed [44]. However, use of PPE is not required if the patient does not have uncontained secretions or excretions.
One of the important steps in controlling the spread of infection in the hospital setting is proper hand hygiene by the HCWs. Hand hygiene may be practiced with the use of alcohol-based hand sanitizer (ABHS), soap and water, or alcohol and chlorhexidine hand rubs [37,45,46,47]. It is imperative for HCWs to practice frequent hand hygiene as it remains one of the most basic components of infection control practices. While all the available guidelines emphasize strict adherence to hand hygiene, the recommended methods, however, differ. CDC recommends use of ABHS or washing with soap and water if the hands are visibly soiled. The Public Health England (PHE) and the South African Center for Opportunistic, Tropical, and Hospital Infections (COTHI) recommend washing hands with soap and water followed by the use of ABHS on dry hands before donning gloves. There are no specific guidelines for hand hygiene by the European Center for Disease Prevention and Control (ECDC), Pan American Health Organization/World Health Organization (PAHO/WHO). There may be additional benefit of ABHS when combined with chlorhexidine [48].
Table
Table 1. Different disinfectants and antiseptic agents found effective against C. auris.
Table 1. Different disinfectants and antiseptic agents found effective against C. auris.
Disinfectants (Concentration)Level of EvidenceReferencesAntiseptic (Concentration)Level of EvidenceReferences
Chlorine (1000 ppm)Good[46,47,49,50,51]Chlorohexidine gluconate (2%)Good[42,45]
Hydrogen peroxide (1.4%) (8 g/m3)Moderate[28,34,46,50]Povidine Iodine (10%)Moderate[52,53]
Phenolics (5%)Low[34]Isopropanol alcohol (70%)Low[54]
Peracetic acid (2000 ppm)Low[52,55]
Benzalkonium bromide (2000 ppm)Low[52]
a UV-C light (253.7 nm)?[53]
Ozone (≥300 mg/m3)?[18]
? Limited studies and comment on the level of evidence. a ultraviolet—C light.
Table
Table 2. Recommendation of infection control of C. auris.
Table 2. Recommendation of infection control of C. auris.
Identification of Colonized/Infected Patients Transmission—Based Precautions Environmental Disinfection
(Health Organization c)		Hand Hygiene Procedures
(Health Organization c)		Decolonization Procedures
Determination of Candida species isolated from sterile site Contact precaution apply for colonized/infected patients in acute care settings Daily and terminal cleaning with registered hospital grade disinfectant effective against C. difficile spores (CDC)Use of alcohol-based hand sanitizer or hand washing with soap and water before and after donning of gloves (CDC)No recommendations by any health organization
Identify Candida species isolated from non-sterile site when patient resides at a location where C. auris has been identified Isolation of all patients infected or colonized in a single room, side room or cohortedTerminal cleaning by using hypochlorite at 1000 ppm.
Shared medical equipment should be cleaned and disinfected (PHE) 		Hand washing with soap and water followed by alcohol-based sanitizer on dried hands before and after donning of gloves (PHE, COTHI)
Screen patients who are admitted to wards where C. auris cases has been identified Equipment should not be shared Terminal cleaning using a disinfectant with antifungal activity (ECDC)No recommendations (ECDC, PAHO, WHO)
same infection control interventions apply for patient colonized or infected with C. auris PPE a in the form of gloves and gowns for HCWs bRegular and terminal cleaning with chlorine—releasing agent at 1000 ppm, use of hydrogen peroxide vapor in terminal cleaning where feasible (COTHI)
Strict adherence of HCEs to standard infection control precautions including hand hygiene Daily and terminal cleaning with soap and water followed by 0.1% bleach. Clean disinfectant and sterilize medical equipment. machine wash linens and clothes (PAHO, WHO)
Visitors encouraged to use PPE
a PPE—Personnel protection equipment; b HCWs—healthcare workers; c CDC Centre for Disease Control; PHE—Public Health of England; ECDC—European Center for Disease and Control; COTHI—Center for Opportunistic, Tropical and Hospital Infections (South Africa); PAHO—Pan American Health Organization; WHO—World Health Organization.

9.2. Decontamination of Environmental Surfaces

Limited data are available in the literature about the most effective agent and methods for the disinfection of environmental surfaces contaminated by C. auris. Several studies have tested the efficacy of different agents such as sodium hypochlorite (NaOCl), hydrogen peroxide, ethanol, and sodium dodecyl sulfate for surfaces contaminated with C. auris [49]. One of the studies showed that 1% of chlorine as NaOCl was effective against all Candida species tested, in both planktonic and biofilm forms [55]. The CDC recommends daily and terminal cleaning using the United States Environmental Protection Agency (EPA)-registered hospital-grade disinfectant effective against C. difficile [52] whereas COTHI and PHE recommend use of hypochlorite as chlorine-based disinfectant at 1000 ppm (parts per million). Several in vitro studies have confirmed the efficacy of chlorine-based disinfectants on different surfaces such as stainless steel, ceramic, plastic and glass. Different concentrations of NaOCl were tested and all demonstrated significant killing of C. auris on all substrate at contact times of 5 and 10 min [53].
Hydrogen peroxide vapor at a concentration of (8 g peroxide/m3) used in conjunction with 10,000 ppm chlorine-based disinfectant has shown to effectively decontaminate the environment [31]. In vitro studies have confirmed the killing efficacy of hydrogen peroxide and found it being comparable to that of chlorine-based disinfectants against C. auris showing 96.6–100% killing [50]. Another study demonstrated that hydrogen peroxide solutions in a concentration of 0.5 and 1.4% was found to be effective in killing C. auris with comparable results to that of chlorine-based disinfectants. A formulation of 11% hydrogen peroxide with 0.01% silver nitrate has also been found to be effective but requires 60 min contact time for complete eradication of C. auris [37]. Disinfection of healthcare equipment such as ECG monitor leads and blood pressure monitor and cuffs with hydrogen peroxide vapor has been used [50].
Although quaternary ammonium compounds are widely used as disinfectants for their fungicidal, bacterial, and virucidal (against lipophilic viruses) activity, a recent study demonstrated them to be ineffective against Candida species including C. auris [52]. Among other disinfectants, alcohol, peracetic acid, acetic acid, phenol, and glutaraldehyde have also been evaluated against C. auris. It was reported that 2% glutaraldehyde and 5% phenol were found to be effective on multiple surfaces with contact times of 20 and 60 min, respectively [37]. While ethyl alcohol 29.4% has been shown to have some killing activity it is not to the same degree as chlorine-based disinfectant or hydrogen peroxide. As with NaOCl, complete eradication of C. auris was achieved by peracetic acid at 2000 ppm. Furthermore, peracetic acid at 1200 ppm in combination with hydrogen peroxide and acetic acid was found to have killing activity similar to chlorine-based disinfectants [50].
Among other measures, efficiency of ultraviolet light was also evaluated against C. auris. Exposure of C. auris to ultraviolet-C (UV-C) light at 254 nm for 20 min at optimal distance produced significant killing of C. auris [56]. UV-C killing can be augmented by increasing the length of exposure and combining it with standard cleaning methods can eliminate C. auris from the environment.
The LK/CXD bed unit ozone disinfection machine, which produces an ozone concentration of ≥300 mg/m3, has been used for disinfecting inpatient bed unit. Two cycles of routine disinfection reportedly completely eradicated C. auris on bed sheets [22].

9.3. Decolonization

Currently, only limited data on the efficacy of skin-antiseptic compounds against C. auris colonization in patients are available. Furthermore, the recommendations of major health organizations regarding hand hygiene procedures for control of C. auris infection are different or lacking [22]. There are no established guidelines for decolonization of patients found to be colonized with C. auris on screening. While no decolonization methods have been offered by CDC, COTHI and ECDC, PHE recommends body washes and mouth gargles with chlorhexidine. However, specific details such as concentration of chlorhexidine, frequency of application etc., are not provided and it is not clear if it is efficacious in clearing colonization with C. auris. Since no specific decolonization protocol is established to date, it is imperative to evaluate other antiseptics. Among compounds which have generated some interests are very dilute NaOCl and povidone iodine which according to some studies appear to support their use for antiseptic skin preparation against C. auris [57,58].
In a recent report from Saudi Arabia, an outbreak due to C. auris in a tertiary-care facility was successfully controlled by employing a combination of infection control measures mentioned in the text above. Briefly, patients with laboratory-confirmed diagnosis of C. auris infection were placed on contact isolation. The positive cases and HCWs were cohorted in the same unit with a strict implementation of hand hygiene, proper use of PPE and limiting the use of shared medical equipment. In addition, the positive patients were subjected to daily bathing using 2% chlorhexidine wipes and daily environmental cleaning was performed using sodium NaOCl 1000 ppm. For terminal cleaning hydrogen peroxide fumigation was included with use of NaOCl 10,000 ppm [51].

10. Conclusions

Since it is difficult to eliminate C. auris from the environment of healthcare facilities or colonized patients, prevention of C. auris will be more effective than the reactive efforts. It is important for clinicians to recognize C. auris infection or colonization in a patient based on known risk factors, use of appropriate antifungal treatment, and implementation of strict infection control measures to prevent transmission. Laboratories need to be well equipped to be able to provide accurate species level identification of Candida isolate and report result to the clinician and infection control team if C. auris is isolated from a suspected case or a screened patient. It is imperative for regional health authorities to educate HCWs about prevention of C. auris transmission. It has been emphasized that the handwashing with soap followed by ethanol-based hand sanitizer is effective in controlling C. auris transmission. Chlorhexidine has been recommended for patients who are colonized by C. auris. Quaternary ammonium disinfectants, UV-C (253.7 nm) and ozone can prove to be as effective as chlorine if the exposure times of the latter two are extended for disinfection.
For controlling C. auris transmission in a healthcare setting, it is imperative to follow set guidelines. Since patients can remain colonized on their skin and other body sites for prolonged periods and persist on environmental surfaces, it remains a threat for transmission to other patients. Control measures require identifying patients who are infected or colonized with C. auris and implementing infection control interventions including hand hygiene, contact precautions and thorough environmental cleaning and disinfection. Once a patient is identified as infected or colonized with C. auris in a healthcare facility, the following actions must be undertaken: first, isolate the patient in a single room under contact precautions followed by notifying the state or local healthcare department and implementation of institute infection control measures (adherence to proper hand hygiene with alcohol-based hand rub or soap and water). In addition, thorough daily and terminal cleaning of patient’s room and mobile equipment should be performed with registered hospital-grade disinfectant effective against Clostridium difficile spores (CDC/EPA). It is imperative to identify infected/colonized patients through contact investigation and travel history. All patients identified as colonized with C. auris should be managed in a similar manner as the index case. Although no known decolonization methods have been established, daily chlorhexidine bathing has been used for source control in certain settings. However, further studies are needed to determine the efficacy of chlorhexidine for decolonization. Finally, infection control assessment should be performed by targeting hand hygiene, contact precautions, and environmental cleaning and disinfection.

Author Contributions

Conceptualization, W.A.A., J.A. and A.A.R.; resources W.A.A., R.D., J.A. and A.A.R.; writing—original draft preparation, R.D.; writing—W.A.A., J.A. and A.A.R. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

Not applicable.

Conflicts of Interest

The authors declare no conflict of interest.

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Alfouzan, W.A.; Dhar, R.; Alabbad, J.; Rabaan, A.A. Infection Control Measures against Candidaauris in Healthcare Facilities. Processes 2022, 10, 1625. https://doi.org/10.3390/pr10081625

AMA Style

Alfouzan WA, Dhar R, Alabbad J, Rabaan AA. Infection Control Measures against Candidaauris in Healthcare Facilities. Processes. 2022; 10(8):1625. https://doi.org/10.3390/pr10081625

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Alfouzan, Wadha A., Rita Dhar, Jasim Alabbad, and Ali A. Rabaan. 2022. "Infection Control Measures against Candidaauris in Healthcare Facilities" Processes 10, no. 8: 1625. https://doi.org/10.3390/pr10081625

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