Compiled December 2016
Centre for Opportunistic, Tropical and Hospital Infections

Interim guidance for management of Candida auris
infections in South African hospitals
What is Candida auris?
Candida auris is an emerging fungal (yeast‐like) pathogen which has caused invasive infections andhospital outbreaks on several continents. The fungus is difficult to identify in the routine laboratory
setting, is associated with a high in‐hospital mortality among patients with invasive infection andmay be difficult to “eradicate” from the hospital environment.
Of most concern, C. auris is often multi‐drug resistant; almost all tested C. auris isolates are resistant
to fluconazole, an important first‐line antifungal agent1‐7, and in a recent global study, more than
40% of isolates were resistant to two or more major classes of antifungals1 .

What is the current global epidemiology?
Since C. auris was first described in Japan in 2009, cases have subsequently been reported in South
Korea, India, Kuwait, Kenya, South Africa and more recently in Colombia, Venezuela, Pakistan, theUnited Kingdom and the United States2‐14. It is possible that C. auris has emerged in other resource‐
limited countries but has remained undetected owing to a limited capacity for case detection. A
whole genome sequencing study documented recent, near‐simultaneous and independent
emergence of C. auris clones on three different continents (Africa, Asia and South America), rather
than spread of a single “clone” across the globe1. To date, infections with C. auris have been largely
acquired in a hospital setting and horizontal spread of the pathogen has been demonstrated throughclonality of isolates within a hospital. Healthcare‐associated outbreaks of C. auris have beenreported in at least three countries to date1, 6, 7.

What infections does it cause?
C. auris has been reported to cause bloodstream infections (including central venous catheter‐
associated bloodstream infections), meningitis, bone infections and wound infections (incl.
colonisation and infection of burns). The fungus has also been isolated from urine (sometimes
implicated in a catheter‐associated urinary tract infection), skin and mucosal membranes, tracheal
aspirates and other sites.

What is the current situation in South Africa and why is there concern?
C. auris was the second most common cause of candidaemia in the South African private sector in2016 based on current active, laboratory‐based surveillance for candidaemia, with most cases
occurring in Gauteng province. In public‐sector hospitals, C. auris was the fourth most commonspecies of Candida causing candidaemia, again with most cases in Gauteng province. Overall, there
Page 1 of 6have been over 1500 cases in South Africa to date (Govender NP, et al. unpublished data), with 70‐
80 new cases every month since April 2016. Large on‐going outbreaks have occurred at several
Johannesburg and Pretoria hospitals, with most cases occurring in private‐sector facilities.
Healthcare facilities are requested to notify the NICD urgently if a new outbreak in a hospital or
long‐term care facility is suspected. To date, no outbreaks have been reported from South African
paediatric or neonatal units – all personnel are requested to maintain high levels of vigilance forsuch an occurrence.

How is this fungal pathogen identified in the laboratory?
C. auris is often misidentified in the routine diagnostic laboratory using commercially‐available
biochemical methods. If Candida haemulonii, Saccharomyces cerevisiae, Rhodotorula glutinis,
Candida sake or Candida famata are identified, further confirmatory testing should be done todetermine if the isolate is C. auris, especially if the fungus is fluconazole resistant. The identificationof this yeast‐like fungus can be currently confirmed by molecular methods or mass spectrometry,including MALDI Biotyper system (Bruker Corporation, Billerica, MA, USA) and Vitek MS (bioMerieux,Marcy l'Etoile, France). Refer to laboratory algorithm below (Figure 1). Note: The Vitek‐2 YST
identification database will be updated to include C. auris in early 2017 (personal communication,bioMerieux). Species‐level identification and antifungal susceptibility testing (AST) of isolates isessential to guide patient management. There are no agreed‐upon interpretive breakpoints for C.
auris and any antifungal agent; however, conservative breakpoints, developed for other Candida
species, have been applied to C. auris for epidemiological purposes. C. auris exhibits resistance tofluconazole in over 90% of isolates. In addition, 35% of isolates are resistant to amphotericin B, 7%resistant to echinocandins and 41% multi‐drug resistant (MDR) (i.e. resistant to at least 2 classes ofantifungals)1. Isolates found to be resistant to an echinocandin or amphotericin B should promptly
be referred to the NICD. In addition, referral of all MDR isolates is required.
Yeast identified as Candida haemulonii,
Saccharomyces cerevisiae, Rhodotorula glutinis,
Candida sake or Candida famataYes
Is the method used to identify yeast Vitek MS(bioMerieux, Marcy l'Etoile, France) or MALDI
Biotyper (Bruker Corporation, Billerica, MA, USA)

Report originalidentification

NoIs the yeast resistant to fluconazole?

Yes

Probable C. auris: Confirm ID by Vitek MS or MALDI
Biotyper. If unavailable, send isolates to the NICD
(until Vitek‐2 YST database updated)

No

Need to exclude C. auris: Confirm ID by Vitek MS or
MALDI Biotyper. If unavailable, send isolates to theNICD (until Vitek‐2 YST database updated)

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Figure 1: Laboratory algorithm to confirm commonly-misidentified yeasts as Candida auris

How is a case identified?
A case of C. auris can be defined as follows:A case of C. auris
infection

A case of C. auriscolonisation

Any patient with confirmed or suspected C. auris infection identified by adiagnostic laboratory from any sterile body site: Blood Central venous catheter (CVC) tip
 Cerebrospinal fluid (CSF) Tissue Fluid from a sterile site
 Urine (NB: to consider clinical picture and the presence of cells or casts inthe urine – see treatment recommendations for urinary tract infectionsbelow)
Patients may or may not have evidence of sepsis or altered biomarkers.
Any patient with confirmed or suspected C. auris from any “non‐sterile” bodysite: Skin
 Tracheal aspirate/ respiratory secretions
 Rectal swab
 Nasal swab
 Urine (NB: to consider clinical picture and the presence of cells or casts inthe urine – see treatment recommendations for urinary tract infections
below)How should a case of Candida auris infection be managed?
An echinocandin (i.e. caspofungin, micafungin or anidulafungin) or amphotericin B deoxycholate
should be used as first‐line therapy, depending on availability. Treatment should be adjusted, basedon AST results, as soon as available. Where feasible, every effort should be made to remove devices
such as CVCs and urine catheters. Antifungal treatment duration is standard as for infections causedby other Candida species; treatment for candidaemia should be continued for 14 days after
documented clearance of Candida from the bloodstream (one blood culture per day until negative)
and resolution of symptoms attributable to candidaemia 15, 16. There is no evidence for combination
antifungal therapy at present for C. auris infections.
The following is recommended for the treatment of patients where C. auris is isolated from urine:
Condition
Asymptomatic
candiduria

Symptomaticlower
urinary tract infection(UTI)
Urinary fungal ball
Pyelonephritis

Recommended treatment
 No antifungal therapy indicated, except if patients are at high risk fordissemination (very low birth weight (VLBW) neonates, patients withneutropenia, urologic surgery pending) Removal of urine catheter Antifungal treatment: consider amphotericin B IV or amphotericin B bladder
irrigation. Echinocandins do not achieve high urine concentrations and are thus
not ideal agents Removal of urine catheter Surgical removal
 Antifungal treatment, as for candidaemia

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What infection prevention and control measures are appropriate to limit
transmission?
Although the dynamics of transmission of C. auris are not clearly established, C. auris is known tocontaminate the immediate environment of infected or colonised patients with hypothesised
onward transmission on the hands of healthcare workers or on fomites (such as shared equipment).
It is essential to have commitment from hospital management, infection prevention and control(IPC) teams and clinical teams, in order to curb the spread of this pathogen. Facilities should update
internal IPC policies and ensure that recommendations are appropriately implemented.
In order to limit transmission within a facility, the following measures are recommended:
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Patients with C. auris infection or colonisation should be isolated in single rooms with en suite
facilities, side rooms or cohorted, wherever possible.
Standard precautions should be strictly adhered to, including hand hygiene using soap and water(especially with visible soiling) followed by alcohol hand rub. Between care activities, alcohol
hand rub can be used if hands are not visibly soiled
In addition, contact precautions are recommended: these include the donning of appropriate
personal protective equipment (PPE) (gloves and aprons) before touching a patient or thepatient’s immediate surroundings (bed linen, bed rails, personal belongings, invasive devices).
PPE should be donned after application of alcohol hand rub and hands should be cleaned withsoap and water followed by alcohol hand rub, after removal of PPE
Improved adherence to bundles of care for venous and urinary catheters, as well as
tracheostomy care is essential
Hand hygiene practices among staff members should also be evaluated and adherenceemphasised
Clinicians and ancillary health professionals (including dieticians, radiographers,physiotherapists, phlebotomists etc.) should also be trained regarding IPC recommendations
Affected patients, visitors and family members should be briefed about the importance of handhygiene and visitors encouraged to use protective aprons
If a patient needs care or investigations in another department within a facility (including
radiology, theatre, outpatient clinic etc.), the receiving department should be notified of thepatient’s C. auris status and advised on what precautionary measures to take prior to and during
the transfer/ procedure. These patients should also be scheduled last on the list for the day, iffeasible.
If a patient needs to be transferred to another healthcare facility, including a long‐term carefacility, the referring facility should ensure that the receiving facility is appropriately notified ofthe patient’s C. auris infection or colonisation status.

Should screening be performed in routine clinical care?
Routine screening for C. auris at the time of hospital admission is not currently recommended owing
to limited evidence.

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How should a case of Candida auris colonisation be managed?
Patients known to be colonised with C. auris should be isolated in side rooms or cohorted, whereverpossible. If a patient has to be transferred to another healthcare facility, including a long‐term carefacility, the referring facility should ensure that the receiving facility is appropriately notified byclearly documenting “Candida auris colonisation” as a diagnosis on the referral letter and/ ordischarge summary. Decolonisation procedures (such as chlorhexidine skin wipes, mouth washes,etc.) are not currently recommended owing to limited evidence.

How should the patient’s immediate environment be cleaned?
Regular cleaning with a chlorine‐releasing agent with a strength of 1000 ppm (i.e. higher than thatroutinely used) is recommended. Terminal cleaning and disinfection of the bed space should beperformed after the patient has left the environment, using a chlorine‐releasing agent (1000 ppm).
Also consider a terminal clean with hydrogen peroxide vapour, where feasible. Multi‐use equipment(including BP cuffs, thermometers, computers/ equipment on wheels, ultrasound machines etc.)
should be thoroughly cleaned during a terminal clean. If a patient needs care or investigations inanother department within a facility, they should be scheduled last on the list for the day, followedby thorough cleaning of the environment in the relevant department, as described above. Standard
waste and linen disposal procedures should be followed. Facilities should ensure buy‐in fromhousekeeping services or outsourced cleaning service providers and ensure that cleaning staff areappropriately trained with regard to cleaning recommendations.

References and further reading:1.
Lockhart SR, Etienne KA, Vallabhaneni S, Farooqi J, Chowdhary A, Govender NP, et al.
Simultaneous emergence of multidrug resistant Candida auris on three continents confirmed bywhole genome sequencing and epidemiological analyses. Clin Infect Dis. 2016:ciw691.
2.
Chowdhary A, Sharma C, Duggal S, Agarwal K, Prakash A, Singh PK, et al. New clonal strain ofCandida auris, Delhi, India. Emerg Infect Dis. 2013;19(10):1670‐3.
3.
Chowdhary A, Kumar VA, Sharma C, Prakash A, Agarwal K, Babu R, et al. Multidrug‐resistantendemic clonal strain of Candida auris in India. Eur J Clin Microbiol Infect Dis. 2014;33(6):919‐26.
4.
Magobo RE, Corcoran C, Seetharam S, Govender NP. Candida auris‐associated candidemia,South Africa. Emerg Infect Dis. 2014;20:1250‐1.
5.
Magobo RE, Corcoran C, Govender NP. Molecular typing of multidrug‐resistant Candida auris
strains in Gauteng province, South Africa. Abstract presented at: ASLM; 2016 December; SouthAfrica. 2016.
6.
Vallabhaneni S. Investigation of the First Seven Reported Cases of Candida auris, a GloballyEmerging Invasive, Multidrug‐Resistant Fungus—United States, May 2013–August 2016. MMWR
Morbidity and Mortality Weekly Report. 2016;65.
7.
Schelenz S, Hagen F, Rhodes JL, Abdolrasouli A, Chowdhary A, Hall A, et al. First hospitaloutbreak of the globally emerging Candida auris in a European hospital. Antimicrobial Resistance &Infection Control. 2016;5(1):35.
8.
Satoh K, Makimura K, Hasumi Y, Nishiyama Y, Uchida K, Yamaguchi H. Candida auris sp. nov.,
a novel ascomycetous yeast isolated from the external ear canal of an inpatient in a Japanesehospital. Microbiol Immunol. 2009;53(1):41‐4.
9.
Kim M‐N, Shin JH, Sung H, Lee K, Kim E‐C, Ryoo N, et al. Candida haemulonii and closely
related species at 5 university hospitals in Korea: identification, antifungal susceptibility, and clinicalfeatures. Clin Infect Dis. 2009;48(6):e57‐e61.
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10.
Lee WG, Shin JH, Uh Y, Kang MG, Kim SH, Park KH, et al. First three reported cases ofnosocomial fungemia caused by Candida auris. J Clin Microbiol. 2011;49(9):3139‐42.
11.
Emara M, Ahmad S, Khan Z, Joseph L, Al‐Obaid Im, Purohit P, et al. Candida auris candidemia
in Kuwait, 2014. Emerging infectious diseases. 2015;21(6):1091.
12.
CDC. Clinical Alert to U.S. Healthcare Facilities: Global Emergence of Invasive Infections
Caused by the Multidrug‐Resistant Yeast Candida auris 2016. Available from:http://www.cdc.gov/fungal/diseases/candidiasis/candida‐auris‐alert.html.
13.
PHE. Guidance for the laboratory investigation, management and infection prevention andcontrol for cases of Candida auris 2016. Available from:https://www.gov.uk/government/collections/candida‐auris. .
14.
Okinda N, Kagotho E, Castanheira M, Njuguna A, Omuse G, Makau P, et al. Candidemia at areferral hospital in sub‐Saharan Africa: Emergence of Candida auris as a major pathogen. Poster
presentation at: ECCMID 2013. 2013.
15.
Pappas PG, Kauffman CA, Andes DR, Clancy CJ, Marr KA, Ostrosky‐Zeichner L, et al. Clinicalpractice guideline for the management of candidiasis: 2016 update by the Infectious Diseases
Society of America. Clin Infect Dis. 2015:civ933.
16.
Cornely O, Bassetti M, Calandra T, Garbino J, Kullberg B, Lortholary O, et al. ESCMID*
guideline for the diagnosis and management of Candida diseases 2012: non‐neutropenic adultpatients. Clin Microbiol Infect. 2012;18(s7):19‐37.

Where can I find more information?
If you require any additional information, please contact NICD:

To notify the NICD if a new outbreak is suspected:− Nelesh Govender: 011‐555‐0353 / neleshg@nicd.ac.za OR− Kerrigan McCarthy: 011‐555‐0542 / kerriganm@nicd.ac.za; OR− Erika Britz: 011‐386‐6452 / erikab@nicd.ac.za OR− After-hours: NICD Doctor‐on‐call: 082 883 9920.
Please contact NICD before any isolates are referred:− Ruth Mpembe: 011‐555‐0325/ ruthm@nicd.ac.za OR− Gloria Zulu: 011‐555‐0323 / gloriaz@nicd.ac.za OR− NICD‐COTHI mycology reference laboratory 011‐555‐0381

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