Date of last update: 5/24/2023

To help infection preventionists quickly activate Candida auris prevention efforts, APIC’s Emerging Infectious
Diseases Task Force has created a Candida auris Playbook that IPs can download and customize for use in
their facilities. The Playbook is a concise workflow document that is designed to be user-friendly and
operational for busy IPs.

Playbook: Candida auris

Candida auris has the potential to impact many organ systems, including infections of skin and soft tissue, ear, and
bloodstream which can have an impact on mortality rates.

Risk/Triage Scale - Level 1: Recommend situation awareness and planning.

Prioritized Audiences: Hospitals, long-term care facilities and public health

Identification
1) Screening Criteria
a. Case Definition (CDC-NNDSS, February 28, 2023)
i. Confirmed (Clinical): Person with confirmatory laboratory evidence from a clinical
specimen (either culture or validated culture-independent test (e.g., nucleic acid
amplification test [NAAT]) collected for the purpose of diagnosing or treating disease in
the normal course of care.
1. This includes specimens from sites reflecting invasive infection (e.g., blood, CSF)
and specimens from non-invasive sites such as wounds, urine, and the respiratory
tract where presence of C. auris may simply represent colonization and not true
infection. This does not include swabs collected for screening purposes.
ii. Confirmed (Screening): Person with confirmatory laboratory evidence from a swab (either
culture or validated culture-independent test (e.g., nucleic acid amplification test [NAAT])
collected for the purpose of screening for C. auris colonization regardless of site swabbed.
1. Typical screening specimen sites are skin (e.g., axilla, groin), nares, rectum, or other
external body sites. Swabs collected from wound or draining ear as part of clinical
care are considered clinical specimens.
b. Symptoms in C. auris positive patients: (CDC, April 9, 2021)
i. Symptoms of infections depend on the part of the body affected including bloodstream
infection, wound infection, and ear infection. (CDC, April 9, 2021)
ii. Prevalence of symptoms may not be noticeable because patients are often sick in the
hospital with another serious illness or condition. (CDC, April 9, 2021)
c. High-risk groups (CDC, May 29, 2020)
i. Highest risk groups for colonization and/or infection (CDC, April 9, 2021)
1. Patients with many medical problems
2. People with frequent hospital stays or who live in nursing homes
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 3. People with weakened immune systems from conditions such as blood cancers,
diabetes, lots of antibiotic use, indwelling devices (breathing tubes, feeding tubes,
catheters in blood & bladder)
ii. Close healthcare contacts of patients with newly identified C. auris infection or
colonization
1. At a minimum, screen roommates at healthcare facilities, including nursing homes,
where index patient resides in the previous month
2. Patients who require higher levels of care (e.g., mechanical ventilation) and who
overlapped (receiving care on the unit during the same time as the index case) on
the unit with the index patient for 3 or more days
iii. Patients who have had an overnight stay in a healthcare facility outside the United States
in the previous year, especially in a country with documented C. auris cases (CDC,
February 14, 2023)

2) Travel Considerations
a. Travel history to a country, region, or area where C. auris is prevalent
i. CDC provides a map of C. auris prevalence in United States (CDC, February 14, 2023)

3) Exposure Definition
a. Assess for recent travel, close contact/exposure to C. auris positive person, or close contact to
individual with recent travel within travel considerations above
b. Assess for symptoms within screening criteria above

4) Test Detection for C. auris

a. C. auris may be misidentified as a number of different organisms (including other Candida species)
when using traditional phenotypic methods for yeast identification; requires specific laboratory
equipment/testing for specificity. (CDC, December 14, 2022)
b. Work with local & state laboratories for additional guidance.

5) Test Collection Instructions

Active surveillance screening considerations
Skin (specifically axilla and groin) (CDC, December 14, 2022)
i. Use a culture collection transport system consisting of a Rayon tip or nylon-flocked swab
and tube with transport media.
ii. Rub all sides of swab tip over left axilla skin surface followed by the right side, targeting
crease in skin where arm meets the body (i.e., swab both armpits, swiping back and forth
5 times per armpit).
iii. Use same swab and rub sides of the swab tip over the left groin skin surface, targeting the
inguinal crease in the skin where the leg meets the pelvic region, repeat on right side (i.e.,
swab the skin of both hip creases, swiping back and forth 5 times per hip crease).
iv. Place soft end of collection swab into transport media, snap off end at marked line &
screw on lid.
v. Specimen should be tested within 4 days of collection or as otherwise indicated by testing
laboratory.
Active infection
For facility protocols for collecting fungal specimens (i.e., wounds, respiratory, blood, etc.)
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 Storage, Handling & Shipping Instructions
Inter-facility Shipping (CDC, December 6, 2022)
a. Use strict BSL2 Laboratory safety precautions including disinfectants with EPA approval for C. auris
b. Follow facility policies & procedures
Intra-facility Shipping
a. Follow guidance from receiving laboratory
6) Differentiation from Similar Diseases
a. Rely on clinical judgment and appropriate laboratory confirmation to differentiate from other
Candida species, along with antifungal treatment

7) Bioterrorism Threat
a. No guidance

8) Antimicrobial Resistance (CDC, May 29, 2020)

a. All C. auris isolates should undergo antifungal susceptibility testing according to CLSI guidelines. C.
auris is commonly multidrug resistant with varying levels of resistance across isolates.
b. Currently no established C. auris specific susceptibility breakpoints are available.

Prevent Transmission
1) Required Precautions for Patient Care
a. Type of precautions & how long they should be used
i. Contact Precautions (hospital) or Enhanced Barrier Precautions (long-term care) should be
continued for the entire duration of stay. (CDC, January 17, 2023)
ii. Evaluate stock of gowns, gloves, and procedure masks
b. Consider contacting your State Department of Health for additional PPE guidance.
c. Guidelines/restrictions about which healthcare providers can care for the patient
i. Consider dedicating healthcare personnel who provide regular care to these patients during
a shift when in dedicated units to decrease movement of HCP and equipment. (CDC,
January 17, 2023)
d. High-Risk Patient Care activities
i. Nursing homes and skilled nursing facilities: utilize either Contact Precautions or Enhanced
Barrier Precautions (CDC, January 17, 2023). Enhanced Barrier Precautions follows contact
precautions (gown and gloves) but is required only when providing high-contact resident
care which has anticipated exposure to blood, body fluids, secretions, or excretions. High-
contact resident care activities include (CDC, July 27, 2022) (CDC, January 25, 2023) (CDC,
June 2021)
1. Dressing
2. Bathing/showering
3. Transferring
4. Providing hygiene
5. Changing briefs or assisting with toileting
6. Device care or use: central line, urinary catheter, feeding tube,
tracheostomy/ventilator
7. Wound care
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 8. Physical and occupational therapy
9. Changing linens
ii. Hospitals (Acute care & Long-term acute care): utilize Contact Precautions for management
of patients with C. auris for the duration of their healthcare stay. (CDC, January 17, 2023)

2) Patient Room Placement (CDC, January 17, 2023)

a. Use single-patient room whenever possible
i. If there are a limited number of single-patient rooms, prioritize their use for patients with
higher risk of transmission (e.g., those with uncontained secretions or excretions, acute
diarrhea, draining wounds)
b. If single room is not available, cohort C. auris patients together
i. Maintain separation of at least 3 feet between beds.
ii. Use privacy curtains to limit direct contact.
iii. Have healthcare personnel change personal protective equipment (if worn), including
gloves, and perform hand hygiene before and after interaction with each roommate.

3) Precautions During Patient Transport

a. For patients on contact precautions, limit patient movement/transport outside of room unless
medically necessary.
b. Long-term care residents on enhanced barrier precautions should not be restricted to their rooms.
c. The receiving department should be notified of the type of the following prior to transfer:
i. See Recommended Transmission-Based Precautions (Contact or Enhanced Barrier
Precautions) (CDC, January 17, 2023)

4) Disinfecting the Environment and Shared Equipment

a. Provide dedicated noncritical medical equipment (e.g., stethoscope, blood pressure cuff, etc.).
When this is not possible, disinfection after use is recommended (CDC May 2022) (CORHA August
2022).
b. Use an EPA registered hospital-grade disinfectant effective against C. auris. (CDC, January 17, 2023)
See EPA’s List P. (EPA, February 2, 2023)
c. See local and state guidance for regulated medical waste considerations.
d. Consult your infectious waste hauler for additional assistance.

5) Air handling Considerations

a. CDC is not prescriptive about air handling for the room(s) where C. auris patients are bedded. Refer
to guidelines provided for individuals on contact precautions. (CDC, July 22, 2019)
b. Check with engineering to ensure the HVAC filters have been changed, per the preventative
maintenance schedule.

6) Incidence of C. auris
a. Calculating the Incidence of patients with C. auris infection may be helpful in determining staffing,
PPE, and infection prevention resources.

Providing Patient Care

1) High-Risk Procedures
a. No known high-risk procedures.
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 b. Considerations if Surgical Procedure is required
i. Patients colonized with C. auris undergoing surgical procedures may be at increased risk for
surgical site infections. Meticulous skin preparation in the operating room should be
performed using an alcohol-based agent unless contraindicated. (CDC, December 14, 2022)

2) Facility Operations
a. Linen management
i. Nursing homes and skilled nursing facilities: Changing linen is considered a high contact
resident care activity; gowns and gloves should be worn by personnel changing the linen of
residents on Enhanced Barrier Precautions (CDC, July 27, 2022)
ii. Hospitals (Acute care & Long-term acute care): Contact precautions (gown & gloves) are
required for all individuals entering the patient’s room, including housekeeping or EVS staff,
including when changing patient’s linens.
iii. No additional precautions for laundry processing. Follow facility processes.
b. Dietary considerations
i. Nursing homes and skilled nursing facilities: Gowns and gloves could be considered for
employees who have extensive contact with the resident or the resident’s environment.
(CDC, July 27, 2022)
ii. Hospitals: Contact precautions (gown & gloves) are required for all individuals entering the
patient’s room, including dietary staff.
iii. Disposable dishware and utensils not required. Follow facility processes.

3) Visitation management
a. Patients with a positive C. auris test may have visitors. Visitors must follow strict infection
prevention measures including appropriate use of PPE and hand hygiene before visiting and after
removing PPE. (LA County Department of Public Health, no date)

4) Infection Prevention Staffing Considerations

a. Facility should establish a C. auris infection limit per facility operations and capacity before
mobilizing increased infection prevention resources.

5) Post-Mortem
a. Follow facility, local and state guidance.

Patient Discharge
1) Communication Considerations
a. Provide the clinical update per facility policy.
i. Ensure relevant healthcare workers are apprised of what information should be included in
the discharge summary and/or referral for post-discharge placement.
ii. Understand requirements from local or state public health departments related to patient
discharge. They may require advanced notice about a C. auris patient moving between
facilities.
b. Notify ambulance/transportation service in advance of discharge about patient C. auris status.

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2) Patient Discharge Information
a. Include relevant clinical information in the discharge summary and/or referral for post-discharge
placement.
b. Patients and family should be instructed on the importance of hand hygiene.
c. Shared items should be cleaned and disinfected after patient use.
d. Wounds should be kept covered to prevent exposure to any drainage.
e. During any healthcare office visits, the patient should alert the office, hospital, or nursing home
that they have previously tested positive for C. auris. (CDC, May 29, 2020)

Occupational Health
1) Occupational Exposure Definition
a. The risk of C. auris infection to healthy individuals, including healthcare personnel, is very low.
(CDC, April 9, 2021)
b. For consideration
i. Employees who are known to have cared for a confirmed positive patient without the
proper PPE may be monitored for symptom development. Follow facility protocols.
ii. Patients that the employee cared for may also be tracked during their hospital stay. Follow
facility protocols.
c. Work with local health department for protocols.

2) Pre- and Post-Exposure Information

a. No screening protocol is currently recommended for employee exposure, given the low risk of
infection.
i. If an employee who took care of a confirmed positive patient without wearing the proper
personal protective equipment develops symptoms, assessment and treatment measures
should be guided by the healthcare institution’s occupational exposure protocol (CDC, April
9, 2021)

3) Vaccine Recommendations
a. No vaccine available

4) Exposure Workflow
a. Employee furlough from work should be directed by the treating physician.
b. Return to work criteria should be guided by the healthcare institution’s occupational exposure
protocol.

5) Contact Tracing
a. Staff who cared for the patient during the period when proper isolation was not established should
be monitored for signs and symptoms of C. auris disease.
b. Patients that the employee cared for can also be monitored during their hospital stay.

6) High-risk Employees
a. Consider employees who are immunocompromised at high risk. Patient care assignment
considerations should be noted so as not to place the employee at risk.

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Outreach Considerations for Healthcare Stakeholders
1) Messaging for Senior Leadership
a. Resources required
i. Consider a plan of when to escalate resource request to senior leaders/supervisor
b. Impact to business continuity
i. Anticipate how C. auris may impact daily operations and communicate to senior
leadership/supervisor

2) Marketing and Communications

a. Media management planning
i. Ensure public information officer (PIO) is updated regularly. If no PIO is in place, one should
be identified. This person is typically responsible for representing the facility during
interviews and media information requests.
b. Communication for hospital staff, and physicians
i. Identify preferred means for staff and physician communication
ii. Create a dated template so team becomes familiar with update format
iii. Consider how often staff and physicians want or need to be updated

3) Public Health
a. Case reporting requirements
i. Determine if C. auris is a reportable condition in your state. (CDC, October 5, 2022)
ii. Connect with local public health to understand what elements are required within reports,
and how often information should be reported
b. Case testing
i. Connect with local public health to understand testing criteria, and if permission must be
granted prior to testing. If permission is not required, public health may require notification
for testing.
c. Patient transfer
i. If the patient is discharged to another facility, ensure the receiving facility is aware of the
patient’s precaution status.
1. Connect with local public health to understand what reporting is needed prior to
patient transfer, or discharge.
2. Ensure effective communication of patient’s C. auris status upon transfer or
discharge to another healthcare facility. (Michigan Department of Health and
Human Services, Feb. 23, 2023)
a. Consider use of an interfacility transfer form (California Department of Public
Health, June 2021) (CDC, 2019) (Michigan Department of Health and Human
Services, no date)
ii. More information can be found above in the ‘Patient Discharge’ section.
d. Exposure communication
i. Connect with local public health to understand reporting requirements for healthcare
worker, patient, or visitor exposure.

4) Pharmacy
a. Prophylaxis procurement
i. No prophylactic treatment available
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 b. Vaccine procurement
i. No vaccine available
c. Treatment requirements
i. Connect with pharmacy to understand treatment options.
ii. Understand resistance patterns in your region in consultation with the local health
department to determine most appropriate choice of therapeutics.
1. Echinocandins are currently recommended as initial therapy for treatment of C.
auris infections (CDC, December 14, 2022)
iii. CDC does not recommend treatment of C. auris identified from noninvasive sites (such as
respiratory tract, urine, and skin colonization) when there is no evidence of infection.
Treatment is generally only indicated if clinical disease is present (CDC, December 14, 2022)

5) Partnering Laboratories
a. Testing methodologies
i. Connect with the laboratory to understand available testing methodologies.
1. Commercial testing for C. auris screening is not currently available. (CDC, February 7,
2023)
ii. Ensure clinical labs can identify C. auris. (Pennsylvania Department of Health, August 3,
2021, California Department of Public Health, July 2020)
iii. Determine facility policy; state and federal testing requirements.
1. Understand if speciation is required for all yeast isolates, or only certain ones.
2. Understand if speciation is required for specimens collected from both sterile and
nonsterile body sites.
3. Determine if specimens are required to be sent to a CDC Antibiotic Resistance
Laboratory Network (ARLN) (CDC, February 7, 2023)
a. Colonization testing for C. auris is available at no cost through the AR Lab
Network but may require coordination through state public health
department.
4. Antifungal susceptibility testing is required for all C. auris isolates (CDC, May 29,
2020)
iv. See “Public Health” above if local public health is involved in testing.
b. Testing procedure
i. Connect with the laboratory to understand testing procedure.
ii. Include testing procedures in communication to clinical teams.
iii. See “Public Health” above if local public health is involved in testing.
c. Specimen shipment
i. Ensure the laboratory is aware of shipping requirements and has the supplies on hand for
shipping requirements.
ii. Understand requirements of shipping specimens such as:
1. Temperature requirements
2. Packaging requirements
3. How soon the specimen needs to be received by the lab following collection
d. Turnaround time for results
i. Connect with the laboratory to understand testing turnaround times.
e. Results reporting
i. Connect with the laboratory to understand reporting workflow.
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 ii. Plan who and how the laboratory will communicate with for results. If testing is sent out,
ensure a point of contact is named.

6) Supply Chain
a. PPE days on hand reporting
i. Connect with supply chain coordinator to identify key PPE to monitor regularly
ii. Include senior leadership in the communication
iii. Identify reporting cadence
b. Contingency planning for PPE
i. Identify thresholds to begin conservation and contingency plans
ii. Provide PPE requirements so supply chain can identify back-up, alternate supplies in the
case of shortage
c. Specific supply planning categories may include:
i. Specimen collection supplies, test supplies
ii. Cleaning supplies and disinfectants planning
d. Patient care supply identification may include:
i. Treatment, or supportive care supplies, including anti-fungal medications

7) Education Resources for HCP and Consumers

Available
Target
Title Documents languages
Audience
Drug-Resistant Candida auris Everyone English

Candida auris: A drug-resistant Everyone English

germ that spreads in healthcare Spanish
facilities Vietnamese
Korean
Haitian
Candida auris Colonization Patients English
Spanish
Vietnamese
Korean
Haitian
Candida auris Testing Patients English
Spanish
Vietnamese
Korean
Haitian
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Candida auris: A drug-resistant Infection English
germ that spreads in healthcare Preventionists Spanish
facilities
A CDC message to infection preventionists

Candida auris: A drug-resistant Laboratory English

germ that spreads in healthcare staff Spanish
facilities
A CDC message to laboratory staff

Healthcare Facility Transfer Form Clinical staff English

Inter-facility Infection Control Clinical staff English

Transfer Form for States
Establishing HAI Prevention
Collaboratives

Candida auris Transfer Clinical staff English

Information Sheet

8) Additional Resources
 Centers for Disease Control and Prevention (CDC), Candida auris, December 27, 2022
 The Council for Outbreak Response: Healthcare-Associated Infections and Antimicrobial-Resistant
Pathogens (CORHA), 2021
 APIC Infection Prevention & You C. auris – A new Threat to patients, March 21, 2023

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