Case of the Month

May 2017

Joy Cleghorn – with kind permission from Nelesh Govender

A 59-year-old man was admitted to an intensive care unit following a motor vehicle accident with a head injury and a ruptured spleen. The patient had a central venous catheter and urine catheter in situ. On day 7 of admission, he developed a low-grade fever and delirium. His platelet count dropped from 170 to 110 X 109 cells/L. He was started on empiric antibacterial treatment; blood and central venous catheter tip specimens were sent for culture. The infection prevention and control practitioner reminded the unit team that several cases of Candida auris infection had been confirmed in the ICU over the last month.

Question 1. What is Candida auris?

Answer to Q1

Candida auris is an emerging fungal (yeast-like) pathogen which has caused invasive infections and hospital outbreaks on several continents. The fungus is difficult to identify in the routine laboratory setting, is associated with high in-hospital mortality among patients with invasive infections and may be difficult to “eradicate” from the hospital environment.

Question 2. What infections does it cause?
Answer to Q2

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.

Question 3. What is the current situation in South Africa and why is there concern?
Answer to Q3

Overall Candida albicans is still the most common species causing invasive candidiasis. However, C. auris was the second most common cause of candidaemia in the private sector in 2016 based on laboratory-based surveillance for candidaemia conducted by the National Institute for Communicable Diseases, with most cases occurring in Gauteng province. In public-sector hospitals, C. auris was the fourth most common species of Candida causing candidaemia, again with most cases in Gauteng province. Overall, there have been over 2500 cases in South Africa to date (Govender NP, et al. unpublished data). Large on-going outbreaks have occurred at several Johannesburg and Pretoria hospitals, with most cases occurring in private- sector facilities.

Question 4. How is a case identified?
Answer to Q4

A case of C. auris can be identified as follows:

Question 5. How should a case of Candida auris infection be managed?

Answer to Q5

An echinocandin (i.e. caspofungin, micafungin or anidulafungin) or amphotericin B deoxycholate should be used as first-line therapy; depending on availability of these agents. Treatment should be adjusted, based on antifungal susceptibility results, as soon as available. Where feasible, every effort should be made to remove devices such as central venous catheters and urine catheters. Antifungal treatment duration is standard as for infections caused by 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:

Question 6. What infection prevention and control measures are appropriate to limit transmission?

Answer to Q6

Although the dynamics of transmission of C. auris are not clearly established, C. auris is known to contaminate 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:

  • 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) such as gloves and aprons before touching a patient or the patient’s immediate surroundings (e.g. bed linen, bed rails, personal belongings, invasive devices). PPE should be donned after application of alcohol hand rub and hands should be cleaned with soap and water followed by alcohol rub, after removal of PPE
  • Improved adherence to bundles of care for central venous and urine catheters, as well as tracheostomy care is essential
  • Hand hygiene practices among staff members should also be evaluated and adherence emphasised
  • 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 hand hygiene 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 the patient’s C. auris infection or colonisation 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, if feasible.
  • If a patient needs to be transferred to another healthcare facility, including a long term care facility, the referring facility should ensure that the receiving facility is appropriately notified of the patient’s C. auris infection or colonisation status.
Question 7. Should screening be performed in routine clinical care?
Answer to question 7
Routine screening for C. auris at the time of hospital admission is not currently recommended owing to limited evidence.


  1. National Institute for Communicable Diseases. Interim Guidance for management of Candida auris infections in South African hospitals. 2016. Available from: http://www.nicd.ac.za/index.php/interim-guidance-for-the-management-of-candida-auris-infections-in-s...
  2. https://www.gov.uk/government/publications/candida-auris-emergence-in-england/candida-auris-identified-in-england
  3. http://www.cdc.gov/fungal/diseases/candidiasis/candida-auris-alert.html
  4. Public Health England. Guidance for the laboratory investigation, management and infection prevention and control for cases of Candida auris (June 2016). Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/534174/Guidance_Candida__auris.pdf

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