Vancomycin-resistant Enterococci (VRE) Infection Prevention and Control Clinical Guideline
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Best practice for the management of patients colonised or infected with VRE in the acute and non-acute care settings.
Candida auris is a newly emerging, multi-resistant fungus (yeast) within the genus Candida. It was first recognised in 2009 in Japan where it was isolated from a sample taken from a patient with a localised ear infection. Subsequently there has been emergence of the organism in many countries including a small number of cases in Australia which have been acquired in overseas healthcare settings. C. auris is of particular concern as a result of difficulty in laboratory identification, the ability for spread within healthcare settings and resistance to multiple antifungal agents with subsequent high mortality rates.
C. auris may manifest as a spectrum of disease in humans. Asymptomatic colonisation occurs commonly and should be considered in patients who have had prior hospitalisation in countries with known C. auris. Blood stream infection (fungaemia) is a serious complication and the leading cause of death with up to 59% mortality reported in such cases. Other reported manifestations include otitis media, meningitis, osteomyelitis, peritonitis, pericarditis, wound infection (both superficial and deep), intravascular access device infection and urinary tract infection (Ong, 2017).
The majority of cases of C. auris globally have been healthcare acquired or linked. This is due to the ability of the organism to persist on surfaces in the hospital environment and form biofilms. There is evidence of persistent contamination of dry linen and a mattress for up to seven days (Chowdhary et al, 2017). Colonisation of humans is also a common feature of the organism with possibly indefinite duration. Strict infection control measures must be implemented to prevent spread of the organism in healthcare settings.
Several risk factors have been identified for acquisition of C. auris. The most significant risk factor is prior hospitalisation in a country with known C. auris. For a reasonably up-to-date map of countries where C. auris has been reported refer to the Centers for Disease Control & Prevention.
Other potential risk factors include: recent surgery (especially abdominal), diabetes, immunosuppression, presence of urinary catheter or central venous access device, prior or current broad spectrum antibiotic or antifungal use and prolonged hospital admission have all been identified as risk factors (CDC, 2017).
Awareness that a person may be at risk of being colonised with C. auris on admission to a healthcare setting is important in preventing further transmission.
At risk patients along with close contacts of newly identified cases should be screened with axilla and groin swabs, ideally whilst off antifungal medications for 7 days and not within 48 hours of using antifungal body washes. The laboratory should be notified that the screen is for C. auris. Patients with a positive culture will remain positive indefinitely.
Since C. auris is not currently a notifiable disease in Australia, infection prevention staff should work with their laboratory to ensure they will be promptly alerted when C. auris is suspected. Any suspected or confirmed case should be notified to the Infection Control Service, Communicable Disease Control Branch.
All patients identified with C. auris should be managed in a single room with standard and contact precautions along with strict adherence to hand hygiene measures.
Rooms should be cleaned daily with 1000 ppm available chlorine solution (or a TGA approved surface disinfectant with activity against Clostridioides difficile) and consideration given to discarding difficult to decontaminate items at time of patient discharge.
Shared patient equipment should be cleaned and disinfected after each patient use. Particular care needs to be taken when undertaking dressings, and managing or changing urinary catheters and other devices.
Refer to the “Further Information” section for links to infection control guidance documents.
As C. auris is frequently resistant to multiple antifungals, individual treatment of patients should be guided by an infectious diseases physician or clinical microbiologist.
The CDC has a useful set of information sheets for patients, laboratory staff and infection prevention and control staff.
Diagnosis, management and prevention of Candida auris in hospitals: position statement of the Australasian Society for Infectious Diseases (ASID)
For further information on the management on C. auris, contact SA Health’s Communicable Disease Control Branch.