Guidance

Management of patients who test positive for C. auris (colonised or infected)

Updated 19 March 2025

Note: numbers in round brackets refer to references which can be found in the References section.

Patient isolation and cohorting

Recommendations

Isolate or cohort patients colonised or infected with C. auris.

Use standard infection control and transmission-based precautions (contact precautions) for direct contact with the patient or their immediate environment.

Use clinical and screening microbiology to guide cohorting decisions, including for other multi-drug resistant organisms (MDROs) as appropriate.

Consider assigning dedicated staff to care for C. auris positive patients, particularly during outbreaks.

Isolate patients colonised or infected with C. auris in a single room with en-suite sanitary facilities where possible, or with their own commode, on contact precautions (see ‘Infection prevention and control’ section). Co-occurrence with other MDROs has been observed, particularly in patients with a history of overseas travel.

Screening for relevant MDROs, including Enterobacteriaceae (CPE) and meticillin resistant Staphylococcus aureus (MRSA), is advised based on known risk factors for colonisation or established local policies.

In the case of multiple positive patients, decisions to cohort should be guided by clinical and screening microbiology.

Consider assigning dedicated staff to care for patients affected by C. auris, where possible, and particularly in an outbreak situation.

De-isolation

Recommendation

Maintain isolation or patient cohorting until discharge for patients colonised or infected with C. auris.

There is currently no evidence to support the de-isolation of patients found to be colonised or infected with C. auris during their hospital stay, as carriage appears to be protracted in this context.

The U.S. Centers for Disease Control and Prevention reports (CDC) reports cases of colonisation for more than a year and suggests colonisation may remain indefinitely, even after treatment for invasive disease. In the UK, colonisation of C. auris positive patients has been observed to be sustained for long periods including post-discharge from critical care.

Readmission of the previously positive patient

Recommendation

Maintain isolation or patient cohorting on re-admission for patients colonised or infected with C. auris.

Continuous carriage for more than a year after initial isolation of C. auris has been documented and routine screening of previously positive inpatients may produce unreliable, intermittent negative screens (8). Due to the uncertainty about how long people may remain colonised, a precautionary approach to patient isolation is advised on readmission where feasible and appropriate for patient management and hospital pathways.

Exceptionally, if bed pressures limit the availability of isolation facilities, previously positive patients could be considered for de-isolation after demonstrating persistent culture negativity over several years. It is advised that de-isolated patients are regularly screened, with ongoing risk assessment, including review of external pressures that may promote re-emergence (for example, antimicrobial selection pressure) and factors that may increase the risk of invasive disease (such as invasive medical or vascular access devices).

Treatment of the infected symptomatic patient

Recommendations

Do not offer treatment to patients colonised with C. auris unless there are clear signs or symptoms of clinical infection. This includes isolates identified from the respiratory tract, urine or wounds.

Use an echinocandin as the first-line empirical treatment for C. auris infection in adults, children and neonates.

The approach to the initial management of candidaemia or invasive candidiasis due to C. auris remains the same as with all invasive candidiasis, and includes source control, clearance blood cultures and excluding organ involvement (25, 26).

Patients should be monitored for clinical improvement, with follow-up cultures and susceptibility testing, as resistance can develop during drug exposure. This includes monitoring for treatment failure and late microbiological recurrence (27, 28).

Considering antifungal resistance patterns identified across all known C. auris clades, first-line therapy remains an echinocandin, pending susceptibility testing. Most C. auris isolates described worldwide are resistant to fluconazole and therefore fluconazole should not be used for treatment or de-escalation. Liposomal amphotericin is recommended for patients infected with echinocandin-resistant C.auris, those experiencing treatment failure or breakthrough infection on an echinocandin, or those with infections at sites poorly penetrated by echinocandins (such as the CNS or eye). For CNS candidiasis, combination therapy with liposomal amphotericin and flucytosine is recommended (25).

There is currently insufficient evidence to recommend combination therapy for all patients with invasive C. auris infection. In vitro studies, including on multi-drug resistant C. auris isolates, lend support to further pre-clinical and clinical investigation of combination therapies using existing and novel antifungal agents (29 to 35). At present, combination therapy could be considered in patients with echinocandin-refractory or relapsed infection, particularly at foci with reduced echinocandin penetration (peritoneal fluid) (36). The antifungal flucytosine demonstrates activity against many C. auris isolates; however, it should only be used in combination and not added as a single drug to a failing regimen, as resistance develops rapidly.

There are several newer antifungal agents at various stages of development, including novel first-in-class drugs (37 to 39). These may offer additional options for the treatment of C. auris infections, particularly for emerging pan-resistant strains as they come to market.

 Antifungal resistance is more commonly observed in isolates from the intra-abdominal cavity compared to those from blood culture isolates. Given the potential for emerging echinocandin resistance on treatment, repeat susceptibility testing of multiple isolates over time is recommended . For detailed treatment regimens, the ‘Global guideline for the diagnosis and management of candidiasis’ should be consulted (25).

Clinicians are advised to make decisions on a case-by-case basis depending on the site of infection. For complicated cases, advice regarding C. auris management should be sought from clinicians with a specialist interest in mycology or reference laboratories.

Neonatal invasive candidiasis due to C. auris

Neonatal invasive candidiasis carries a high risk of disseminated disease, including CNS involvement. Candida meningoencephalitis occurs in 15 to 20% of cases of invasive candidiasis and may contribute to increased mortality and long-term neurodevelopmental abnormalities (25). The principles of management are similar to those in adults.

In the UK, C. auris neonatal colonisation remains rare and invasive infections have not been reported. Internationally, amphotericin B formulations have traditionally been the treatment of choice for invasive C. auris in neonates due to their CNS penetrance. Given C. auris resistance rates to amphotericin B are approaching 20%, echinocandins – particularly caspofungin and micafungin – are recommended as the empirical treatment of choice for neonates in the UK. Echinocandins are increasingly used for invasive candidiasis in the neonatal setting, with growing evidence supporting their safety and efficacy (25, 40, 41).

Decolonisation and skin antisepsis

Recommendation

Do not routinely offer decolonisation therapy to C. auris patients.

There are no established routine protocols for decolonisation of patients with C. auris and the evidence base does not support routine decolonisation (42). Clinical experience to date has shown that colonisation may persist despite a range of approaches and is difficult to eradicate, making infection prevention and control (IPC) strategies particularly important. Persistence may also be associated with recolonisation from the environment.

According to in vitro evidence, C. auris is susceptible to chlorhexidine, however activity may depend on formulation, biocide concentration, the presence of alcohol, and contact time used (43 to 45). Skin decontamination with chlorhexidine (twice-daily with 2% chlorhexidine gluconate wipes or once daily with 4% chlorhexidine gluconate aqueous solution), mouth gargles with 0.2% chlorhexidine, and/or chlorhexidine-impregnated pads for vascular catheter exit sites may be considered on a case-by-case basis, such as for certain high-risk procedures or patient groups, or in settings where there is ongoing transmission despite other IPC measures and interventions. However, there are documented failures of this approach in the literature (46). Octenidine-based products have also demonstrated efficacy in vitro (25).

There is limited evidence for use of topical nystatin and terbinafine in decolonisation (47). This may be considered for targeted management of high-risk sites such as venous cannula entry sites. The drug preparation, including inactive substances, should be checked for device compatibility. Special attention should be paid to known carriage sites such as the axilla, groin, and perineal area. After each wash the patient should be provided with clean bedding, clothes and towels.

Both alcohol-based chlorhexidine and povidone-iodine skin preparations may be considered for skin antisepsis prior to invasive procedures such as line insertions or surgical procedures in colonised patients to reduce the risk of invasive infection. Follow contact times as advised by the manufacturer to optimise efficacy. The use of chlorhexidine impregnated protective discs for centrally-sited intravascular catheters and arterial lines may be useful in minimising the risk of invasive infection, although not specific for C. auris (48).

Antimicrobial stewardship

Recommendations

Ensure appropriate antimicrobial use and stewardship to optimise service user outcomes and reduce the risk of adverse events and antimicrobial resistance (Criterion 3, Health and Social Care Act 2008).

Prioritise antimicrobial stewardship interventions in outbreak settings to reduce exposure to antimicrobials.

Prolonged exposure to broad-spectrum antibiotic and antifungal agents are identified risk factors for C. auris colonisation and infection (49, 50). It is important to ensure antibiotic and antifungal stewardship programmes are embedded and optimised within healthcare settings (51). Antifungal stewardship interventions have led to improvements in outcomes, safety and side-effect profiles, cost and time to effective therapy, and decreases in antifungal consumption (52 to 54).

In outbreak settings additional focus on antimicrobial stewardship interventions are recommended.

Measures to reduce exposure to broad spectrum antimicrobials include:

• local review of guidelines and prescribing practice
• ensuring the shortest effective course necessary
• appropriate use of diagnostics and biomarkers to guide commencement and duration of antimicrobial therapy
• optimising intravenous (IV) to oral switch of antimicrobial agents to reduce the use of invasive lines and devices

Measures to reduce exposure to antifungal agents include:

• review of antifungal treatment guidelines to support appropriate management of C. auris
• review of antifungal prophylaxis guidelines, particularly the use of triazoles, which are associated with increased risk for C. auris
• dedicated antifungal stewardship rounds on affected wards or units, if not already routine

Patient communications

Recommendations

Provide comprehensive information on C. auris to patients, ensuring materials are accessible and available to support non-English speakers.

Clearly document and record the patient’s infection status and communicate to receiving healthcare providers upon discharge or transfer.

Patients should be fully briefed on their condition and advised on how to prevent both onward transmission and entry of the organism into wounds or other broken skin. An information leaflet for affected patients and relatives is available.

English may not be a patient’s first or familiar language, therefore patient information should be made accessible to the patient via their preferred means.

C. auris colonisation or infection information should be clearly visible on the patient record and included in any discharge summary or patient transfer documents. Where a patient is transferred, information should also be communicated directly with IPC representatives at the receiving hospital or community care facility, such as supported living, custodial settings, care homes, mental health facilities, and learning disability and care settings of working age people.

If positive results become available after discharge or transfer, information should be relayed to the receiving hospital, care facility or general practitioner for onward communication to the patient and relevant public health action.