42-year-old Man With Osteomyelitis and a C auris Infection

Presented by Dr Justin Hayes

Case Presentation

A 42-year-old man currently receiving antibiotic treatment with vancomycin for methicillin-resistant Staphylococcus aureus vertebral osteomyelitis at a long-term acute-care hospital presents to the hospital febrile. An initial exam is performed, and the right upper extremity peripherally inserted central catheter (PICC) is identified as a likely source of the fever. Blood cultures are immediately obtained, and the PICC line is subsequently removed. On day 3, blood cultures return positive for Candida auris. The catheter tip also returns positive for C auris. The patient is immediately placed on contact precautions and is currently on day 5 of micafungin 100 mg daily for therapy.1

How long should the patient remain on contact precautions?

  1. For duration of hospitalization
  2. For 48 hours
  3. Until the patient is reassessed for C auris colonization and this returns negative
  4. For 7 days

Click Here to View Answer and Discussion

Discussion:

Correct answer: 1. For duration of hospitalization

Because patients can remain colonized for months, or even indefinitely with C auris, the CDC recommends continuing contact precautions for the entire duration of an inpatient stay, including stays in long-term acute-care hospitals (LTACHs).1,2

Answers 2, 3, and 4 are incorrect because the patient should remain on precautions for the entire stay. Furthermore, the CDC does not recommend regular reassessment of patients’ colonization status.2

Case Continued

Environmental services staff inquire about disinfection procedures and protocols for the patient’s room.

What are the recommended agents for disinfection?

  1. Any household disinfectant product
  2. Environmental Protection Agency List P agents
  3. Environmental Protection Agency List A agents
  4. Environmental Protection Agency List C agents

Click Here to View Answer and Discussion

Discussion:

Correct answer: 2. Environmental Protection Agency List P agents

C auris can persist on surfaces, including multiple locations in patients’ rooms. The Environmental Protection Agency (EPA) has a list of products with claims for C auris. These are designated as List P.3 If these products are not available, the CDC recommends using EPA-registered products for Clostridioides difficile spores (List K).4,5

Appropriate cleaning and disinfecting of the patient-care environment (daily and terminal cleaning) and of reusable equipment with recommended products are essential, because C auris can persist for so long on healthcare surfaces. It is particularly crucial to focus on appropriate cleaning of shared mobile equipment (eg, glucometers, blood pressure cuffs), since these may be important sources of C auris spread. Ensure that environmental services personnel and healthcare providers are well trained on the use of these products, taking particular note of required contact times.2

Answers 1, 3, and 4 are incorrect because these types of cleaners are not considered acceptable for cleaning the patient-care environment or shared mobile equipment associated with a C auris case.

Case Continued

The patient is now hemodynamically stable with clearance of the fungemia.

When can he return to the LTACH?

  1. Once he has negative cultures for C auris
  2. As soon as he is stable for discharge
  3. Never
  4. After he has received antifungal therapy for 2 weeks

Click Here to View Answer and Discussion

Discussion:

Correct answer: B. As soon as he is stable for discharge

A patient infected or colonized with C auris can be transferred to another facility. That decision should be based on clinical criteria and the ability of the accepting facility to provide care.2 Of paramount importance, the receiving facility should be notified of the patient’s status, including the recommended transmission-based precautions. CDC has a specific tool to facilitate transfer, included in the reference list.6 In some states, use of this form is mandated.

Answer A is incorrect because overall clinical status is the deciding factor, not just C auris status.

Answer C is incorrect because patients can be transferred when stable.

Answer D is incorrect because it does not reflect the patient’s clinical status.

Click Here to View Resources

Resources

    1. Centers for Disease Control and Prevention. Candida auris information for patients and family members. Reviewed April 8, 2021. Accessed April 6, 2024. https://www.cdc.gov/fungal/candida-auris/patients-qa.html
    2. Centers for Disease Control and Prevention. Infection prevention and control for Candida auris. Reviewed January 17, 2023. Accessed March 27, 2024.https://www.cdc.gov/fungal/candida-auris/c-auris-infection-control.html
    3. United States Environmental Protection Agency. EPA’s registered antimicrobial products effective against Candida auris [List P]. Updated March 28, 2024. Accessed March 28, 2024. https://www.epa.gov/pesticide-registration/epas-registered-antimicrobial-products-effective-against-candida-auris-list
    4. United States Environmental Protection Agency. EPA’s registered antimicrobial products effective against Clostridioides difficile (C. Diff) spores [List K]. Updated February 26, 2024. Accessed March 27. 2024. https://www.epa.gov/pesticide-registration/epas-registered-antimicrobial-products-effective-against-clostridioides
    5. Centers for Disease Control and Prevention. Candida auris: A drug-resistant fungus that spreads in healthcare facilities. A CDC message for preventionists. Reviewed March 20, 2020. Accessed March 27, 2024. https://www.cdc.gov/fungal/candida-auris/fact-sheets/cdc-message-infection-experts.html
    6. Centers for Disease Control and Prevention. Inter-facility infection control  transfer form for states establishing HAI prevention collaboratives. Reviewed June 28, 2019. Accessed April 7, 2024.
      https://www.cdc.gov/hai/prevent/prevention_tools.html

Chair

Jose Vazquez, MD, FACP, FIDSA

Division Chief, Department of Infectious Diseases
Augusta University. Medical College of Georgia
Augusta, Georgia

Faculty

Mohanad M. Al-Obaidi, MD, MPH

Clinical Assistant Professor, Medicine
The University of Arizona College of Medicine
Tucson, Arizona

Justin F. Hayes, MD

Clinical Assistant Professor, Medicine
Co-Director, Antimicrobial Stewardship Program
The University of Arizona College of Medicine
Tucson, Arizona

Sophie Jones Allen, PhD, MSc

Epidemiologist
Centers for Disease Control and Prevention
Atlanta, Georgia

Meghan Lyman, MD

Epidemiology Team Lead
Medical Officer
Mycotic Diseases Branch
Division of Foodborne, Waterborne, and Environmental Diseases
Centers for Disease Control and Prevention
Atlanta, Georgia, USA

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