61-year-old Woman With Diabetes Mellitus and a Foot Ulcer

Presented by Dr Justin Hayes

Case Presentation

A 61-year-old woman with diabetes mellitus presented to the hospital with worsening pain, redness, and drainage from an ulcer on her right foot. The patient previously received multiple courses of antibiotic therapy for diabetic foot infections and resides at a long-term acute-care hospital (LTACH).

After admission, podiatry took the patient to the operating room for debridement and partial right calcanectomy. Operative cultures returned positive for methicillin-resistant Staphylococcus aureus and yeast. The yeast is identified as Candida auris. This is the first known case of Candida auris at your hospital.

What entity should be contacted as soon as possible?

  1. All LTACHs in the state
  2. Public health department
  3. The public
  4. Local media


Correct answer: 2. Public health department. Healthcare facilities that identify or suspect a case of C auris should contact local or state public health departments and CDC immediately for further guidance. In addition, C auris is a nationally notifiable condition and reportable in many states.1,2

Answers 1, 3, and 4 are incorrect. The healthcare facility is responsible for reporting to public health officials and other facilities where the patient was cared for or is being transferred to.

What isolation precautions are recommended for the patient?

  1. Contact precautions
  2. Airborne precautions
  3. Droplet precautions
  4. Airborne and contact precautions


Correct answer: 1. Contact precautions. The appropriate measures for preventing transmission of C auris are:

  • Hand hygiene
  • Contact precautions in hospitals
  • Cleaning and disinfection of the patient care environment and reusable equipment with recommended products (paying particular attention to high-touch surfaces)

In addition, the facility should also ensure:

  • Communication of the patient’s status when transferred
  • Screening contacts of new cases of C auris
  • Laboratory surveillance.3

Answers 2, 3, and 4 are incorrect. C auris is not spread via droplets or airborne mechanisms, so respiratory precautions are not needed.

Additional Points

For hand hygiene to prevent the spread of C auris, an alcohol-based hand sanitizer (ABHS) is the preferred method when hands are not visibly soiled. If hands are visibly soiled, washing with soap and water is recommended.3 The World Health Organization’s five moments of hygiene should be followed, which indicate that hand hygiene should be performed (1) before touching a patient; (2) before a clean/aseptic procedure; (3) after body fluid exposure risk; (4) after touching a patient; and (5) after touching patient surroundings.4 Visitors should also perform hand hygiene before and after visiting the patient.5

In terms of transmission-based precautions, healthcare providers should use contact precautions when caring for patients in hospitals and long-term acute-care facilities. These recommendations mirror those for patients who are infected with other multidrug-resistant organisms. These procedures include the donning of gowns and gloves on every entry into a resident’s room and doffing those gowns and gloves on exit.6

Additionally, a single-patient room is preferable for isolation. If a limited number of single-patient rooms are available, they should be prioritized for people at higher risk of pathogen transmission (eg, those with uncontained secretions or excretions, acute diarrhea, or draining wounds). Where possible, it is best to dedicate mobile medical equipment to the individual patient. For equipment that cannot be dedicated, staff should ensure the equipment is cleaned and disinfected adequately between uses.3

Since this is the first case of C auris at the healthcare facility, it is especially important to provide healthcare worker education about infection control and prevention, transmission routes, and other aspects of care. For example, staff need to be clear about who is cleaning what. Is it the healthcare workers themselves, or environmental services? Many public health departments’ investigations have found that healthcare providers are often unclear about who is responsible for cleaning mobile or reusable equipment and how it should be cleaned. Infection preventionists can create a “who cleans what” list to clearly designate responsibilities. They can also make sure that there is routine (at least daily) cleaning and disinfection of patients’ rooms and other places where patients receive care. They can also ensure that reusable equipment is cleaned after each use, labeled as cleaned and disinfected, and stored away from dirty equipment.3

What is an additional strategy to prevent transmission in your healthcare facility?

  1. Placing all patients on the unit of the case patient on antifungal prophylaxis
  2. Having all healthcare workers who came into contact with the patient screened for C auris
  3. Screening of patient contacts in order to identify colonized individuals needing isolation precautions to prevent spread
  4. Transfer the patient to another facility as soon as possible


Correct answer 3. Screening of patient contacts in order to identify colonized individuals needing isolation precautions to prevent spread

Screening contacts of the case patient is an additional strategy to prevent transmission of C auris in the healthcare facility. Screening to identify individuals who are colonized with C auris can be accomplished by testing with skin swabs of the axilla and groin. A screening strategy is important and can be informed by local epidemiology, patient risk factors, facility characteristics, and the purpose of the screening. Screening of individuals can be considered when there is an epidemiologic link to a case-patient or resident, patients with high-risk or concerning healthcare encounters, and patients with risk factors for acquiring C auris. Examples of patients who would be considered epidemiologically-linked include those7:

  • Sharing the same room, unit, or other care areas as a patient or resident with C auris, even if that person has been discharged
  • Receiving care from the same healthcare personnel during the same time as a person with C auris, OR
  • Being exposed to common mobile medical equipment that was used by a patient or resident with C auris, especially if there are concerns about adequate cleaning and disinfection.

Answer 1 is incorrect. Antifungal prophylaxis is not indicated for C auris. In fact, CDC only recommends treating patients with clinical disease.8

Answer 2 is incorrect. The CDC does not recommend screening healthcare workers for C auris.7

Answer 4 is incorrect. The patient should be provided appropriate care and transferred when necessary.


    1. Centers for Disease Control and Prevention. Surveillance for Candida auris. Reviewed February 14, 2024. Accessed April 2, 2024. https://www.cdc.gov/fungal/candida-auris/c-auris-surveillance.html
    2. Centers for Disease Control and Prevention. Tracking Candida auris.  Reviewed February 14, 2024. Accessed April 2, 2024. https://www.cdc.gov/fungal/candida-auris/tracking-c-auris.html
    3. Centers for Disease Control and Prevention. Infection prevention and control for Candida auris. January 17, 2023. Accessed April 2, 2024. https://www.cdc.gov/fungal/candida-auris/c-auris-infection-control.html
    4. World Health Organization. Your 5 moments for hand hygiene. May 5, 2009. Accessed April 2, 2024. https://www.who.int/multi-media/details/your-5-moments-for-hand-hygiene-poster
    5. Centers for Disease Control and Prevention. Candida auris information for patients and family members. Reviewed April 9, 2021. Accessed April 6, 2024. https://www.cdc.gov/fungal/candida-auris/patients-qa.html
    6. Centers for Disease Control and Prevention. Implementation of personal protective equipment (PPE) use in nursing homes to prevent spread of multidrug-resistant organisms (MDROs). Reviewed August 1, 2023. Accessed April 2, 2024.  https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html
    7. Centers for Disease Control and Prevention. Screening for Candida auris colonization in healthcare settings. Reviewed February 20, 2024. Accessed April 2, 2024. https://www.cdc.gov/fungal/candida-auris/c-auris-screening.html
    8. Centers for Disease Control and Prevention. Treatment and management of C. auris infections and colonization. Reviewed December 14, 2022. Accessed April 2, 2024. https://www.cdc.gov/fungal/candida-auris/c-auris-treatment.html


Jose Vazquez, MD, FACP, FIDSA

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


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

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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