Tennessee, New Jersey, North Carolina, and South Carolina evaluated by Alexandra Kurutz and Simone Godwin in review of C auris containment efforts in dialysis facilities using standard IPC measures.
Alexandra Kurutz, MPH
Image credits: LinkedIn
Simone Godwin, DVM, MPH, MS, CIC
Image credits: LinkedIn
Candida auris, a multidrug-resistant fungal pathogen, presents an ongoing challenge to infection control in healthcare settings due to its ability to persist in the environment and resist common antifungal treatments. While transmission has been documented in hospitals and long-term care facilities, data on containment in dialysis settings remain limited.
Between 2020 and 2023, six patients infected or colonized with C auris received dialysis at five outpatient facilities across four states, New Jersey, North Carolina, South Carolina, and Tennessee, for up to four months. Notably, five of the facilities were unaware of the patients' C auris status during treatment and applied only standard dialysis infection prevention and control (IPC) measures. Among 174 potentially exposed contacts, only one additional patient with previously known colonization was identified, with no new transmissions detected.
To better understand these findings and their implications for practice, Contagion spoke with Alexandra Kurutz, MPH, an epidemiologist at the Tennessee Department of Health specializing in dialysis-related infection prevention, and Simone Godwin, DVM, MPH, MS, CIC, an infection prevention expert with the CDC. They discussed IPC protocol effectiveness, communication breakdowns, and the role of targeted screening in outpatient dialysis settings.
Kurutz and Godwin: This outcome is one we considered given that standard dialysis IPC practices go beyond the usual precautions a healthcare facility would follow. Dialysis facilities already use bleach solutions as their primary disinfectant, which we know to be effective against C auris, and elements of personal protective equipment (PPE) are used and changed for each patient as a standard. Patients also typically receive dialysis on an outpatient basis and are only present in the facility a few hours, which equates to less time exposed compared to patients admitted to a hospital or residents of a nursing home for extended periods of time. There are some additional risks of infection with dialysis treatment such as an immune-compromised patient population and the access of indwelling devices, but we felt the standard dialysis IPC practices already address many of those risks. This is not to say additional precautions shouldn’t be taken with this and other particularly vulnerable patient populations, just that the baseline practices are already more extensive than in other settings.
Kurutz and Godwin: In all, we were not overly surprised that dialysis facilities can provide safe healthcare to patients regardless of their C auris status, and this is something we wanted to show dialysis groups that had expressed concern that they were putting other patients at risk by treating patients with C auris. The surprising part was that across different states, facilities, and settings, adherence was consistent enough that transmission was prevented even when the facility was not aware the patient had C auris. There can be a lot of variation in adherence to guidance across healthcare facilities—one person forgetting to perform hand hygiene and change gloves between patients can be enough for transmission to occur. Auditing IPC practices through methods such as the infection control assessment and response (ICAR) tool, and re-educating staff regularly, helps to ensure adherence is consistent.
Kurutz and Godwin: One suggestion that can help bridge the communication between dialysis facilities and other healthcare facilities includes filling out an inter-facility infection control transfer form, such as the example form provided by the CDC below. Filling out a similar form after every new or readmission a dialysis patient has to the dialysis setting can help catch any new information that may have been missed. We know dialysis patients may be admitted to hospitals intermittently given their underlying condition(s) and return to the dialysis setting at discharge. Catching these additional details, such as a pending test or a new multidrug-resistant organism (MDRO) diagnosis, can affect how quickly a patient is put on appropriate precautions.
Standard dialysis IPC protocols prevented C auris transmission across multiple facilities, even when patient colonization status was initially unknown.
Communication failures between care settings delayed containment, highlighting the need for consistent use of inter-facility transfer forms and data-sharing systems.
Targeted screening remains the preferred strategy for C auris in dialysis settings due to low transmission risk and limited public health resources.
Kurutz and Godwin: Looking to the future, more public health jurisdictions are exploring information exchange systems for patients with multidrug-resistant organisms. These platforms can be queried by healthcare facilities to determine if admissions have a historic or new diagnosis with an MDRO so they can be flagged for additional precautions. These systems are difficult to get off the ground, however, and there is some concern around patients’ MDRO status being used as a basis to deny care out of fear or lack of knowledge around how to prevent transmission. Projects like this multi-state effort help relieve those fears and bridge knowledge gaps when there is not much known about transmissions in certain settings.
CDC Inter-Facility Transfer Form:
https://www.cdc.gov/healthcare-associated-infections/media/pdfs/Interfacility-IC-Transfer-Form-508.pdf
Kurutz and Godwin: Due to the lack of evidence of increased transmission risk in dialysis settings for C auris, targeted screening seems to be the most effective approach. Targeted approaches include screening patients that are being transferred from high-risk settings like Long-term Acute Care Hospitals (LTACHs) or Ventilator-capable Skilled Nursing Facilities (vSNFs) and expanding screening when active outbreaks are occurring in the facility’s patient sharing network. Previously, public health jurisdictions could support broader screening approaches through federal funding and laboratory services, but recent changes to the public health funding landscape also mean these resources are more limited now. Facilities that are concerned about C auris or other MDROs in their area should work with their jurisdiction’s public health authorities to determine the best approach for their patients, as there is not a “one size fits all” approach when it comes to containment.
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