ABSTRACT
Background:Candida auris (C. auris) has been identified as an emerging pathogen of interest in healthcare settings. Its resistance to antimicrobials, high mortality rates, ability to persist in the environment and increasing instances of outbreaks in healthcare settings constitute major concerns among healthcare practitioners across the globe. To address concerns regarding preventing transmission of C. auris, the Public Health Agency of Canada (PHAC) conducted a literature review to inform guidance for the infection prevention and control of C. auris in hospitals and long-term care facilities (LTC).
Steven Ettles, HBMSc, MPH1*, Teri Wellon, MSc (HQ), BScN, RN, CIC1, Hannah Hardy, BSc, MPH, MBA1, Amanda Graham, BSc, MPH1, Chatura Prematunge, MSc, CIC1
1Centre for Communicable Disease and Infection Control, Public Health Agency of Canada, Ottawa, Ontario, Canada
*Corresponding author
Steven Ettles
Centre for Communicable Disease and Infection Control
Public Health Agency of Canada
130 Colonnade Road, Ottawa
Ontario, Canada, K1A 0K9
613-371-9702
Email: steven.ettles@phac-aspc.gc.ca
ABSTRACT
Background: Candida auris (C. auris) has been identified as an emerging pathogen of interest in healthcare settings. Its resistance to antimicrobials, high mortality rates, ability to persist in the environment and increasing instances of outbreaks in healthcare settings constitute major concerns among healthcare practitioners across the globe. To address concerns regarding preventing transmission of C. auris, the Public Health Agency of Canada (PHAC) conducted a literature review to inform guidance for the infection prevention and control of C. auris in hospitals and long-term care facilities (LTC).
Methods: Electronic databases were searched to identify peer-reviewed evidence published between database inception until September 7, 2023. Peer-reviewed primary evidence and literature reviews, in English or French, reporting on infection prevention and control (IPC) practices put into place to prevent transmission of C. auris in healthcare settings were eligible for inclusion. Title and abstract screening, full-text review, critical appraisal, and data extraction processes were performed by two reviewers using DistillerSR systematic review software and the PHAC Infection Prevention and Control Critical Appraisal Toolkit. A scan of grey literature was also conducted to inform the review.
Results: Thirty-two articles of medium- to high-quality detailing C. auris IPC were included in the review. Settings reporting no transmission beyond the index case were more likely to report the use of risk-factor-based screening, private accommodation with dedicated toileting facilities, the use of personal protective equipment (PPE) consisting of gown and gloves at all times and the application of no-touch cleaners and disinfectants.
Conclusion: Multiple IPC interventions appear to be effective at minimizing transmission. However, determining effectiveness is challenging due to variability in intervention reporting and due to the lack of understanding of C. auris burdens before and after their implementation. Increased vigilance with screening and reporting would be advisable, and future work would benefit from multi-centre comparison of interventions using prevalence data.
KEYWORDS
Candida auris, outbreak, transmission, healthcare, hospital, long-term care, infection prevention and control
INTRODUCTION
Candida auris (C. auris) has been identified as a pathogen of concern and a growing threat in healthcare settings globally. C. auris is an antimicrobial-resistant organism (ARO) that is often resistant to multiple classes of antifungals, which can limit the effectiveness of available treatments (Chen et al., 2020). It is also notable for its ability to cause invasive infections with high mortality (>40%) (Chen et al., 2020). Once C. auris becomes established in a healthcare environment, it can be difficult to eradicate and can lead to outbreaks (Eyre et al. 2018)
C. auris can become resistant to all available antifungal drugs (Carolus et al., 2021; Burrack et al., 2022), persist on surfaces and multi-use equipment for extended periods of time (Welsh et al., 2017; Biswal et al., 2017; Abdolrasouli et al., 2017), extensively contaminate healthcare environments (Adams et al., 2018; Kumar et al., 2019; Ruiz-Gaitan et al., 2019; Eyre et al., 2018; Patterson et al., 2021), and be resistant to quaternary ammonium-based hospital disinfectants (Cadnum et al., 2017; Heaney et al., 2020). Some of the most prevalent reported risk factors for C. auris colonization and infection include: prolonged exposure to broad-spectrum antibiotics (Bougnoux et al., 2018; Cortegiani et al., 2018; de Cassia Orlandi et al., 2018; Sarma et al., 2017), indwelling medical devices (Bougnoux et al., 2018; Cortegiani et al., 2018; de Cassia Orlandi et al., 2018; Sarma et al., 2017), diabetes mellitus (Bougnoux et al., 2018; Cortegiani et al., 2018; de Cassia Orlandi et al., 2018; Sarma et al., 2017; Taori et al., 2019), prolonged intensive care unit (ICU) hospitalization (Bougnoux et al., 2018; Cortegiani et al., 2018; de Cassia Orlandi et al., 2018; Sarma et al., 2017; Taori et al., 2019, Tsay et al., 2018), haemodialysis (Bougnoux et al., 2018; Cortegiani et al., 2018; de Cassia Orlandi et al., 2018; Sarma et al., 2017; Taori et al., 2019, Tsay et al., 2018), immunocompromised patients (Bougnoux et al., 2018; Cortegiani et al., 2018; de Cassia Orlandi et al., 2018; Sarma et al., 2017; Taori et al., 2019, Tsay et al., 2018), admission to a hospital or long-term care (LTC) facility outside of Canada, and transfer from a healthcare facility with an ongoing C. auris outbreak.
In Canada, numerous jurisdictions have existing guidance specific to C. auris, as do a number of international organizations, such as the Centres for Disease Control and Prevention, World Health Organization and Public Health England. However, there is frequent jurisdictional variation in different settings (e.g., acute vs. LTC) and specific guidance, for example variations in risk factor-based screening, screening sites and laboratory identification methods.
Reports of C. auris cases and outbreaks in healthcare settings globally, including across North America, have increased in recent years (Garcia-Bustos et al., 2021). Currently in Canada, C. auris is only reportable in the provinces of Alberta and British Columbia. From 2012 to 2023 a total of 53 C. auris cases had been reported to the Public Health Agency of Canada (PHAC), representing isolates for both colonized and infected cases submitted to the Agency voluntarily via the Canadian Nosocomial Surveillance Program (CNISP) and provincial/territorial reference laboratories, and in reportable provinces. The objective of this work was to identify and summarize C. auris infection prevention and control interventions (C. auris IPC) described in the literature to ultimately inform the development of guidance for C. auris in Canadian healthcare settings.
METHODS
Search strategy
A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Page et al., 2021). The search strategy was developed collaboratively by IPC experts and library information specialists. Population, Exposure, Intervention, Control and Outcomes (PEICO) criteria for the literature search are detailed in Table 1. Ovid MEDLINE, Embase, Global Health and Scopus bibliographic databases were searched for evidence published from inception up to September 7, 2023. In June 2023, a grey literature search of outbreak registries and IPC conference publications was completed. The reference lists of relevant literature reviews (n=20) were also scanned.
Study eligibility
The review aimed to inform guidance for Canada, focusing on countries with comparable healthcare settings and IPC practices. Eligible publications included primary evidence on C. auris IPC implemented in response to C. auris cases or transmission events in hospital or long-term care (LTC) settings in the following countries: Belgium, Canada, France, Germany, Italy, Japan, the Netherlands, Sweden, Switzerland, the United Kingdom, the United States, Australia, and New Zealand. Included evidence was restricted to English and French to ensure language comprehension during review. The primary outcomes of interest were the C. auris IPC interventions implemented and their effectiveness. News articles, editorials, commentaries, opinion pieces, policy statements and government white papers lacking primary evidence on C. auris IPC were excluded. Research on C. auris species distribution, phylogeny, antifungal susceptibilities, molecular identification, clinical outcomes, or treatments were also excluded.
Study selection and data extraction
Following article de-duplication, title and abstract screening, full-text review, data extraction was performed in duplicate by reviewers (SE, HH, CP, TW) using DistillerSR and Microsoft Excel. Conflicts were reviewed and discussed among reviewers until consensus was reached. A total of 2,342 reports were identified, after removing duplicates, 987 reports were retained and were screened for eligibility. Reports were excluded if they did not report a C. auris case or transmission in healthcare settings (n=475), or if they were not from a selected country (n=254). The remaining 257 reports underwent full-text review. Reports were further excluded if they did not describe a C. auris intervention (n=110), if the study was a review (n=71), an abstract (n=35), or if the appraisal tool rated the study as having low-quality evidence (n=9). After review and quality appraisal, 32 reports were included in the data synthesis.
Evidence synthesis
Studies providing relevant evidence appraised as medium or high-quality, as described by PHAC (PHAC, 2014) were qualitatively synthesized to reflect the hierarchy of controls as described by PHAC (PHAC, 2016). Basic descriptive statistics (i.e., proportions) were used to compare the reporting frequency of various interventions.
Evidence quality appraisals
Evidence included in the narrative synthesis was critically appraised using PHAC’s Infection Prevention and Control Guidelines Critical Appraisal Toolkit (CAT) (PHAC, 2014). Appraisals were completed in duplicate by four reviewers (SE, HH, CP, TW). Conflicts were discussed among all reviewers until consensus was reached. Conference abstracts were excluded from the critical appraisals due to limited reporting of study details and methodologies.
RESULTS
Overview of included studies
PRISMA results can be found in Figure 1. Thirty-two reports were appraised as providing medium quality evidence on C. auris IPC implemented in response to C. auris cases and/or transmission and were captured within the narrative synthesis (Tables 2 and 3).
Sixteen of the included studies described events that occurred in the United States, followed by the United Kingdom (n=5), Italy (n=2), Canada (n=3), Germany (n=2), Australia (n=2), France (n=1) and Japan (n=1). Nineteen studies described IPC interventions implemented in response to C. auris transmission events, while the remaining 13 studies described IPC interventions where C. auris was limited to the index case (i.e., no transmission).
Reports that detailed C. auris transmission events were more likely to include the use of multiple C. auris IPC interventions. Figure 2 shows the relative proportions of various IPC interventions described. In cases where no transmission was reported, authors were more likely to indicate the use of risk-factor-based screening, private accommodation with dedicated toileting facilities, the use of PPE consisting of gown and gloves, the use of contact precautions and the application of no-touch cleaners and disinfectants.
Engineering controls
Seventeen studies reported the use of some sort of private accommodation for C. auris-positive patients. Details about these accommodations, including the type of toileting facilities, were infrequently and inconsistently reported. Only one study specifically reported the use of “private toileting facilities” (Eckbo et al., 2021). Twenty-four studies reported the use of contact precautions and isolation. No variations in isolation, such as use of higher-level precautions or restrictions to movement, were reported.
Administrative controls
Admission screening
Factors considered to warrant C. auris screening on admission were variable across reports. Some of the reported risk factors for screening admissions included international medical transfers (Patterson et al., 2020), transfers from facilities with known C. auris transmission (Karmarkar et al., 2021) and history of antifungal use (Osbourne-Townsend et al., 2022).
Compliance monitoring
Multiple authors (n=12) reported utilizing auditing and/or
compliance monitoring processes in response to cases of C. auris. These processes often targeted hand hygiene and environmental cleaning. Hand hygiene audits, the presence of alcohol-based hand sanitizer (ABHS) in and outside of patient rooms, verification of adequate cleaning and disinfection by a unit manager or fluorescent markers on high-touch surfaces was reported (Austin et al. 2022, de St Maurice et al., 2023, Karmarkar et al., 2021, Lesho et al., 2018, Pacilli et al., 2020, Patterson et al., 2020, Prestel et al., 2021, Reimer-McAtee et al., 2021, Sticchi et al., 2023, Taori et al., 2019, Walits et al., 2020, Waters et al., 2023). Karmarkar et al. (2021) reported the used of environmental cleaning checklists in LTC settings to be effective at reducing C. auris transmissions. These checklists considered the type of disinfectant used, recommended wet contact time, procedures for mixing disinfectant solutions, PPE use, and environmental service staff cleaning protocols (Karmarkar et al., 2021).
Education
The delivery of information and education on C. auris to patients, families, staff and physicians was a part of C. auris IPC in a number of reports (Corcione et al., 2022, Eckbo et al., 2021, Hinrichs et al., 2022, Lesho et al., 2018, McGann et al., 2023, Osbourne Townsend et al., 2021, Pacilli et al., 2020, Sticchi et al., 2023, Taori et al., 2019, Walits et al., 2020). This education was provided in multiple formats, such as one-on-one or group huddles among staff (Eckbo et al., 2021), and written materials (e.g., educational posters) targeting patients and families (Corcione et al., 2022). Topics addressed included proper hand hygiene, proper use of PPE, as well as compliance monitoring results (Pacilli et al., 2020).
Stakeholder communications
Fourteen reports detailed the implementation of stakeholder communications. Communication strategies included alerts issued to health services or diagnostic laboratories (Adams et al., 2018; Eyre et al., 2018; Hinrichs et al., 2022; Karmarkar et al., 2021; Lane et al., 2019; Lesho et al., 2018; Reimer-McAtee et al., 2021; Worth et al., 2020), notifying public health authorities (Austin et al., 2022; Karmarkar et al., 2021; Lane et al., 2019; Reimer-McAtee et al., 2021; Waters et al., 2023; Worth et al., 2020), communications with transfer facilities (Austin et al., 2022; Karmarkar et al., 2021; O’Connor et al., 2019; Prestel et al., 2021; Sticchi et al., 2023), and engagement and communication with partners/colleagues at a local, national and international level (Austin et al., 2022; Eckbo et al., 2021; Reimer-McAtee et al., 2021; Waters et al., 2023). Austin et al. (2022) used a combination of these strategies, included hosting a conference call with partners to alert them to the transmission event and the facility’s plan.
Contact tracing
A majority of reports (n=26) recorded the use of contact tracing. Procedures for this practice were variable in terms of who was screened, frequency of screening and clearance criteria. Most reports indicated screening of patients only on the same ward or unit during contact tracing (Alanio et al., 2022; Brooks et al., 2019; Eckbo et al., 2021; Eyre et al., 2018; Lane et al., 2018; Lesho et al., 2017; McGann et al., 2023; Osbourne Townsend et al., 2021; Patterson et al., 2020; Prestel et al., 2021; Reimer-McAtee et al., 2021; Sticchi et al., 2023; Waters et al., 2023; Worth et al., 2020), whereas others screened patient contacts who had epidemiologic links to index patients (Adams et al., 2018; Austin et al., 2022; Corcione et al., 2022; O’Connor et al., 2019; Schelenz et al., 2016; Taori et al., 2019)(n=6). For example, Corcione et al. (2022) conducted screening for all close patient contacts, including patients who shared the same room with the index case, those who were cared for by the same healthcare staff and those who occupied the same bed of the index case after cleaning and disinfection. Weekly contact screening was the most common timeline for contact tracing (Alanio et al., 2022; Corcione et al., 2022; Eckbo et al., 2021; Eyre et al., 2018; Lesho et al., 2017; Osbourne Townsend et al., 2021; Patterson et al., 2020; Sticchi et al., 2023; Taori et al., 2019), followed by bi-weekly screening (Austin et al., 2022; Karmarkar et al., 2021; Waters et al., 2023).
C. auris negative screening swabs over three consecutive weeks was the accepted clearance criteria for contacts in six studies (Alanio et al., 2022; Eckbo et al., 2021; Eyre et al., 2018; Osbourne Townsend et al., 2021; Schelenz et al., 2016; Taori et al., 2019). This was established in a report published by Eyre et al. (2018), where they estimated the sensitivity of a single C. auris screen to be 78% and defined loss of colonization to be three consecutive negative screens.
Environmental cleaning and disinfection
C. auris outbreak assessments at multiple LTC facilities observed the use of inappropriate cleaning products (i.e., household cleaners), inadequate disinfectant concentrations, and uncertainty regarding cleaning frequency and surfaces cleaned by staff (Adams et al., 2018; Karmarkar et al., 2021).
Reports describing enhanced cleaning and disinfection of surfaces in the environment of a patient known to be C. auris positive mentioned the use of chlorine-based disinfectants (1:10 bleach/sodium hypochlorite solution or 1000pm chlorine-based solution), hydrogen peroxide, peracetic acid or sporicidal disinfectants. Details on enhanced cleaning frequency ranged from daily to up to four times a day and in case of spills or visible dirt (Alanio et al., 2022; Corcione et al., 2022; Eckbo et al., 2021; Lane et al., 2018; Lesho et al., 2018; Worth et al., 2020; O’Connor et al., 2018; Reimer-McAtee et al., 2021; Schelenz et al., 2016; Taori et al., 2019). Six reports stated cleaning frequency of high-touch surfaces was increased to more than two times a day (Alanio et al., 2022; Corcione et al., 2022; Eckbo et al., 2021; Reimer-McAtee et al., 2021; Schelenz et al., 2016; Taori et al., 2019). The addition of no-touch disinfection technologies, such as hydrogen peroxide vapor or ultraviolet-C light, in terminal cleaning practice was noted in 11 studies (Austin et al., 2022; Corcione et al., 2022; de St. Maurice et al.,2023; Lesho et al., 2018; McGann et al., 2023; Osbourne Townsend et al., 2022; Patterson et al., 2020; Prestel et al., 2021; Reimer-McAtee et al., 2021; Schelenz et al., 2016; Taori et al., 2019). Some cleaning processes were validated by supervisor or charge nurse inspections, cleaning checklists, adenosine triphosphate validation, and the testing of environmental surface swabs for C. auris (de St. Maurice et al.,2023; Karmarkar et al., 2021; Osbourne Townsend et al., 2022; Pacilli et al., 2020; Patterson et al., 2020; Taori et al., 2019). Furthermore, enhanced cleaning practices in some instances were coupled with extensive decluttering of the impacted wards/facilities (Eckbo et al., 2021; Eyre et al., 2018; Taori et al., 2019).
Similar to environmental cleaning, cleaning and disinfection of medical equipment mentioned the use of agents with established effectiveness against C. auris such as those mentioned above. It is worth noting that several C. auris transmission events were linked to improperly cleaned or difficult to clean equipment in the patient care environment, such as axillary temperature probes and lanyards (Eyre et al., 2018; Hinrichs et al., 2022; Patterson et al., 2020).
Fourteen reports mentioned environmental sample testing for C. auris contamination (Adams et al., 2018; Alanio et al., 2022; Corcione et al., 2022; Eyre et al., 2018; Hinrichs et al., 2022; Lesho et al., 2018; McGann et al., 2023; O’Connor et al., 2018; Osbourne Townsend et al., 2022; Pacilli et al., 2020; Patterson et al., 2020; Reimer-McAtee et al., 2021; Schelenz et al., 2016; Sticchi et al., 2023). These studies identified contamination on reusable and/or mobile devices/equipment (e.g., IV administration equipment, temperature probes, etc.), surfaces in C. auris positive patient rooms (e.g., recliner chair, bed rails, etc.), and to a minimal extent surfaces outside patient rooms (e.g., keypad and hand washing sink) (Adams et al., 2018; Alanio et al., 2022; Eyre et al., 2018; Lesho et al., 2018; Pacilli et al., 2020; Patterson et al., 2020; Schelenz et al., 2016; Taori et al., 2019; Waters et al., 2023). Most tested surfaces were C. auris negative after specified cleaning and disinfection regimens, but a small number of samples) from three studies, ranging from two to three surfaces per study, remained C. auris positive post‑cleaning and disinfection (Lesho et al., 2018; Patterson et al., 2020; Waters et al., 2023).
Laboratory identification
For the majority of studies (n=17) reporting their isolate identification methods, the use of Matrix-assisted Laser Desorption/Ionization Time-of-flight (MALDI-TOF) in the initial speciation of their isolates was identified (Adams et al., 2018; Alanio et al., 2022; de St Maurice et al., 2023; Eckbo et al., 2021; Lane et al., 2018; Worth et al., 2020; Lesho et al., 2018; Pacilli et al., 2020; Patterson et al., 2020; Prestel et al., 2021; Reimer-McAtee et al., 2021; Rowlands et al., 2023; Steinmann et al., 2021; Sticchi et al., 2023; Taori et al., 2019; Vu et al., 2022; Sexton et al., 2021). Two studies utilized whole-genome sequencing (Eyre et al., 2018; Lane et al., 2018) to identify isolates, and two sent isolates to a reference lab for identification, where specific methods were not reported (Sticchi et al., 2023; Rowlands et al., 2023). No issues with isolate identification (e.g., inaccurate speciation) using reported methods were identified. Confirmation of isolate speciation was also reported, in particular, sequencing of internal transcribed spacer regions half and D1D2 28s rDNA. The use of regional reference laboratories to confirm identification of isolates was also reported. These confirmations were frequently reported as being completed to ensure accurate species identification by the MALDI-TOF system.
Personal protective equipment
Twenty-six studies reported the use of PPE when caring for patients. Of the studies reporting details of type of PPE used (n=3), included gown and gloves (Hinrichs et al., 2022; Walits et al., 2020) and gown and gloves with an apron (Schelenz et al., 2016). No specific details were given on other PPE parameters such as gown fluid resistance or whether PPE should be worn at all times while in the patient care area.
Other interventions
Other reported C. auris IPC measures not captured within the above categories included chlorhexidine gluconate (CHG) bathing (Corcione et al., 2022; Eckbo et al., 2021; Hinrichs et al., 2022; Pacilli et al., 2020; Proctor et al., 2021; Schelenz et al., 2016; Taori et al., 2019), the use of ABHS hallway dispensers (Pacilli et al., 2020), increased presence of IPC professionals (Hinrichs et al. 2022), and increased frequency of changing and laundering of linens and gowns of cases and contacts (Eckbo et al., 2021). Although the effectiveness of CHG bathing in the reduction of C. auris skin bioburden is uncertain, several studies used this practice with patients who are C. auris positive (Corcione et al., 2022; Eckbo et al., 2021; Hinrichs et al., 2022; Pacilli et al., 2020; Proctor et al., 2021; Schelenz et al., 2016; Taori et al., 2019).
DISCUSSION
This review identified 32 reports detailing C. auris IPC interventions in hospital and LTC facilities with evidence applicable to Canadian settings. Reports with no onward transmission beyond the index case more often included the use of risk-factor-based screening, private accommodation with dedicated toileting facilities, the use of PPE and contact precautions and the application of no-touch cleaners and disinfectants. This suggests these C. auris IPC interventions may be effective at halting transmission of C. auris in healthcare settings, findings that are consistent with reviews conducted by others (Ahmad et al., 2021; Paudel, 2023; Sanyaolu et al., 2022; Asadzadeh et al., 2023).
The overall identified body of evidence was predominantly appraised to be of medium to high quality, providing some confidence regarding the incorporation of applicable findings into C. auris IPC guidance. However, as C. auris is an emerging pathogen, there is a general paucity of data regarding its environmental reservoirs, transmission dynamics and prevention. For instance, information regarding the role of linen management in C. auris IPC was limited. The role of linens and other surfaces in the transmission of C. auris should be better investigated, as recent evidence indicates that C. auris can survive in both planktonic and biofilm forms on various surfaces for up to three weeks (Dire et al., 2023), and has been found on surfaces such as identification lanyards during outbreaks (Patterson et al., 2021). Additional research regarding duration of precautions, risk factors for colonization/infection, and effectiveness of no-touch disinfection technologies for C. auris (e.g., UV) would fill vital gaps in current knowledge.
Although a number of relevant reports were identified, none directly measured the effectiveness of individual interventions on transmission. Most reported on a bundle of C. auris IPC interventions implemented following the identification of C. auris positive individual(s), and prevalence rates pre- and post-intervention were not reported. As such, it was difficult to ascertain the effectiveness of individual C. auris IPC measures. Muti-centre comparisons of varying outbreak interventions or investigations pre- and post-C. auris IPC would help to better determine the effectiveness of each intervention. Despite this knowledge gap, measures reported in this review were generally consistent with existing guidance recommendations.
A key strength of this review is that the search was limited to healthcare settings in G12 countries and New Zealand, to ensure compatibility of findings. However, due to variation in health standards and IPC practices, findings of these studies may not be generalizable to countries that are not part of the G12 and New Zealand. Further strengths of this review include the utilization of standardized evidence screening, extraction and appraisal processes, and the inclusion only of studies appraised as being of medium-to-high quality. Finally, to our knowledge, at the time of authorship, this was the first Canadian systematic review encompassing 986 articles on the management of C. auris, adding to the overall body of evidence regarding C. auris IPC.
This study was limited by the lack of statistical result pooling as there was a high degree of heterogeneity across settings and reporting of C. auris IPC. Furthermore, the possibility of reporting bias should also be considered, as only C. auris IPC interventions that were explicitly reported were captured and authors may be more likely to report successful C. auris IPC interventions and outcomes in comparison to less successful experiences. It is also possible that more specific details were left out to accommodate brevity in reporting of their experiences and do not truly represent the entire suite of interventions used. Additionally, while all instances of nosocomial transmission were explicitly reported by the authors, in reports identified as no transmission, there were several instances where reporting of lack of transmission was inferred based on report details, instead of being explicitly stated by the authors (e.g., it was reported that patients were placed on precautions on arrival due to other reasons and no transmission was reported by the authors), which should be taken into consideration when interpreting the results (Rowlands et al., 2023, Sexton et al., 2021, Schwartz et al., 2017).
In closing, this review identified numerous healthcare institutions reporting a lack of adequate screening as being an important factor in the introduction of C. auris to healthcare settings. In Canada, C. auris is currently only reportable in Alberta and British Columbia, and as such greater jurisdictional reporting of cases to public health authorities would be helpful in understanding the true C. auris burden in Canadian healthcare settings. Healthcare institutions would also benefit from timely identification and reporting of new cases, more robust risk-based patient screening programs, an overall awareness and suspicion of the possibility of C. auris colonization or infection during patient encounters and ensuring the application of fulsome C. auris IPC during patient care. Improved control of the spread of C. auris, and AROs in general, would help to reduce morbidity and mortality associated with healthcare-acquired infections, reduce spread to community settings, and help to improve anti-microbial stewardship.
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