Discussion

Candidozyma auris continues to spread across U.S. healthcare facilities despite containment efforts.^{Reference Lyman, Forsberg and Sexton7} We surveyed C. auris prevention practices in U.S.-based acute care SRN hospitals to better understand barriers to control and identify opportunities to improve prevention strategies. Two-thirds of participating hospitals reported having provided care to a patient with C. auris colonization or infection, with half of those also experiencing at least one C. auris outbreak. Prevention strategies commonly included contact isolation, with approximately half of hospitals surveyed also performing C. auris screening. Barriers to effective C. auris prevention focused on challenges when accepting patients from other healthcare facilities, including poor communication regarding C. auris status and perceived suboptimal infection control practices at the originating healthcare facility. The most helpful tools to improve C. auris containment included the development of effective decolonization regimens and standardized screening strategies.

Reported C. auris prevention practices varied among participating facilities, and there was no single element that was universally applied across SRN acute care hospitals. There was strong, but not universal, alignment across facilities regarding use of contact isolation, placement into single occupant rooms, and use of signage to notify staff of isolation status. Future prevention efforts should focus on aligning these critical prevention practices, as C. auris is known to rapidly contaminate the healthcare environment and may serve as an important intermediary of transmission.^{Reference Sansom, Gussin and Schoeny18} In contrast to other prevention practices, the use of targeted environmental disinfection was less consistent, although over 70% of participants did report ensuring the use of EPA list P products for environmental disinfection.¹⁷ Survey questions were not tailored to explore the reasoning behind facilities’ use of disinfectants outside of EPA list P products, and this represents an area for future research. Our current findings suggest that additional education and training in environmental disinfection is an area of opportunity to prevent C. auris spread, potentially through multimodal training approaches (ie, in-person teaching by experts as well as self-guided modules).^{Reference Sansom, King and Lucky19}

Our study adds to the growing body of literature regarding screening practices for C. auris. In a survey of 253 Emerging Infection Network facilities, 36% reported screening patients for C. auris.^{Reference Hennessee, Forsberg and Beekmann20} Another survey of French mycologists from facilities in France (n = 36) found that 31% were aware of C. auris screening being conducted in their facility.^{Reference Guitard, Bellanger and Dorin21} In the current survey, nearly 50% of participants reported screening for C. auris, which may reflect growing awareness of C. auris or the greater resources available to teaching hospitals,^{Reference Valencia, Arora, Ranji, Meza and Moriates22} who comprised most survey participants. Barriers to screening for C. auris in this study aligned with prior work,^{Reference Hennessee, Forsberg and Beekmann20,Reference Guitard, Bellanger and Dorin21} including limited microbiologic laboratory capabilities. Participants noted the development of standardized screening protocols for C. auris as the second most commonly reported tool to help improve C. auris containment. Expanded engagement of local public health departments to provide guidance and microbiologic support for screening may help contain C. auris spread. Additionally, development of strong regional collaborations between healthcare facilities to contain C. auris may be needed, which would facilitate alignment of screening protocols and communication of screening results.

Effective communication of patient C. auris status between healthcare facilities at the time of patient transfer was identified as an important barrier across multiple questions in our survey. Interfacility transfer communication is a major challenge due to gaps, inconsistencies and heterogeneity in practice.^{Reference King, Gilmore-Bykovskyi, Roiland, Polnaszek, Bowers and Kind23–Reference Ellingson, Noble and Buser25} Despite its importance, communication of C. auris status at the time of interfacility transfer has not been standardized and most jurisdictions in the U.S. do not have such interfacility communication requirements.^{Reference Ellingson, Noble and Buser25} Among states mandating interfacility communication of multidrug-resistant organism status, compliance is heterogeneous, with <50% using standardized communication processes.^{Reference Ellingson, Noble and Tran26} Some strategies to overcome this barrier have been developed, such as statewide web-based registries (eg, Illinois XDRO registry^{Reference Trick, Lin and Cheng-Leidig27}) for data exchange, but additional work is needed. Standardization and automation of clinical information sharing may improve the quality and safety of patient transitions, while simultaneously preventing C. auris spread at receiving facilities due to rapid initiation of prevention measures.

This study has several limitations. The survey was distributed to U.S.-based acute care hospitals, which may limit generalizability to global health systems. The SRN, as a consortium of hospitals with explicit interest in infection control practices, may not represent all acute care facilities in the U.S. and thus generalizability may be limited. Most participants self-identified as teaching hospitals; this may also limit generalizability because teaching hospitals may have more resources than community hospitals to implement prevention programs.^{Reference Valencia, Arora, Ranji, Meza and Moriates22} As such, our findings may overestimate the true prevalence of some practices, such as C. auris screening. The survey instructed participating facilities to describe their own screening practices, but not those performed by the public health department. Facilities that were reliant on public health for surveillance would not have reported this practice, and this should be taken into consideration when interpreting results. Inherent limitations of survey-based research should also be considered, such as non-response, recall and social desirability biases.^{Reference Vetter and Mascha28,Reference Vesely and Klöckner29} The influence of non-response bias is anticipated to be low within this report, as the majority of respondents completed all questions: four declined to answer detailed questions about screening for C. auris, but all respondents completed the sections detailing infection prevention practices. Strengths of this study include alignment of reported data with the previously described epidemiology of C. auris; for example, reports of antifungal-resistant strains are present in previously described geographic regions of the Northeastern U.S.^{1–Reference Zhu, Liu and Boekhout5} This study reflects the experience of the SRN facilities at the time of survey completion in 2024, and Figure 2 should not be interpreted with the implication that resistant isolates of C. auris are limited to regions marked within the figure.

In this survey of U.S.-based acute care SRN hospitals, we identified multiple barriers and potential solutions to improve C. auris infection prevention and control. Increased education and support for effective environmental disinfection and interfacility communication are potential targets for future interventions. Additionally, development of effective C. auris decolonization regimens and more discrete guidance for surveillance programs should be prioritized.