Candida auris in Dialysis Centers: What Four States Learned About Containing It

Candida auris is a fungus that is often resistant to several drugs and can spread quickly inside and between health care facilities, which makes it an urgent public health threat. Because the patients it infects are often already very ill or immunosuppressed and treatment options are limited, an estimated 39% of C. auris infections are fatal. Its ability to spread and its high antifungal resistance set it apart from most other Candida species.

Dialysis patients are especially exposed. People with end-stage kidney disease often need complex hospital care, use invasive devices, have weakened immune systems and regularly receive broad-spectrum antimicrobials. Dialysis centers add their own challenges: frequent invasive procedures and shared treatment areas. Yet no studies had examined whether C. auris spreads in dialysis settings.

A report in CDC's Morbidity and Mortality Weekly Report, written by the health departments of New Jersey, North Carolina, South Carolina and Tennessee, reviewed what happened when patients with C. auris turned up in five facilities that provide dialysis in those states during 2020–2023.

Why colonization matters

Patients colonized with C. auris often carry it indefinitely without ever getting sick. That makes it essential to find these carriers quickly, clean equipment and surroundings with an approved disinfectant such as a product on the Environmental Protection Agency's List P, and use the right transmission-based precautions.

In the report, a colonization case meant C. auris found by PCR or culture on swabs of the armpit, groin or nostrils taken for surveillance. A clinical case meant C. auris found in any other specimen taken during a patient's care, classified by where the specimen came from rather than by symptoms.

The patients and facilities

The cases came to light on quarterly calls CDC holds with health departments about C. auris infection control. In 2023–2024, the four states reported that people with positive C. auris tests had received on-site dialysis at five facilities, some of which had not known the patients' status.

There were six index patients, averaging 64 years old (range 38–79). Three were colonized and three had clinical cases, from blood, urine and wound specimens. Two were found at the same North Carolina outpatient center; both had received care in other states and at the same North Carolina hospital, at different times.

The response

Each index case set off a containment response following CDC's interim guidance for novel or targeted multidrug-resistant organisms:

1. notifying the facilities where the patient had received care
2. advising on infection prevention and control (IPC), including transmission-based precautions and proper cleaning and disinfection
3. testing the patient's health care contacts for colonization: people dialyzed at the same facility on the same or the next shift, or cared for in the same hospital or unit
4. recommending an on-site infection control assessment

Testing began as early as possible; South Carolina and Tennessee also recommended a second round 2 weeks later. Swabs were sent to each state's Antimicrobial Resistance Laboratory Network regional lab for PCR. In New Jersey and North Carolina, patients not on dialysis were tested too.

Before CDC published dialysis-specific guidance, advice for these centers was adapted from other settings: change gowns and gloves between patients; clean and disinfect the dialysis station between treatments with a List P (or, where appropriate, List K) product; schedule the patient for the last shift of the day, when traffic is lower and just before the daily terminal cleaning; and place the patient next to as few other stations as possible, such as at the end or corner of the unit. Isolation rooms were not required.

What they found

No spread. Testing of 174 potential contacts turned up no new colonization. One Tennessee patient tested positive, but that patient had already tested positive 4 months earlier, and the result had never been passed to the dialysis facility on admission.

Patients treated without extra precautions. Index patients received dialysis for up to 4 months after their first positive specimen, in some cases with nothing beyond standard dialysis IPC, because the facility had not been told. Even so, no transmission was seen. At the North Carolina center the two index patients overlapped for 2 weeks, but the one who tested positive first was under C. auris precautions throughout; their fungi were the same clade but judged unrelated by genetic comparison. Because the timing of colonization could not be pinned down, the authors could not rule out that an index patient had first been exposed at a dialysis facility.

Communication broke down. In three states, information about a transferred patient's C. auris status did not travel with them, once across state lines.

Facilities were wary. Outside these responses, dialysis centers told health departments they worried about treating patients with C. auris, citing open treatment floors, few isolation rooms and vulnerable patients. Two states reported patients being turned away by other dialysis centers for those reasons. One state assessed two facilities with CDC's Infection Control Assessment and Response tool and found no gaps.

Follow-through varied. Facilities in two states were slow to arrange colonization testing, citing no designated contact person and high staff turnover. One health department referred a facility to the state licensing body over IPC deficiencies; another state reported that clinical teams welcomed the testing.

Why standard precautions may have been enough

Dialysis centers already follow stricter routines than most other settings because of the heightened risk of contamination with blood and germs: frequent cleaning of equipment and surfaces with bleach solution, limits on shared supplies and instruments, and no shared medication carts. The authors suggest strict adherence to these standard dialysis practices may explain why no transmission was seen. Since isolation rooms are not required, a lack of them should not stop patients with C. auris from getting dialysis.

The study had limits: few states and facilities, some of them unlike the settings where most chronic outpatient dialysis happens; data collected secondhand, with little detail on the precautions each facility used; testing methods that differed by state; and, at two facilities, no breakdown of how many people tested were on dialysis.

Conclusions

With appropriate precautions, the report concludes, dialysis appears to be safely possible for patients whatever their C. auris status. Finding carriers, including those without symptoms, still matters, and better case coordination between dialysis centers and the facilities that transfer patients to them would let every recommended precaution start promptly. More research is needed on how common C. auris transmission is in dialysis and what drives it.

Sources

• Kurutz A, Innes GK, Sherman A, et al. "Candida auris Containment Responses in Health Care Facilities that Provide Hemodialysis Services — New Jersey, North Carolina, South Carolina, and Tennessee, 2020–2023." MMWR 74(25). https://www.cdc.gov/mmwr/volumes/74/wr/mm7425a1.htm
• The report's summary says five of the facilities did not know the patients' status; its abstract says five patients' status was unknown to the facilities treating them. This page gives neither count.