Candidozyma (formerly Candida) auris (C. auris), is a multidrug-resistant fungus associated with high mortality and numerous healthcare-associated transmission worldwide. Reference Ademe and Girma1 C. auris outbreaks pose unique infection prevention and control (IPC) challenges in mental health settings, where communal living arrangements and complex patient behaviors can hinder effective implementation of standard IPC measures.
Therefore, it differs from an acute general hospital, for which guidelines are largely designed. In contrast, patients in mental health settings often have different medical profiles, typically presenting with less severe medical conditions and fewer risk factors for C. auris, such as indwelling medical devices or the need for mechanical ventilation.
Outbreak description: In June 2021, a 65-year-old long-stay patient at the Institute of Mental Health (IMH), a 2,000-bed tertiary psychiatric hospital in Singapore, was found to be colonized with C. auris. Due to multiple macerated skin lesions, fungal cultures were taken from his hands, axillae, buttocks, and interdigital spaces, all of which grew C. auris. The IPC team responded immediately by isolating the index patient in a single room with an attached toilet, implementing contact precautions, restricting ward movement, and initiating enhanced surveillance. Group therapy and communal activities were temporarily suspended following detection of the index case to minimize the risk of transmission in shared ward and communal areas and prevent inter-ward spread. Given the ward’s open-layout environment, where patients often reside for extended periods, interact freely, and frequently share personal items, all 48 patients underwent screening for C. auris colonization as part of contact tracing efforts. Screening was performed using culture-based testing on nasal, axillary, and groin swabs collected from all patients, with additional wound swabs obtained from those with chronic skin lesions. This contact screening identified two additional colonized patients, both of whom had shared a room with the index case. Whole genome sequencing verified the three isolates as clonally related (0–2 single nucleotide polymorphism differences) and South Asian Clade I carrying the Y132F mutation in the ERG11 gene associated with fluconazole resistance. The entire ward underwent terminal cleaning twice using 5,000 ppm sodium hypochlorite, covering all patient areas, communal spaces, and shared equipment. The first round of terminal cleaning was performed following the identification of the index case, whereas the second round was carried out after two additional patients were found to be colonized with C. auris.
Adaptation of IPC Protocols: International guidance suggests that C. auris colonization may persist indefinitely. 2 Long-term contact precautions are generally recommended. However, indefinite isolation was impractical in this psychiatric ward as prolonged isolation would negatively impact patients’ mental health and recovery. In consultation with Singapore’s National Infection Prevention and Control Committee (NIPC), the IPC team implemented a clearance protocol to safely discontinue isolation. The index case had a negative first clearance swab 19 days after detection, whereas the two additional colonized patients had negative first clearance swabs 15 days after detection. All three patients tested positive for C. auris on only a single occasion. Following four weeks of consecutive negative surveillance screens, patients were de-isolated and returned to their unit, with monthly surveillance screening continued for six months. No additional clinically identified C. auris cases have been detected since the outbreak, suggesting effective containment; however, asymptomatic colonization cannot be excluded as routine surveillance screening was not continued after de-isolation.
Challenges and Tailored Strategies: The outbreak revealed several challenges requiring specialized interventions, as summarized in Table 1. Notably, staff shortages and resource constraints during the concurrent COVID-19 pandemic which required redeployment of personnel to maintain containment efforts. Patient non-compliance with general hygiene (eg, sharing items, sleeping in others’ beds) necessitated repeated education and visual reminders.
Challenges and tailored IPC strategies
Table 1. Long description
A table with two columns and six rows. The first column is labeled ‘Challenges’ and the second column is labeled ‘Tailored IPC strategies’. Row 1: Prolonged isolation not feasible for psychiatric patients (potential harm to mental health), Implemented a C. auris clearance protocol (approved by NIPC Singapore) with weekly screening for 4 weeks followed by monthly screening for 6 months; patients were deisolated after sustained negative screens. Row 2: Limited staffing and resources (eg, COVID-19 pandemic strain on workforce), Redeployed and allocated additional staff from other wards to support outbreak containment; ensured essential supplies (PPE, disinfectants) were maintained. Row 3: High risk of transmission in communal and ward areas, Positive cases were immediately isolated, and the entire ward were treated as contacts rather than limiting tracing to individual cubicles. Terminal cleaning was performed throughout the ward, including all communal areas. Row 4: Non-compliance with hygiene practices (for example, sharing of personal items, lying on the floor, sleeping on other patients’ bed, and sharing linen), Conducted repeated staff and patient education on hygiene and IPC practices. Posters on hygiene practices were displayed as visual reminders to both staff and patients. Row 5: Potential for inter-ward transmission during group activities, Shared equipment and tools were disinfected with 5,000 ppm chlorine-based disinfectant. Paused inter-ward group therapy and recreational activities during outbreak management. Activities resumed after contact tracing identified no further cases, whereas affected patients remained isolated under targeted IPC measures. Row 6: Patient refusal to be swabbed, Sought help from ward staff and medical teams to explain and obtain agreement from patients. Established rapport with patients was key to improving compliance.
Outcomes and Lessons: The successful containment of the C. auris outbreak at IMH underscores the importance of early detection, rapid isolation, and aggressive contact precautions in high-risk settings. Equally critical was the multidisciplinary collaboration among psychiatry, infectious disease, nursing, environmental services, and administrative teams to implement IPC measures effectively. Behavioral and environmental factors unique to mental health facilities must be accounted for when designing IPC protocols, as standard hospital practices may not be directly applicable. This experience highlights the need for adaptable, setting-appropriate IPC strategies in mental healthcare environments.
