Introduction
First identified in Japan in 2009, Candidozyma auris (formerly known as Candida auris, C. auris) has since been reported in more than 60 countries. Reference Shing, Chen and ES-k.1 It causes invasive infections with a crude mortality rate reaching 78%. Reference Shing, Chen and ES-k.1,Reference Zhang, Zhong and Chen2 Therefore, the World Health Organization has recognized C. auris as a critical priority pathogen. Reference Gaetano, Midiri and Mancuso3
In Israel, the first cases appeared in 2014–2015 at two hospitals in Tel Aviv. Subsequent surveillance revealed a low incidence and few significant nosocomial clusters. Reference Biran, Cohen and Finn4 Controlling C. auris remains challenging; it colonizes patients, survives on surfaces for months, and often resists common disinfectants. 5
In 2019, a 12-bed state-of-the-art intensive care unit (ICU) opened at Barzilai Medical Center. This unit experienced a nearly three-year outbreak starting in August 2023. We share our experience managing this prolonged outbreak and outline the interventions our infection prevention and control (IPC) team implemented, which ultimately led to a radical environmental intervention.
Methods
Patient screening and microbiological identification
We maintained an active surveillance program throughout the outbreak period. Universal contact precautions were mandated for all patients admitted to ICU. Surveillance screening was performed at admission, weekly (every Sunday), and 3 days after any initial positive screen. For patients discharged from the ICU to general medical wards, active surveillance was maintained in isolation for 14 days, with mandatory screening on days 0, 7, and 10.
Patient screening was performed using Amies gel swabs (Copan Diagnostics, Brescia, Italy) to sample the bilateral nostrils, axillae, and groin. Swabs were inoculated onto selective chromogenic media (Chromagar Candida Plus, Hylabs, Rehovot, Israel) and incubated for 48 hours at 36°C–37°C. We confirmed fungal isolates with characteristic colony morphology using Matrix-Assisted Laser Desorption Ionization-Time of Flight mass spectrometry (MALDI Biotyper Sirius, Bruker, Massachusetts, USA). Rapid molecular screening was performed using polymerase chain reaction (CFX96, Bio-Rad Laboratories, California, USA) with the AURIS-ID amplification kit (IMMY-MDX, Braintree, UK).
Environmental surveillance
To identify persistent reservoirs, we conducted systematic environmental sampling across three sampling intervals during the endemic period, yielding 550 environmental samples. We used sterile sponges premoistened with neutralizing buffer (Hygiene sponge sampling kit, Technological Services Consultants Ltd., Lancashire, UK) or eSwabs (Copan Diagnostics, Brescia, Italy). Targeted surfaces included high-touch areas, medical equipment, and storage facilities.
Sponges and swabs were enriched in 30 ml of Sabouraud Dextrose Broth at the collection site and transported to an external reference laboratory. Aliquots were inoculated onto Chromagar Candida Plus plates and incubated for 72 hours at 36°C–37°C. Species identification of positive cultures was validated via MALDI-TOF mass spectrometry.
Standard daily and terminal disinfection protocols during the baseline period used automated dilution centers delivering sodium hypochlorite at 5,000 ppm (Sano Professionals, Emek Hefer, Israel) or advanced peracetic acid (APA, Clinell, GAMA Healthcare Ltd., Hertfordshire, UK). For daily cleaning, routine cleaning personnel used 2,000 ppm hypochlorite or APA wipes and used separate, disposable equipment at the end of their cleaning round. For terminal cleaning (upon patient discharge), a dedicated team used 5,000 ppm hypochlorite and APA wipes.
The “Unit reset” operational protocol
By early 2026, the persistent escalation of patient acquisitions indicated that routine environmental disinfection was insufficient. Two strategic alternatives were evaluated by hospital leadership: (1) a full 4-week closure and comprehensive architectural renovation of the unit, reducing institutional critical care bed capacity from 12 to 8 beds; or (2) a hyper-compressed, 120-hour operational “decant and reset” protocol utilizing an existing 5-bed temporary critical care satellite site. The latter protocol was selected.
Executing the 120-hour protocol required strict multi-sectoral synchronization across technical services, bioengineering, pharmacy, logistics, procurement, and environmental services. On February 21st, all active ICU patients were hemodynamically stabilized and transferred to the temporary 5-bed satellite. Immediately after patient evacuation, a complete inventory disposal was conducted: all medications, intravenous fluids, and disposable medical supplies stored in active clinical zones and central storage depots were discarded to eliminate any hidden contamination.
Simultaneously, bioengineering teams completely disassembled all patient-care infrastructure. Equipment was triaged into items capable of validated chemical decontamination and items designated for immediate disposal (eg, reusable telemetry and ECG monitoring cables that cannot be cleaned and disinfected in accordance with IPC standards). Technical teams carried out structural remediation, including mechanically removing oxidation from bed frames, repainting degraded structural components, and replacing all sink siphons in patient care and common areas.
Environmental decontamination began on February 23rd by a dedicated sanitation workforce of more than 20 personnel, trained specifically in C. auris remediation. We recruited an experienced team that completed face-to-face training with the IPC team, housekeeping, and bioengineering, including hands-on simulations. We emphasized proper cleaning procedures, workflow, and standard IPC measures. The disinfection sequence progressed directionally from clean zones to highly contaminated patient care areas. Every surface underwent dual rounds of mechanical cleaning with 5,000 ppm sodium hypochlorite or peracetic acid wipes, with successive rounds performed by independent cleaning cohorts to reduce human error.
On the night of February 23rd, following IPC team clearance, the empty unit underwent decontamination utilizing 18% hydrogen peroxide vapor (HPV) delivered by an external specialized contractor.
On February 24th, the bioengineering and nursing teams re-entered the unit to recalibrate machinery, restock storage depots with pristine, unexposed inventory, and complete final preparations. All team members arrived wearing fresh scrubs, did not perform any other assignments in the hospital that day, and were met and instructed regarding hand hygiene and PPE by an IPC team member before entering the ICU. The IPC team closely observed the entire process.
The unit officially reopened for new patient admissions on the afternoon of February 25th. A postintervention environmental screen was implemented, collecting 120 targeted surface samples, including samples that correlate with the precleaning assessment.
Costs
The “Unit Reset” cost roughly 450,000 USD; bio-engineering and computer support—25,000 USD, logistics and construction—150,000 USD, disposable medical equipment—50,000 USD, pharmacy—70,000 USD, cleaning and housekeeping—75,000 USD, environmental sampling—25,000 USD, man hours 50,000 USD, loss of income—20,000 USD.
Results
Outbreak dynamics and conventional IPC intervention exhaustion
Sporadic cases of C. auris colonization were identified in the ICU in 2021; however, a significant rise in August 2023 initiated a 30-month endemic cycle. Between August 2023 and December 2025, 1059 patients were admitted to the ICU, of whom 172 (16.2%) acquired C. auris skin colonization.
Although secondary clusters emerged within the Internal Medicine wards during 2025, epidemiological mapping confirmed these cases were driven exclusively by horizontal transfer from the primary ICU reservoir (Figure 1).
Aggregate Volume and Growth Metrics (ICU vs Internal Medicine): Annual prevalence of C. auris skin colonization and year-over-year volume changes during 2023–2025, in ICU and Internal Medicine wards. A – ICU, B - Internal Medicine.
Figure 1. Long description
Sporadic cases of C. auris colonization were identified in the ICU in 2021; however, a significant rise in August 2023 initiated a 30-month endemic cycle. Between August 2023 and December 2025, a total of 1513 patients were admitted to the ICU, of whom 172 individuals (11.4%) acquired C. auris colonization. While secondary clusters emerged within the Internal Medicine wards during 2025, epidemiological mapping confirmed these cases were driven exclusively by the horizontal transfer of colonized individuals from the primary ICU reservoir.
Initial reactive IPC interventions—including thorough epidemiological investigations, in-depth reviews of work processes across all sectors, cohorting colonized patients, deploying a dedicated nursing staff, restricting visiting hours, mandatory workflow orientation (clean-to-contaminated), and audited terminal cleaning with 5,000 ppm hypochlorite—failed to achieve sustained reductions in transmission. Extensive reviews of nursing, medical, and cleaning processes showed high protocol compliance, yet patient acquisition rates continued to rise.
The challenges of identifying an environmental reservoir
To identify the drivers of persistence, systematic environmental cultures were gathered across three distinct sampling intervals. C. auris was successfully isolated from multiple high-touch surfaces, including a computer keyboard, a paper towel dispenser, a patient bed rail, and a laundry cart (11 positive of 550 samples obtained, Table 1).
Sites selected for environmental sampling for C. auris (n = 550) and positive samples obtained during the sampling
Table 1. Long description
A table detailing sites selected for environmental sampling for C. auris, including the number of samples taken and positive cultures. The table has 26 rows and 4 columns. Column headers are Site, Samples taken, Positive cultures, and Number of positive cultures. Row 1: Main nurse station, Computer keyboard and mouse, phone, chair armrest, counter, water tap, sink, siphon, hand towel dispenser, drawer handles,, . Row 2: Shared equipment, Equipment carts (laundry and medical supplies)—handles and shelves,, . Row 3: Portable ultrasound Machine, Main panel, transducer housings, transducer handles, carrying handle,, . Row 4: ABG machine, Panel, barcode reader,, . Row 5: GlucoCheck, Panel, Handle, external surface,, . Row 6: Portable ECG, Panel, carrying handle, cables,, . Row 7: Portable monitor, Panel. Carrying handle, external surface, Portable monitor, 1 (out of 3 portable monitors). Row 8: Portable ventilator, Panel. Carrying handle, external surface, Portable ventilator, 1 (out of 3 portable ventilators). Row 9: Portable resuscitation suitcase, External surface, handle, portable oxygen tanks,, . Row 10: Bear Hugger, Panel, hose,, . Row 11: Crash cart, Carrying handles, drawers, shelves,, . Row 12: Defibrillator, Panel, carrying handle, paddles,, . Row 13: Intubation Cart, Carrying handles, drawers, shelves,, . Row 14: Portable X-ray machine, Cassette, cassette housing, carrying handle, panel,, . Row 15: Bronchoscope, Handle, panel, suitcase,, . Row 16: Portable working station, Computer screen, mouse, keyboard, carrying handle,, . Row 17: Pneumatic transport machine, Panel,, . Row 18: Medication room, Door handle. Door opening button, refrigerator handle, storage closet handles. Computer (keyboard and mouse), drawers, shelves, sink, water tap, siphon, hand sanitizer dispenser, hand towel dispenser, Computer keyboard and mouse, 1 (single workstation). Row 19: Patient room, Disposable PPE storage rack, laundry cart, visitors’ chair, monitor, ventilator, surgical lamp, boom, ventilation openings, wall, patient bed and mattress—multiple sites, syringe pumps, medication cart, sink, water tap, hand towel dispenser, intermittent pneumatic compression device, Hand towel dispenser, 1 (out of 12 rooms sampled). Row 20:, , ECG monitor cables, 3 (out of 12 rooms sampled). Row 21:, , Laundry cart, 1 (out of 12 rooms sampled). Row 22:, , Patient bed, 2 (out of 12 rooms sampled). Row 23:, , Medication cart, 1 (out of 12 rooms sampled). Row 24: Mail hall, Ceiling, ventilation openings,, . Row 25: Storage rooms, Door handles, shelves—multiple sites,, . Row 26: Utility room, Sink, water tap, sluice sink and siphon, dishwasher,, . Row 27: Housekeeping, Cleaning cart, mops, water tap,, . Row 28: Staff changing room, Door handle, scissors, shelves,, . Row 29: Staff break room, Door handle, table, chairs, microwave, refrigerator handle, countertop water dispenser,, . Row 30: Staff offices, Door handle, chair and armrest, computer keyboard and mouse, table, drawer handles,, . Row 31: Family break room, Refrigerator, microwave, countertop water dispenser, sofas and tables,, .
Significantly, environmental sampling yielded positive cultures from reusable electrocardiograph (ECG) monitoring cables. Furthermore, internal inspections during the decanting phase revealed that certain complex medical devices—specifically, continuous venovenous hemofiltration housings and syringe pump frames—may have accumulated internal contamination that standard cleaning checklists had not detected for over 24 months.
Post-intervention surveillance
The ICU successfully executed the decanting, decontamination, and reconstruction protocol within the allocated 120-hour window. After the unit reopened on February 25th, active surveillance screening continued at the same baseline frequencies. Over the subsequent 16-week postintervention observation window, the unit recorded zero new clinical infections or asymptomatic acquisitions of C. auris. This represents a statistically significant, immediate cessation of nosocomial transmission compared with the 16.2% baseline endemic rate (P value < .001). This represents the first complete and sustained cessation of nosocomial transmission since the outbreak’s inception in August 2023.
Discussion
C. Auris, a critical priority pathogen according to the World Health Organization, is linked to outbreaks in hospitals and other healthcare settings. It is associated with high morbidity and mortality rates, especially among vulnerable populations. Reference Shing, Chen and ES-k.1 Previous reports suggest that C. auris can persist for at least 2 weeks on wet or dry surfaces Reference Zhang, Zhong and Chen2 and for up to 7 days on fabrics. Reference Biswal, Rudramurthi and Jain6 C. auris has a particular predilection for the skin, particularly the axilla and groin. Reference Zhang, Zhong and Chen2 The duration of C. auris carriage in community settings has been reported to exceed 8 months. Reference Shing, Chen and ES-k.1
The yeast can easily spread between patients and within healthcare settings through contaminated environments or equipment. Reference Gaetano, Midiri and Mancuso3 The spread of this fungal pathogen is complex and influenced by multiple factors, including lapses in hand hygiene among healthcare workers, deficiencies in implementing IPC measures, and inadequate disinfection of patient equipment, such as ventilators, and of the environment. Reference Zhang, Zhong and Chen2
Some report that a bundle of infection-control measures, including active surveillance cultures upon admission and enhanced environmental cleaning, can help contain the spread of C. auris in acute healthcare settings. Reference Biswal, Rudramurthi and Jain6,Reference Kontopidou, Antonopoulou and Votsi7 However, the pathogen’s ability to form biofilm layers that are resistant to standard hospital disinfectants allows it to persist on surfaces for extended periods, Reference Kontopidou, Antonopoulou and Votsi7 which is worrisome and may explain reports of recurring incidents. Reference Shing, Chen and ES-k.1
Barzilai Medical Center’s outbreak peaked in August 2023 and persisted through February 2026. We localized the source to the ICU because all admission screens were negative and point-prevalence surveys in other wards were consistently negative. The IPC team traced outbreaks in Internal Medicine wards to ICU transfers and successfully managed them.
A critical finding of our outbreak investigation was the identification of non-critical medical equipment and structural components that may serve as “cryptic reservoirs” and completely evaded standard decontamination checklists. Although routine protocols target exposed, flat surfaces (eg, overbed tables, monitors, and keyboards), our systematic 550-sample prereset environmental sweep isolated C. auris from complex, high-touch assemblies—most notably reusable ECG monitoring cables.
The structural complexity of tangled wire arrays presents an inherent mechanical barrier to manual wiping. Furthermore, we hypothesize that cumulative exposure to high-concentration disinfectants (5,000 ppm sodium hypochlorite) and routine mechanical wear induced microscopic fractures in the rubberized exterior sheathing of these reusable cables. These micro-fissures might provide an ideal, shielded niche for biofilm sequestration, effectively protecting fungal cells and allowing them to continuously seed the immediate patient-care environment.
This also underscores the importance of supplemental disinfection with HPV or UV-C light, especially for difficult-to-eradicate pathogens. The human hand cannot reach all areas in a highly equipped ICU patient room or fully equipped storage rooms.
The outbreak also highlights the broader operational and clinical liabilities of a prolonged C. auris endemic state. The mandate for strict contact isolation and patient cohorting severely strained nursing workflows and led to a profound reduction of elective surgical activity throughput due to extended operating room turnover times. Additionally, the colonization status of these vulnerable patients created severe disposition bottlenecks, blocking timely discharges to postacute rehabilitation facilities and compromising the continuity of care.
Faced with a persistent acquisition rate, the decision to execute a 120-hour “Unit Reset” represented a calculated epidemiological trade-off. Voluntarily reducing ICU bed capacity in a frontline trauma center amid acute geopolitical uncertainty introduced substantial institutional risk. However, continuing with incremental, low-yield interventions was deemed clinically unacceptable, as it guaranteed the continued exposure of vulnerable patients to a contaminated environment.
We recognize several limitations, especially maintaining cleanliness standards after the operation ends, which requires resources equal to those invested before the operation. Because of the complexity of ICU equipment, patient load, and pressure to ensure quick turnover, staff can’t routinely disassemble every screw and clean every spot in the room. Making everything disposable, like ECG cables, isn’t feasible in the public health system. Therefore, we implemented a comprehensive cleaning plan that includes periodic disassembly of patient rooms and storage areas, ongoing staff training, close supervision to maintain high standards, continued extensive screening in and out of the ICU, and the introduction of advanced technologies, including a UV-C disinfection device. Planning for the “day after” and maintaining what has been achieved are key parts of outbreak management.
The “Unit Reset” cost roughly 450,000 USD. However, although resource-intensive, a compressed, multi-sectoral decanting and decontamination protocol may ultimately prove more clinically sound and cost-effective than enduring the compounding, long-term costs of extended hospital stay, wasted supplies, staff burnout, and institutional reputational damage.
Conclusion
Our experience demonstrates that when C. auris establishes deep environmental sequestration within degraded medical equipment and hidden infrastructure housings, standard enhanced cleaning protocols can reach a point of absolute exhaustion.
Although the 120-hour “Unit Reset” protocol required complex, multisectoral coordination and immediate capital expenditure, it successfully terminated a severe 30-month endemic cycle in which all conventional clinical interventions had failed. This radical, one-time systemic correction should be considered a viable, alternative to prolonged and unsuccessful containment strategies. Ultimately, mitigating modern epidemiological crises requires a paradigm shift that recontextualizes hospital infection control as a synchronized clinical, logistical, and bioengineering imperative.
Acknowledgements
None.
Financial support
No external funding was received for this work.
Competing interests
There is no conflict of interest to declare.
Ethical standard
Helsinki approval is not necessary.
