Introduction

Candidozyma auris (C. auris) causes serious invasive fungal infections which are difficult to treat and are associated with crude mortality of 30–60%. ^{Reference Chowdhary, Jain and Chauhan1} Since it was first reported in 2009, C. auris has spread to over 40 countries and across multiple healthcare settings, including both acute and long-term care. ^{Reference Huang, Hurabielle and Drummond2} Residents in long-term acute care hospitals (LTACHs) are disproportionately affected by C. auris. ^{Reference Rossow, Ostrowsky and Adams3} Risk factors for C. auris colonization and infection include invasive medical devices, prior antimicrobial use, prior multi-drug-resistant organism (MDRO) colonization or infection, and extensive healthcare exposure, which are common factors among patients residing in LTACHs. ^{Reference Rossow, Ostrowsky and Adams3,Reference Shastri, Shankarnarayan, Oberoi, Rudramurthy, Wattal and Chakrabarti4} Prevalence of C. auris colonization among LTACH patients is high, with a median of 31% reported in some facilities. ^{Reference Pacilli, Kerins and Clegg5} Despite available public health guidance on infection control practice ⁶ and collaborative efforts for containment, ^{Reference Karmarkar, O’Donnell and Prestel7–Reference Dratch, Le and Zahn9} C. auris continues to proliferate in these settings. ^{Reference Lyman, Forsberg and Sexton10}

The Society of Hospital Epidemiology of America (SHEA) Research Network (SRN), a consortium of healthcare facilities collaborating research projects to advance the fields of healthcare epidemiology and antimicrobial stewardship, was used previously to query infection prevention and control practices for bacterial MDROs and C. auris in acute care hospitals. ^{Reference Lichota, King and Medernach11,Reference Coffey, Grossman and Banach12} Top barriers to containment of other MDROs in U.S.-based acute care hospitals include training and adherence of frontline staff, unavailability of private rooms, and lack of evidence-based strategies to eradicate reservoirs. ^{Reference Coffey, Grossman and Banach12} Similarly, barriers to C. auris containment in U.S.-based acute care hospitals include lack of interfacility communication, lack of infection control at connected healthcare facilities, and lack of frontline staff training. ^{Reference Lichota, King and Medernach11}

Barriers to containment of C. auris in LTACHs may be shared with those reported in acute care hospitals, but LTACH environments are unique due to a high concentration of chronically ill individuals, prolonged length of stay, and more limited infection prevention and control resources. As such, understanding current LTACH C. auris containment practices will provide important context to translate and unify containment practices across the healthcare continuum. In this study, we surveyed facilities that were members of the National Association of Long-Term Hospitals (NALTH) network to better understand current LTACH C. auris prevention practices, perceived barriers to control, and potential targets for improved containment.

Methods

Our multidisciplinary team developed a survey comprising 31 multiple choice, free response, and ranked choice questions pertaining to facility characteristics, current C. auris prevention practices, and barriers to C. auris infection prevention. This survey was revised and adapted for the LTACH setting from our survey of acute care hospitals. The survey was distributed in November 2025 to U.S.-based LTACHs in the NALTH network via email using Research Electronic Data Capture (REDCap). ^{Reference Harris, Taylor, Thielke, Payne, Gonzalez and Conde13} To maximize response potential, three monthly reminder email messages followed survey distribution.

The total number of questions answered by each participating facility varied, with branching logic used to clarify responses. Completion of all survey questions was not required for form submission, and facilities could leave questions unanswered. Percentages were calculated against the denominator of the total pool of survey participants (n = 33) unless otherwise noted. For ranked choice questions, responses were analyzed by non-weighted counts. When appropriate, qualitative responses were analyzed using an iterative review process with coding by study team members (KT, SS). ^{Reference Catherine and Nicholas14} Quantitative and descriptive analyses were performed for completed surveys using SAS (Statistical Analysis System version 9.4). ¹⁵

Results

Responses were received from 33 of 56 (58%) U.S.-based NALTH LTACH facilities. Survey responses were nearly complete, with only three questions left unanswered by a single participating facility. Most respondents self-identified as independent free-standing hospitals or free-standing hospitals connected to a network of other facilities (74%) (Table 1, Figure 1). The median facility census on the day of survey completion was 20 (IQR 18–38) residents, and the median number of ventilated residents per facility was nine (IQR 3–12). Facilities reported median staffing ratio of one nurse to five patients and one patient care technician to five patients.

Figure 1.

Geographic distribution of 33 long-term acute care hospital participants. Facility location was classified by geographic region, including Southeast (red, n = 15), Midwest (yellow, n = 8), West (blue, n = 6), or Northeast (purple, n = 4).

Table 1.

Participating long-term acute care hospital characteristics

Table 1. Long description

A table detailing characteristics of 33 participating long-term acute care hospitals. The table has 33 rows and 3 columns. The columns are labeled ‘Facility characteristic’, ‘Self-identified facility type’, ‘Bed capacity’, ‘Room occupancy’, and ‘Number of facilities (N = 33) (%)’. The ‘Self-identified facility type’ includes independent free-standing long-term hospital, free-standing long-term hospital connected to a network of other facilities, and long-term unit inside an acute care hospital. The ‘Bed capacity’ includes 10-29 beds, 30-49 beds, 50-99 beds, and more than 100 beds. The ‘Room occupancy’ includes single patient rooms, semi-private rooms, shared rooms, and wards. Each row lists the number and percentage of facilities for each characteristic.

*Selected categories are not mutually exclusive.

Twenty-three facilities (70%) reported ever identifying at least one case of C. auris infection or colonization. Eighteen facilities (54%) reported identifying a case of C. auris within the past three months, and nine (27%) reported suspected within-facility C. auris transmission. Four (12%) facilities had identified an antifungal-resistant C. auris isolate, most frequently to azoles; two facilities had identified C. auris isolates resistant to all three antifungal classes (ie, azoles, echinocandins, and polyenes).

Nearly all facilities (97%) reported having an MDRO prevention policy; however, only 18% had a policy specific to C. auris. Infection control committee membership most commonly included a nurse (96%), pharmacist (81%), hospital administrator (72%), infectious disease physician (69%), and advanced practice provider of unspecified specialty (45%). Sixty percent of facilities held infection control meetings at least once per quarter. The remaining respondents reported holding infection control meetings monthly (27%), annually (3%), or never (6%). Most facilities (72%) reported having a full-time infection preventionist, with the majority (84%) being nurses. All infection preventionist nurses worked on-site for 5 days per week. Less than half (46%) of infection prevention nurses had obtained a Certification in Infection Prevention and Control. ^{Reference Hsu, Zhou, Nosakhare and Marsteller16}

All facilities employed multimodal approaches for C. auris infection prevention (Table 2). More than half of LTACHs reported routine C. auris surveillance programs (n = 21, 64%), including in response to a new case of C. auris or suspected transmission (n = 15) and/or screening for asymptomatic colonization at the time of LTACH admission (n = 12). Universal screening occurred in more than one-third of facilities (n = 12, 36%). Surveillance samples were most commonly collected from the axilla (77%) and inguinal crease (58%). Patients were preemptively isolated pending screening results for C. auris in 72% of facilities. Less than one-quarter of facilities had capabilities for on-site testing of surveillance specimens, with most sending samples to a centralized, commercial reference, or public health laboratory.

Table 2.

Targeted prevention practices reported by participating facilities for suspected or confirmed cases of C. auris

Table 2. Long description

The table is divided into three main columns: Isolation practices, Environmental disinfection practices, and Other practices. Each column lists specific practices along with the number and percentage of facilities employing them. Isolation practices include signage at patient room entrances, contact isolation for C. auris cases, electronic health record flags, use of dedicated medical equipment, preemptive isolation, enhanced barrier precautions, cohort healthcare staff, and cohort patients. Environmental disinfection practices involve ensuring the use of specific cleaning products, Enhanced cleaning of shared equipment, daily disinfection of patient rooms, and use of adjunctive environmental disinfection methods. Other practices include education of healthcare personnel, enhanced monitoring of compliance, antiseptic bathing of patient skin, and other approaches. Each practice is accompanied by the number and percentage of facilities implementing it.

*Specified adjunctive environmental disinfection methods included: bleach (9), ultraviolet light (9), hydrogen peroxide (9), whole-room disinfectant fogging (3).

**Includes family and visitor education, precautions in high traffic areas.

Commonly reported infection control strategies included contact isolation, environmental disinfection, and education of healthcare personnel (Supplemental Table). The most reported isolation strategies included contact isolation (n = 33, 100%), use of electronic health record flags to designate C. auris colonization status (n = 28, 85%), and use of dedicated medical equipment (n = 25, 76%). The most reported environmental disinfection methods included use of cleaning products with claims for C. auris disinfection (n = 31, 94%), enhanced cleaning of shared patient equipment (n = 29, 88%), and at least daily disinfection of patient rooms (n = 24, 72%). Additionally, 85% of facilities partnered with a healthcare contractor for off-site laundering of linens. All facilities employed compliance monitoring (eg, direct observation, secret shopper, supervisor report, peer report) for hand hygiene and personal protective equipment (PPE) (Supplemental Table).

Facilities were most commonly notified regarding inbound transfer of a positive C. auris case via written documents (58%) and verbal communication from the originating facility (55%) prior to transfer. Sixty-nine percent of facilities identified C. auris positivity as a barrier to discharge to a lower level of care. Of the 22 facilities who identified C. auris positivity as a barrier to discharge, all but one reported difficulty in transferring patients to non-ventilator capable skilled nursing facilities; challenges were also reported with discharge to ventilator capable skilled nursing facilities and acute inpatient rehabilitation (both 14/22, 64%). Other barriers to discharge from LTACHs were not assessed.

The top three reported barriers and requested tools for improved C. auris containment were recorded as non-weighted counts. Barriers included lack of communication between healthcare facilities at the time of patient transfer (n = 16), lack of training and education for frontline staff (n = 15), and lack of compliance with PPE (n = 12). The most often requested tools anticipated to improve C. auris containment were improved communication between facilities at the time of patient transfer (15, 45%), standardized protocols for C. auris decolonization (15, 45%), and standardized protocols for C. auris screening and isolation (14, 42%) (Table 3).

Table 3.

Top 10 perceived barriers and needed tools to support C. auris containment

Table 3. Long description

A table with two columns and 18 rows. The first column lists top barriers and needed tools, and the second column shows the number of facilities. Top barriers include lack of communication between healthcare facilities (16), lack of training and education for frontline staff (15), and lack of compliance with personal protective equipment (12). Top tools needed include effective patient decolonization regimen for C. auris (15), improved communication at time of patient transfer between facilities (15), and standardized protocols for C. auris screening (14).

Facilities were asked to select their top 3 perceived barriers and tools needed.