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| This is the sentence to cite.<ref name=cdc1>Centers for Disease Control and Prevention. https://www.cdc.gov/fungal/diseases/candidiasis/candida-auris-alert.html Accessed on November 11th, 2016. </ref>
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| Therefore it is important that any Candida spp isolates associated with invasive infections and isolates from superficial sites in patients from high intensity settings and those transferred from an affected hospital (UK or abroad) should be analysed to species level. If Candida haemulonii, Candida famata, Candida sake or Saccharomyces cerevisiae are identified, further work should be undertaken to ensure that they are not C. auris. This would involve either molecular sequencing of the D1/D2 domain or MALDI-TOF Biotyper analysis with C. auris either already present or added to the database.<ref name=cdc2>Public Health England.https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/534174/Guidance_Candida__auris.pdf. Accessed on November 11th, 2016.</ref>
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| According to published data, commercially available biochemical-based tests, including API AUX 20C and VITEK-2 YST, used in many front line diagnostic laboratories can misidentify C. auris as Candida haemulonii, Saccharomyces cerevisiae or Rhodotorula glutini.<ref name="cdc2" />
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| Therefore, it is important that any Candida spp. isolates associated with invasive infections and isolates from superficial sites in patients from high intensity settings and those transferred from an affected hospital (UK or abroad) should be analysed to species level. As knowledge on the epidemiology and prevalence in the UK is as yet limited, PHE is currently not in a position to make specific recommendations with regards to screening policy. However, C. auris screening could be considered for patients at risk for Candida disease (ESCMID guidance developing group define such patients as “[…] mainly ICU patients, paediatric, HIV/AIDS and patients with malignancies including haematopoietic stem cell transplantation.”)<ref name="pmidRef: HPR 10(21)">{{cite journal| author=Schmoldt A, Benthe HF, Haberland G| title=Digitoxin metabolism by rat liver microsomes. | journal=Biochem Pharmacol | year= 1975 | volume= 24 | issue= 17 | pages= 1639-41 | pmid=Ref: HPR 10(21) | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10 }} </ref>
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| Since April 2015, an adult critical care unit in England has been managing an outbreak of C. auris, with more than 40 patients either colonised or infected; approximately 20% with candidaemia. The hospital outbreak has been difficult to control, despite enhanced infection control interventions, including regular patient screening, environmental decontamination and ward closure<ref name="pmidRef: HPR 10(21)" />
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| C. auris, on microscopy, is indistinguishable from most other Candida species, it is a germ tube test negative budding yeast, however some strains can form rudimentary pseudohyphae on cornmeal agar. Most C. auris isolates are a pale purple or pink colour on the chromogenic agar, CHROMagar Candida, in common with several other non C. albicans species. Growth on this and other chromogenic agars (which may display a different colour) cannot be used as a primary identification method. Chromogenic agars are useful to identify mixed cultures including the presence of C. albicans. If there is evidence of non - albicans on chromogenic agar these should be sub-cultured on Sabouraud’s agar and identified according to local laboratory protocols. It is unlikely that any of the currently available biochemical-based tests will include C. auris in their database as it is a newly recognised species so laboratories are advised to check the databases provided for their current methods. According to published data, commercially available biochemical-based tests, including API AUX 20C and VITEK-2 YST, used in many front line diagnostic laboratories can misidentify C. auris as Candida haemulonii, Saccharomyces cerevisiae or Rhodotorula glutinis (the latter species is pink on Sabouraud’s agar and is easily distinguished). Therefore it is important that any Candida spp isolates associated with invasive infections and isolates from superficial sites in patients from high intensity settings and those transferred from an affected hospital (UK or abroad) should be analysed to species level. If Candida haemulonii, Candida famata, Candida sake or Saccharomyces cerevisiae are identified, further work should be undertaken to ensure that they are not C. auris. This would involve either molecular sequencing of the D1/D2 domain or MALDI-TOF Biotyper analysis with C. auris either already present or added to the database.<ref name="cdc2" />
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| Antifungal susceptibility testing: There are no established minimum inhibitory concentration (MIC) breakpoints at present for C. auris. Using breakpoints for other Candida spp the Centers for Disease Control and Prevention (CDC) demonstrated that of the global outbreaks that they have been investigating, nearly all isolates are highly resistant to fluconazole. In their analysis, more than half of C. auris isolates were resistant to voriconazole, one- third were resistant to amphotericin B (MIC ≥2 mg/L), and a few were resistant to echinocandins. Some isolates have demonstrated elevated MICs to all three major antifungal classes, including azoles, echinocandins, and polyenes indicating that treatment options would be limited. Whole genome sequencing of the organism has found resistant determinants to a variety of antifungal agents. <ref name="cdc2" />
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| Treatment
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| Experience to date from the PHE Mycology Reference Laboratory indicates that so far no multi-drug resistant strains have been found in the UK but all isolates are resistant to fluconazole and often cross-resistant to other azoles. First-line therapy remains an echinocandin pending specific susceptibility testing which should be undertaken as soon as possible. However, there is evidence that resistance can evolve quite rapidly in this species, ongoing vigilance for evolving resistance is advised in patients who are found to be infected or colonised with C. auris. There is currently no evidence or experience to support combination therapy in invasive infections with this organism and clinicians are advised to make decisions on a case by case basis.<ref name="cdc2" />
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| Decolonisation:
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| Colonisation of patients has been reported from affected hospitals around the world. There is no evidence currently that can establish whether C. auris is susceptible or resistant to chlorhexidine. More work is being done in this area. Clinical experience to date has shown that colonisation is difficult to eradicate and colonisation tends to persist making infection prevention and control strategies particularly important. However it is still recommended that strategies to prevent and/or treat colonisation include:
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| strict adherence to central and peripheral catheter care bundles, urinary catheter care bundle and care of the tracheostomy site, skin decontamination and mouth gargles with chlorhexidine washes use of topical nystatin and terbinafine would be options for targeted topical management of key sites such as venous cannula entry sites.<ref name="cdc2" />
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| Screening
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| All Trusts are encouraged to develop a screening policy after local risk assessments are undertaken. Screening is recommended in units that have ongoing cases or colonisations. Screening is also advised for patients coming from other affected hospitals / units in the UK and abroad. Currently hospital outbreaks have been reported from India, Pakistan, Venezuela and Colombia; although UK and worldwide prevalence is still to be established due to problems with laboratory diagnosis. Suggested screening sites, based on the predilection of Candida species to colonise the skin and mucosal surfaces ie genitourinary tract, mouth and respiratory tract, are: nose, throat, groin urine / urethral swab perineal or low vaginal swab if appropriate. sputum / endotracheal secretions, drain fluid (abdominal/pelvic/mediastinal), cannula entry sites if clinically indicated, wounds.<ref name="cdc2" />
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| Routine wound swabs may be used to collect the screening sample. All screen positive patients should be isolated or cohorted as described below. As for other healthcare associated infections, a series of three negative screens taken 24 hours apart are needed to de-isolate the patient. As there is clinical experience of recurrence of colonisation, the need for ongoing vigilance in the form of weekly screens in certain clinical environments should be considered by performing local risk assessments.<ref name="cdc2" />
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| '''Candida auris Microchapters'''
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| [[Candida auris (patient information)|'''Patient Information''']]
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| [[Candida auris overview|'''Overview''']]
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| [[Candida auris historical perspective|'''Historical Perspective''']]
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| !'''Microbiology'''
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| [[Candida auris pathophysiology|'''Pathophysiology''']]
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| [[Candida auris differential diagnosis|'''Differentiating Candida auris infection from other Diseases''']]
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| [[Candida auris epidemiology and demographics|'''Epidemiology and Demographics''']]
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| [[Candida auris risk factors|'''Risk Factors''']]
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| [[Candida auris screening|'''Screening''']]
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| [[Candida auris natural history, complications and prognosis|'''Natural History, Complications and Prognosis''']]
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| '''Diagnosis'''
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| [[Candida auris history and symptoms|'''History and Symptoms''']]
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| [[Candida auris clinical presentation|'''clinical presentation''']]
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| [[Candida auris laboratory findings|'''Laboratory Findings''']]
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| [[Candida auris x ray findings | '''X Ray''']]
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| [[Candida auris CT| '''CT''']]
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| [[Candida auris other imaging findings| '''Other Imagining Findings''']]
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| [[Candida auris other diagnostic studies|'''Other Diagnostic Studies''']]
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| '''Treatment'''
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| [[Candida auris medical therapy|'''Medical Therapy''']]
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| [[Candida auris surgery|'''Surgery''']]
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| [[Candida auris primary prevention|'''Primary Prevention''']]
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| [[Candida auris secondary prevention|'''Secondary Prevention''']]
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| [[Candida auris cost-effectiveness of therapy|'''Cost-Effectiveness of Therapy''']]
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| [[Candida auris future or investigational therapies|'''Future or Investigational Therapies''']]
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| '''Case Studies'''
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| [[Candida auris case study one|'''Case #1''']]
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| '''{{PAGENAME}} On the Web'''
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| [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?CMD=search&db=pubmed&term={{urlencode:{{#if:{{{1|}}}|{{{1}}}|{{PAGENAME}}}}}} '''Most recent articles''']
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| [http://scholar.google.com/scholar?ie=UTF-8&oe=utf-8&q={{urlencode:{{#if:{{{1|}}}|{{{1}}}|{{PAGENAME}}}}}}&qt_s=Search&sa=N&tab=ps '''Most cited articles''']
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| [http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=search&db=pubmed&term={{urlencode:{{#if:{{{1|}}}|{{{1}}}|{{PAGENAME}}}}}}%20AND%20systematic%5Bsb%5D '''Review articles''']
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| :[http://goldminer.arrs.org/search.php?query={{urlencode:{{#if:{{{1|}}}|{{{1}}}|{{PAGENAME}}}}}} '''All Images''']
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| :[http://goldminer.arrs.org/search.php?query={{urlencode:{{#if:{{{1|}}}|{{{1}}}|{{PAGENAME}} X-ray}}}} '''X-rays''']
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| :[http://goldminer.arrs.org/search.php?query={{urlencode:{{#if:{{{1|}}}|{{{1}}}|{{PAGENAME}} Ultrasound}}}} '''Echo & Ultrasound''']
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| [http://clinicaltrials.gov/search/open/condition={{urlencode:{{#if:{{{1|}}}|{{{1}}}|{{PAGENAME}}}}}} '''Ongoing Trials at Clinical Trials.gov''']
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| [http://www.guideline.gov/search/searchresults.aspx?Type=3&txtSearch={{urlencode:{{#if:{{{1|}}}|{{{1}}}|{{PAGENAME}}}}}}&num=20 '''US National Guidelines Clearinghouse''']
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| ==Overview of Candida auris==
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| Candida auris is a fungus, recently described as a rare cause of fungal infection with significant resistance to antifungal medications.<ref name="pmid24357342">{{cite journal| author=Chowdhary A, Anil Kumar V, Sharma C, Prakash A, Agarwal K, Babu R et al.| title=Multidrug-resistant endemic clonal strain of Candida auris in India. | journal=Eur J Clin Microbiol Infect Dis | year= 2014 | volume= 33 | issue= 6 | pages= 919-26 | pmid=24357342 | doi=10.1007/s10096-013-2027-1 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24357342 }} </ref> Candida auris isolates from north and south Indian hospitals, Japan and Korea were all found to be resistant to the antifungal medication fluconazole.<ref name="pmid24357342></ref> Some isolates were also noted to be resistant to flucytosine and voriconazole.<ref name="pmid24357342></ref> The high rate of therapeutic failure noted in cases of Candida auris fungemia poses significant concerns.<ref name="pmid24357342></ref> It's high potential for nosocomial horizontal transmission has been demonstrated.<ref name="pmid27452195">{{cite journal| author=Calvo B, Melo AS, Perozo-Mena A, Hernandez M, Francisco EC, Hagen F et al.| title=First report of Candida auris in America: Clinical and microbiological aspects of 18 episodes of candidemia. | journal=J Infect | year= 2016 | volume= 73 | issue= 4 | pages= 369-74 | pmid=27452195 | doi=10.1016/j.jinf.2016.07.008 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27452195 }} </ref><ref name="pmid27777756">{{cite journal| author=Schelenz S, Hagen F, Rhodes JL, Abdolrasouli A, Chowdhary A, Hall A et al.| title=First hospital outbreak of the globally emerging Candida auris in a European hospital. | journal=Antimicrob Resist Infect Control | year= 2016 | volume= 5 | issue= | pages= 35 | pmid=27777756 | doi=10.1186/s13756-016-0132-5 | pmc=5069812 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27777756 }}</ref>An outbreak of fifty cases over a sixteen month period (April 2015-July2016) in a cardiothoracic center in London is the first reported case, and the largest outbreak in Europe.<ref name="pmid27777756"></ref> It is recognized as a globally emerging fungal pathogen<ref name="pmid27777756"></ref>.
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| ==Historical Perspective==
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| ==References==
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| {{Reflist|2}}
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