Journal of Infection and Public Health 13 (2020) 730–736

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Journal of Infection and Public Health

journal homepage: http://www.elsevier.com/locate/jiph

Different efficacies of common disinfection methods against candida

auris and other candida species
Leiwen Fu a,1 , Tingting Le c,1 , Zhihua Liu b , Ling Wang c , Huijie Guo a , Jun Yang a ,
Qing Chen a , Jing Hu a,c,∗
a
Department of Epidemiology, School of Public Health, Southern Medical University, Guangzhou, China
b
Department of Infectious Disease, Nanfang Hospital, Guangzhou, China
c
Department of Nosocomial Infection Administration, Zhujiang Hospital, Southern Medical University, Guangzhou, China

a r t i c l e i n f o a b s t r a c t

Article history: Background: Candida auris can form long-lasting colonies in the hospital environment and on human
Received 11 September 2019 skin. There is limited evidence regarding the efficacy of different methods and products for disinfecting
Received in revised form hospitals and colonized patients to prevent the spread of C. auris.
20 December 2019
Methods: The minimum inhibitory concentration of three disinfectant products (“84” disinfectant,
Accepted 6 January 2020
IodineTincture disinfectant, and quaternary ammonium) and 75% ethanol against C. auris and other Can-
dida species were measured. A pig skin model was used to evaluate the efficacy of three hand hygiene
Keywords:
products in killing pathogens. The killing effect of ultraviolet-C (253.7 nm) and the LK/CXD bed unit ozone
Candida auris
Disinfection
disinfection machine on C. auris was also evaluated.
Infection control Results: Thirty seconds of pig skin washing with bacteriostatic hand sanitizer followed by drying and 15 s
Ultraviolet-C of ethanol-based gel can completely eradicate the colonization of C. auris (3.00 log10 CFU). The antifungal
Ozone activity of ultraviolet-C to C. auris inoculated on bed sheets was significantly reduced (P < 0.01) at a
Hand hygiene distance of 1 m. Candida glabrata and C. auris showed greater resistance to ozone than other Candida
species. The ozone could completely eradicate C. auris (3.60 log10 CFU) on bed sheets at dosage of 300
mg/m3 for 40 min of exposure.
Conclusions: We recommend extending the disinfection times of ultraviolet-C and ozone and emphasizing
the effectiveness of washing skin with soap, drying skin, and then applying an ethanol-based gel to remove
C. auris from skin.
© 2020 The Author(s). Published by Elsevier Ltd on behalf of King Saud Bin Abdulaziz University for
Health Sciences. This is an open access article under the CC BY-NC-ND license (http://creativecommons.
org/licenses/by-nc-nd/4.0/).

Introduction outbreaks in healthcare facilities around the world within a short

Since it was first reported in Japan in 2009, Candida auris has
been isolated on five continents and has become a global con-
cern [1–6]. Increasingly, infections caused by C. auris, an emerging
multidrug-resistant fungal pathogen, are posing serious problems
in healthcare settings. Despite the implementation of enhanced
infection control measures, C. auris still caused nosocomial blood-
stream infections with high mortality rates, which has led to several
∗ Corresponding author at: Department of Epidemiology, School of Public Health,
Southern Medical University, Guangzhou, China; Department of Nosocomial Infec-
tion Administration, Zhujiang Hospital, Southern Medical University, Guangzhou,
China.
E-mail address: hjalzh@smu.edu.cn (J. Hu).
1
These authors contributed equally to this study.
period of time [6–8].
C. auris has been recovered from contaminated environmen-
tal surfaces such as bedside tables, chairs and temperature probes
in several investigated outbreaks, and persistent colonization on
surfaces for 28 days has been reported [9,10]. The continued colo-
nization of C. auris on skin surfaces and medical devices facilitates
cross-transmission in hospital environments has been demon-
strated previously [6,10,11]. At present, as the limited data on the
efficacy of skin-disinfecting gel products against C. auris colonized,
the recommendations of major world health organizations regard-
ing hand hygiene procedures for control of C. auris infection are
different or lacking [12]. Such as, the Centers for Disease Control
and Prevention recommends using ethanol-based hand sanitizer or
washing with soap and water before and after donning gloves. The
Public Health England and the Centre for Opportunistic, Tropical
and Hospital Infections (South Africa) recommend washing hands

https://doi.org/10.1016/j.jiph.2020.01.008
1876-0341/© 2020 The Author(s). Published by Elsevier Ltd on behalf of King Saud Bin Abdulaziz University for Health Sciences. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
 L. Fu et al. / Journal of Infection and Public Health 13 (2020) 730–736
with soap followed by the use of ethanol-based disinfection gels on
dry hands. While other organizations do not suggest any specific77\
hand hygiene methods.
Recently, several studies evaluated the effectiveness of disin-
fection methods in the hospital environment and on colonized
patients during C. auris infection outbreaks. Abdolrasouli et al. eval-
uated the in vitro efficacy of chlorhexidine gluconate, iodinated
povidone, chlorine and H2 O2 vapor in killing C. auris and other Can-
dida species [13]. Ultraviolet-C light (UV-C) was confirmed to be
effective in inhibiting C. auris growth with sufficient exposure by
Ponnachan et al. and Cadnum et al. [14,15]. However, C. auris strains
isolated in different regions have their own biological character-
istics, and the disinfection regulations recommended by different
countries are also different [16,17]. No published studies have
reported the efficacy of the bed unit ozone disinfection machine
against C. auris. There is an urgent need to supplement the rele-
vant data on C. auris disinfection to fully prepare for controlling
the spread of C. auris. Therefore, we investigated common disin-
fection methods, including chemical disinfectants containing high,
medium and low levels, hand hygiene, UV-C light disinfection and
inpatient bed unit disinfection, in several large healthcare settings
in China and evaluated their efficacy in killing C. auris and other
Candida species.
Methods
Fungal isolates
A total of 12 yeast isolates were selected for this study, includ-
ing Candida auris (n = 3), Candida albicans (n = 3), Candida glabrata
(n = 2), Candida tropicalis (n = 2) and Candida parapsilosis (n = 2).
Among the three C. auris strains, one was recovered from a male
patient in 2012 in India (CBS12766), and the others were obtained
from blood samples in clinics in India (INCa-1, INCa-2). The other
Candida isolates were recently isolated from a large medical cen-
ter in Guangzhou. All of the isolates were identified by sequencing
D1/D2 and internal transcribed spacer (ITS) regions of ribosomal
DNA, as described by Ferrer et al. and Kathuria et al. [18,19], and
then subcultured onto Sabouraud dextrose agar (SDA) plates and
incubated at 37 ◦ for 48 h.
Chemical disinfectants
We evaluated the efficacy of 4 commercial chemical disinfec-
tants commonly used in hospitals in China (Table 1), including
“84” disinfectant (chlorine-based disinfectant, Caoshanhu, Jiangxi,
China), IodineTincture (iodine-based disinfectant, ANNJET, Shan-
dong, China), Ethanol (Guanghua, Guangdong, China) and benza-
lkonium bromide (LIRCON, Shandong, China).
Determination of MIC values
For each chemical disinfectant product except ethanol, the
microdilution method was used to test the minimum inhibitory
concentration (MIC) of each pathogen at each time point a previ-
ously described according to CLSI M27-A2 [13]. The concentration
of the effective substance in all the compounds except ethanol was
adjusted to 2000 mg/L and serially diluted two-fold in a 96-well
microtiter plate. The ethanol was diluted to 75% of the original con-
centration and added directly to the well. Then, 50 ␮l of the yeast
culture of each isolate was added, and the density was adjusted
to 0.5 McFarland standard (1−5 × 106 CFU/mL) by measuring the
absorbance on a UV spectrophotometer (Shanghai Youke Instru-
ment Co, Shanghai, China) at a wavelength of 530 nm; the samples
in each well were then mixed for 1 min, 10 min, 30 min, 1 h and
24 h at 25 ◦ . After the contact time, 10 ␮l of the suspension in each
731
well was transferred to SDA and incubated for 3 days at 37 ◦ . The
MIC for each compound was defined as the lowest concentration
at which no growth was observed. The experiment was performed
in duplicate.
Products for hand hygiene
Two commercially available skin antibacterial gels and one
hand sanitizer were used in this study, namely, Jifro disinfectant
gel (LiKang, Shanghai, ethanol (54%–66%), n-propanol (9%–11%)),
Annjet disinfectant gel (ANNJET, Shandong, ethanol 75% ± 5% (v/v))
and Walch liquid soap (Weilai, Guangzhou, p-chloro-xylenol 0.1%
– 0.2% (w/w)).
This was a modification of the method of Bush et al. [20]. The
pig skin model was used to evaluate the antiseptic effects of three
hand products on C. auris; many reports have confirmed that the
characteristics and function of pig skin are comparable to those of
human skin [21,22]. Fresh pig skin was obtained from the market
and repeatedly rinsed with sterile water. Then, it was cut into 2
× 2 cm test pieces. The pieces were thawed and dehaired, and the
subcutaneous fat was removed. All pig skin pieces were soaked with
75% ethanol for 5 min to disinfect their surfaces.
For each test, the test suspension was adjusted to 0.5 McFarland
standard (1−5 × 106 colony-forming units (cfu)/mL) in phosphate-
buffered saline (PBS) for each pathogen. Two pig skin pieces were
used: one piece was inoculated with 10 ␮l of a test fungal isolate
suspension and then air-dried, and the other piece was clean. One
hundred microliters of different hand hygiene products, matching
the amount per area of skin that healthcare workers would use,
was placed on one of the pieces, and the two pieces were rubbed
against each other for 15 s, 30 s and 1 min. For the disinfectant gel,
the two pig skin pieces were placed directly onto the SDA plate
after the contact time. The skin was inoculated with the strain with
no hand hygiene products as the control. For the Walch liquid soap,
the surface of the pig skin was rinsed with 10 ml of running sterile
water to inactivate the product and then dried with sterile tissue
and placed onto the SDA plate. For controls, the skin was treated in
a similar way with sterile water instead of liquid soap.
In addition, considering actual situations in the hospital, we also
tested the activity of a combination of Walch liquid soap and Jifro
disinfectant gel against pathogens (after 15 s or 30 s of pig skin
rubbing with Walch liquid soap, skin drying followed by 15 s of
Jifro disinfectant gel).
Ultraviolet-C (UV-C) light disinfection
The 253.7 nm UV-C light (Thermo Fisher Scientific, Waltham,
MA, USA), recommended by “Regulation of the disinfection tech-
nique in healthcare settings in China,” (WS/T 367–2012) was used
to evaluate the efficacy of UV-C light devices (30 W) on the activity
of the fungal isolates. The cell density was adjusted to 0.5 McFarland
standard (1−5 × 106 cfu/mL) in PBS for each pathogen. Ten micro-
liters of cell suspension and 5 ␮l of 0.3% bovine serum albumin
(Sigma-Aldrich, USA) were spread to cover SDA plates and 20 mm x
20 mm bed sheets and were desiccated in 96-well microtiter plates.
The three different types of substrates were exposed to UV-C light
for 10, 30, and 60 min at a distance of 100 cm from the lamp where
UV-C intensity was 120 ␮W/cm2 . According to the WS/T 367–2012,
the hanging ultraviolet disinfection lamp in patient rooms should
be 180–250 cm away from the ground. When UV-C is used for dis-
infecting the surface of the object, the lamp should be within 100
cm of the illuminated surface. In order to explore whether the UV-
C lamp in the ward can inhibit the growth of C. auris colonized
on the ground and according to the results of preliminary experi-
ments, we prolonged the irradiation time appropriately and tested
the disinfectant effect of fungal isolates at exposure times of 1, 3,
732 L. Fu et al. / Journal of Infection and Public Health 13 (2020) 730–736
Table 1
Chemical disinfectants used in this study.
Chemical disinfectants Active ingredient
“84” disinfectant Chlorine
IodineTincture Iodine
Ethanol Ethanol
Quaternary ammonium Benzalkonium bromide
and 6 h at a distance of 250 cm from the ultraviolet light source
where UV-C intensity was 25 ␮W/cm2 . The untreated substrates of
the same material were used as controls. All the carriers were held
parallel to the UV-C source throughout the period of exposure. The
temperature and relative humidity were recorded at 25 ◦ and 60%,
respectively.
After exposure, the SDA test plates were incubated directly. Fifty
microliters of PBS was used to reconstitute the fungal cells in 96-
well microtiter plates, and then 10 ␮l of the cell suspensions were
subcultured onto the SDA plates and incubated at 37 ◦ for 48 h.
The test sheets and the control sheets were placed in test tubes
containing 5 ml of diluent and were fully shaken and eluted. Ten
microliters of the eluent was subcultured onto SDA and incubated
at 37 ◦ for 48 h. The experiments were performed in triplicate.
Disinfectants for inpatient bed units
The LK/CXD bed unit ozone disinfection machine (LAOKEN
TECHNOLOGY, Chengdu, China) is commonly used in Chinese hos-
pitals. When disinfecting, it produces an ozone concentration of
≥300 mg/m3 and ozone leakage of ≤0.2 mg/m3 . The cell density and
sheets were treated the same as UV-C experiments. The untreated
sheets of the same material were used as controls.
The contaminated sheets were placed in sterile dishes that were
placed in the disinfection cover of the bed unit and in the interlayer
of the quilt, whereas the positive control was placed outside the bag
without exposure to ozone. The closed disinfection bag was tiled on
the bed unit and its integrity was checked to make sure that there
was no air leakage. The bed unit was enclosed with the sterilization
bag, and the device was connected to the closed bag with a sterile
gas pipe to ensure that the connection was intact. The operating
procedures of the bed unit include pumping for 10 min, charging
ozone for 5 min, maintaining disinfection for 20 min, and removing
residual gas for 10 min as a routine disinfection cycle. After disin-
fection, the test pieces and the control pieces were processed as
previously described. The test was repeated 3 times. The temper-
ature and relative humidity were recorded at 25 ◦ and 55%–65%,
respectively.
Statistical analysis
Statistical analysis and comparisons of reductions of the
pathogens on different surfaces were performed using one-way
ANOVA (SPSS software, version 20.0). P values <0.05 were consid-
ered significant.
Results
Chemical disinfectants
All C. auris isolates were effectively killed at an available chlo-
rine concentration of 1000 mg/L for at least 1 min of exposure and
500 mg/L for at least 30 min of exposure (Fig. 1A), which is 1/2 – 1/4
times as high as that recommended (2000 mg/L, more than 30 min)
by WS/T 367–2012 and its effectiveness gradually increases with
the extension of exposure time. MIC levels for the “84” disinfectant
were higher for single C. auris isolates and C. albicans than for other
Recommend concentration Recommend contact time
400−700 mg/L (400−700 ppm) 10–30 min
2% (W/V) 1–2 min
75%(V/V) 10–30 min
2000 mg/L (2000 ppm) 10–30 min
Candida species (Fig. 1A). In comparison, C. auris is more sensitive
to IodineTincture disinfectants. The least sensitive strain of C. auris
can be killed at an available iodine concentration of 500 mg/L for 1
min (Fig. 1B). Compared to most C. auris isolates and other Candida
species isolates, C. albicans and C. parapsilosis expressed proportion-
ately higher MIC to IodineTincture disinfectant. Candida isolates
showed strong resistance to quaternary ammonium disinfectants.
Exposure to an available benzalkonium bromide concentration of
1000 mg/L for 10 min could kill all C. auris isolates; this indicated
a significantly different MIC compared to that of all other Candida
species except for one C. glabrate isolate, but the difference gradu-
ally decreased with increasing exposure time (Fig. 1C). 75% ethanol
can completely kill C. auris at each time point (data not shown).
Products for hand hygiene
In the pig skin model, there were significant differences in the
reduction of Candida species between the two commercially avail-
able skin antibacterial gels and the liquid hand soap at 30 s and
1 min contact time (P < 0.05) (Table 2). At 15 s of contact time,
according to the time recommended in WS/T 367–2012, C. auris
was reduced by 2.92 log10 CFU after contact with Jifro disinfectant
gel and by 2.44 log10 CFU after contact with Walch liquid soap, and
Jifro disinfectant gel was 100% effective in killing all tested Candida
isolates at 1 min of exposure time. Compared with other Candida
isolates, C. auris and C. glabrata had more fungal residues on the pig
skin, and the fungal residues gradually decreased with prolonged
disinfection time. The 54%–66% ethanol with 9%–11% n-propanol
gel was more effective in killing C. auris than the 75% ± 5% ethanol
gel alone, with each contact time, but the reduction in Candida iso-
lates was not significantly different between the two commercial
ethanol-based disinfectant gels.
After 30 s of pig skin rubbing with Walch liquid soap, skin dry-
ing followed by 15 s of Jifro disinfectant gel use could completely
eradicate any residual C. auris (Table 2); this treatment also led to
a significantly increased log reduction in the fungal isolates com-
pared with the two products used separately (P < 0.05).
Ultraviolet-C (UV-C) light disinfection
As shown in Table 3, the growth of C. auris could be completely
inhibited on 96-well microtiter plates and bed sheets after 1 h of
exposure and on SDA plates after 30 min of exposure at a distance of
1 m from the ultraviolet light source. After 30 min of exposure, all
fungal isolates (4.00 log10 CFU) on the 96-well microtiter plates
could be completely killed except C. auris (3.99 log10 CFU). We
observed that after 10 min and 30 min of exposure, the disinfec-
tant effect of UV-C on fungal isolates reduction inoculated on bed
sheets was significantly lower than that in the 96-well microtiter
plate and on SDA (P < 0.05). Compared with the other fungal isolates
tested, the efficacy of UV-C in killing C. auris is lower.
For each of the Candida species, increasing the vertical distance
up to 2.5 m led to a significant decline in the efficiency of killing
fungal isolates, even if the exposure time was prolonged (Table 3).
C. auris was reduced by 3.45 log10 CFU, 3.22 log10 CFU and 3.70 log10
CFU, respectively, after 1 h of UV-C exposure at a distance of 2.5 m
on 96-well microtiter plates, bed sheets, and SDA plates. None of
 L. Fu et al. / Journal of Infection and Public Health 13 (2020) 730–736
Fig. 1. In vitro susceptibility of Candida species to three commercial disinfectants at each time point. Dotted lines indicate the average value of the MIC of the active substance
in the disinfectants (A) 84 disinfectant (chlorine-based disinfectant), (B) IodineTincture (Iodine-based disinfectant),(C) Benzalkonium Bromide.
the isolates showed any residual in the 96-well microtiter plates
and on SDA plates after 6 h of UV-C exposure; on bed sheets, no
residuals were found after 3 h of exposure.
Disinfectants for inpatient bed units
As described in Table 4, after a routine disinfection cycle of
the LK/CXD bed unit ozone disinfection machine, C. auris and C.
glabrata on contaminated bed sheets were reduced by 3.57 and
3.56 log10 CFU, respectively. There were no signifificant differences
in reductions of the different Candida species. Two cycles of routine
disinfection could completely eradicate tested C. auris (3.60 log10
CFU) on bed sheets.
Discussion
Quaternary ammonium disinfectants, which are classified as
low-level disinfectants, are widely used in routine disinfection of
hospital environments and surfaces to avoid increasing microbial
resistance due to the widespread use of high-level disinfectants.
Previous studies have demonstrated their poor activity against
Candida species including C. auris [10,23,24]. Likewise, our study
showed that quaternary ammonium disinfectants, were less effec-
tive in killing all Candida species, and that all tested C. auris isolates
expressed proportionately higher MICs compared to other Candida
species. Concentrations of 1000 mg/L for 30 min currently used in
China hospital may, nevertheless, show sufficient growth inhibi-
tion. However, the test method in this study had some limitations
that different from some guidelines, such as EPA MB-35-00, and
no neutralizing medium was used to eliminate residues and false
negatives.
733
Chlorine-based disinfectants, high-level disinfectant, have been
proven to have good disinfection efficacy during the outbreak of C.
auris [7]. Similarly, in this in-vitro study, chlorine-based disinfec-
tant (1000 mg/L) inhibited the growth of all tested Candida isolates
within 10 min, which agree with current studies on the evalua-
tion of the effectiveness of chlorine-based disinfectants against C.
auris on surfaces [10,23,25,26]. Our result also showed that all C.
auris isolates were effectively killed at an available chlorine con-
centration of 500 mg/L for at least 30 min of exposure, proving
the chlorine-based disinfection methods currently used in Chinese
hospital environment and on the surface of objects are effective in
killing Candida species, including C. auris.
UV-C devices have been widely used as an auxiliary disinfection
method for surfaces and air in hospitals around the world. Although
many studies have shown that UV-C can effectively kill bacterial
pathogens, the research on C. auris is limited [27,28]. The report of
Ponnachan et al. found that UV-C could kill all C. auris on SDA plates
with 15 min exposure at distance of 1 m [14]. Cadnum et al. and De
Groot et al. demonstrated a maximal effect of C. auris killing after
30 min of UV-C exposure at 1.5 m and 2 m, respectively [15,29].
Although we extended the exposure time with placing the con-
taminant at 2.5 m from the UV-C device, in order to observe the
complete kill of C. auris, our findings are largely in agreement with
these studies on the efficacy of UV-C killing C. auris and emphasiz-
ing that the distance from the light source has a greater impact on
the disinfectant effect of UV-C.
This study also found that the effect of UV-C devices on killing
C. auris on bed sheets is significantly lower than that on 96-well
microtiter plates and SDA plates. The bed sheets contained absorb-
ing and scattering particulates, which can well reduce the efficacy
of UV-C, may be an explanation for the results obtained on bed
 734
Table 2
Mean log reductions for the different hand hygiene products and combinations against Candida species on pig skin (C. auris n = 3 strains, C. albicans n = 3, C. glabrata n = 2, C. tropicalis n = 2, C. parapsilosis n = 2).

Jifro disinfectant gel (ethanol Annjet disinfectant gel Walch liquid soap Walch liquid soap +
(54%–66%), n-propanol (9%–11%)) (ethanol 75% ± 5% (v/v)) (p-Chloro-xylenol 0.1%–0.2% (w/w)) Jifro disinfectant gel

Fungal isolates 15 s 30 s 1 min 15 s 30 s 1 min 15 s 30 s 1 min 15 s + 15 s 30 s + 15 s

C. auris 2.92 ± 0.05 2.99 ± 0.00 3.00 ± 0.00 2.85 ± 0.16 2.95 ± 0.02 2.98 ± 0.01 2.44 ± 0.38 2.79 ± 0.06 2.94 ± 0.01 2.99 ± 0.00 3.00 ± 0.00
C. albicans 2.97 ± 0.02 3.00 ± 0.00 3.00 ± 0.00 2.98 ± 0.01 2.98 ± 0.00 2.99 ± 0.00 2.93 ± 0.00 2.96 ± 0.00 2.97 ± 0.00 3.00 ± 0.00 3.00 ± 0.00
C. glabrata 2.91 ± 0.01 3.00 ± 0.00 3.00 ± 0.00 2.71 ± 0.03 2.94 ± 0.01 2.98 ± 0.01 2.50 ± 0.07 2.78 ± 0.02 2.90 ± 0.01 2.99 ± 0.00 3.00 ± 0.00
C. tropicalis 2.98 ± 0.00 3.00 ± 0.00 3.00 ± 0.00 2.97 ± 0.01 2.99 ± 0.00 2.99 ± 0.01 2.86 ± 0.01 2.90 ± 0.01 2.95 ± 0.01 3.00 ± 0.00 3.00 ± 0.00
C. parapsilosis 2.97 ± 0.00 3.00 ± 0.00 3.00 ± 0.00 2.96 ± 0.00 2.99 ± 0.00 2.99 ± 0.00 2.94 ± 0.01 2.97 ± 0.01 2.98 ± 0.00 3.00 ± 0.00 3.00 ± 0.00

L. Fu et al. / Journal of Infection and Public Health 13 (2020) 730–736

The control sample contained 1 × 103 CFU strains.
Data are mean log10 reduction ± standard deviation.

Table 3
Comparison of the efficacy of UV-C against Candida species on different surfaces at distances of 1 m and 2.5 m.

96-well plates; mean log10 reduction ± Sheets; mean log10 reduction ± standard plates; mean log10 reduction ± standard
standard deviation; control 1 × 104 cfu/sample deviation; control 2 × 103 cfu/sample deviation; control 1 × 104 cfu/sample

1 meter
Fungal isolates 10 min 30 min 1h 10 min 30 min 1h 10 min 30 min 1h
C. auris 3.98 ± 0.02 3.99 ± 0.00 4.00 ± 0.00 3.07 ± 0.07 3.22 ± 0.03 3.30 ± 0.00 3.99 ± 0.00 4.00 ± 0.00 4.00 ± 0.00
C. albicans 3.99 ± 0.00 4.00 ± 0.00 4.00 ± 0.00 3.23 ± 0.08 3.28 ± 0.03 3.30 ± 0.00 3.99 ± 0.00 4.00 ± 0.00 4.00 ± 0.00
C. glabrata 3.99 ± 0.00 4.00 ± 0.00 4.00 ± 0.00 3.23 ± 0.04 3.27 ± 0.03 3.30 ± 0.00 3.99 ± 0.00 4.00 ± 0.00 4.00 ± 0.00
C. tropicalis 4.00 ± 0.00 4.00 ± 0.00 4.00 ± 0.00 3.30 ± 0.00 3.30 ± 0.00 3.30 ± 0.00 3.99 ± 0.00 4.00 ± 0.00 4.00 ± 0.00
C. parapsilosis 3.99 ± 0.00 4.00 ± 0.00 4.00 ± 0.00 3.22 ± 0.11 3.27 ± 0.03 3.30 ± 0.00 3.99 ± 0.00 4.00 ± 0.00 4.00 ± 0.00
2 .5 meters
Fungal isolates 1h 3h 6h 1h 3h 6h 1h 3h 6h
C. auris 3.45 ± 0.05 3.97 ± 0.00 4.00 ± 0.00 3.22 ± 0.03 3.30 ± 0.00 3.30 ± 0.00 3.70 ± 0.00 3.99 ± 0.00 4.00 ± 0.00
C. albicans 3.58 ± 0.03 4.00 ± 0.00 4.00 ± 0.00 3.28 ± 0.03 3.30 ± 0.00 3.30 ± 0.00 3.78 ± 0.00 3.99 ± 0.00 4.00 ± 0.00
C. glabrata 3.56 ± 0.12 3.99 ± 0.00 4.00 ± 0.00 3.26 ± 0.00 3.30 ± 0.00 3.30 ± 0.00 3.81 ± 0.00 3.99 ± 0.00 4.00 ± 0.00
C. tropicalis 3.79 ± 0.02 4.00 ± 0.00 4.00 ± 0.00 3.26 ± 0.02 3.30 ± 0.00 3.30 ± 0.00 3.95 ± 0.01 3.99 ± 0.00 4.00 ± 0.00
C. parapsilosis 3.84 ± 0.00 3.99 ± 0.01 4.00 ± 0.00 3.27 ± 0.00 3.30 ± 0.00 3.30 ± 0.00 3.98 ± 0.00 3.99 ± 0.00 4.00 ± 0.00
 L. Fu et al. / Journal of Infection and Public Health 13 (2020) 730–736
Table 4
Disinfection with the LK/CXD bed unit ozone disinfection machine.
Sheets; mean log10 Sheets; mean log10
Fungal isolates
reduction ± standard reduction ± standard
deviation; control 4.0 × deviation; control 4.0 ×
103 cfu/sample 103 cfu/sample
Once Twice
C. auris 3.57 ± 0.02 3.60 ± 0.00
C. albicans 3.59 ± 0.00 3.60 ± 0.00
C. glabrata 3.56 ± 0.01 3.60 ± 0.00
C. tropicalis 3.60 ± 0.00 3.60 ± 0.00
C. parapsilosis 3.60 ± 0.00 3.60 ± 0.00
Ozone concentration (≥300 mg/m3 ) and ozone leakage (≤0.2 mg/m3 ).
The operating procedures of the product include pumping for 10 min, charging ozone
for 5 min, maintaining disinfection for 20 min, and removing residual gas for 10 min
as a routine disinfection cycle.
sheets. It is worth noting that on 96-well microtiter plates, UV-C
was effective at 30 min of exposure and on SDA plates, only 10 min
of exposure was required for complete reduction, reflecting the lim-
itation of UV-C that it is a direct line of site technology. Compared
with other Candida species, C. auris shows less sensitive to UV-C.
Our results recommend that extending the exposure time may be
beneficial, and disinfection of contaminants on different surfaces
should be treated differently.
Recent studies have confirmed that C. auris can colonize the
hands and axilla of patients, and there is a high probability that
the isolates could spread to bed surfaces and medical equipment,
due to the shedding of skin scales [5–7]. Cadnum et al. reported
that ethyl alcohol 29.4% have some killing activity to C. auris but
not to the degree as chlorine-based disinfectants [23]. 75% ethanol,
considered to be an intermediate-level disinfectant, is commonly
used for the disinfection of medical instruments in Chinese hospi-
tals by soaking the instruments for at least 30 min. In our study, we
demonstrated that 75% ethanol can completely kill all the Candida
species that we tested, including C. auris, after 1 min of contact, so
the routine disinfection method used for medical instruments in
the hospital can completely eradicate colonies of C. auris.
Iodine-based disinfectants, which are also classified as
intermediate-level disinfectants, are commonly used for skin dis-
infection at injection and surgical sites at a concentration of 20,000
mg/L for 2−3 min, and they displayed increased activity against
the tested C. auris strains. The least sensitive strain of C. auris can
be killed at an available iodine concentration of 500 mg/L for 1 min,
and this result is similar to that of a previous study by Abdolrasouli
et al. [13].
We also evaluated the rapid efficacy of different hand hygiene
products in China against C. auris with a pig skin model. Until
now, chlorhexidine gluconate (CHG) is the most studied antisep-
tic against C. auris [13,30,31]. Moore et al. reported that isopropyl
alcohol seemed to enhance the disinfection efficacy of CHG [31]. But
there are rarely published studies that directly evaluate ethanol-
based antiseptic against C. auris, which is widely used in China
hospital. Our results showed that the gel combination of ethanol
(54%–66%) and n-propanol (9%–11%) was more effective in killing
C. auris than ethanol alone (75% ± 5%) and liquid soap at each con-
tact time (P < 0.05), which may indicate that the addition of n-propyl
ethanol could enhance the disinfecting activity of ethanol against
pathogens as the consequence of synergistic effects between the
two substances. The higher viscosity of ethanol gels typically slows
down the evaporation, which may be the reason for the higher log
reduction with gels.
The measured fungal titer reached 103 CFU after pig skins were
washed with bacteriostatic hand sanitizer for 30 s and the Jifro dis-
infectant gel was rubbed on the dried pig skin surface for 15 s,
indicating the C. auris was completely eradicated. A major limita-
tion of this research is that in order to better simulate the process
735
of washing hands, there was no neutralization of the biocidal agent
performed at the end of the exposure time after the used of soap
and hand sanitizer gels in pig skin model, which may overestimate
the efficacy of the test product. There is no evidence that C. auris
is more resistant than other Candida species. Although the major
world health organizations have recommended different methods
of hand hygiene for controlling the spread of C. auris [12], the results
of the ex vivo skin contamination model may support the recom-
mendations of PHE and COTHI, that is, washing hands with soap,
then using ethanol-based disinfection gels on dry hands.
Microbial contamination of bed sheets in wards is mainly caused
by direct contamination from secretions and excreta of patients,
and normal cleaning does not achieve effective disinfection. Stud-
ies have shown that ozone disinfection can effectively inhibit the
growth of microorganisms, whether bacterial samples were dried
onto soft or plastic surfaces [32,33]. Livingston et al. demonstrated
that repeated exposure to ozonated water is effective in reduc-
ing P. aeruginosa and C. auris in colonized sinks [34]. Data in this
study showed that the routine disinfection (≥300 mg/m3 , humid-
ity 60%, 25 ◦ ) resulted in 3.57 and 3.56 log reductions in C. auris and
C. glabrata, respectively. Two cycles of routine disinfection, which
means a 40-minute effective disinfection time, could completely
eradicate tested C. auris and C. glabrata on bed sheets.
Due to the few available C. auris strains isolated from China cur-
rently, the C. auris strains tested in this study were isolated from
India, which has showed close genetic relationships with Chinese
isolates [16]. According to CLSI M27-A2, the Candida species should
be incubated at 35 ◦ C. Previous studies have shown that the opti-
mum growth temperature of C. auris is 37 ◦ C – 40 ◦ C [1,35,36]. So all
the fungal isolates were incubated at 37 ◦ C in this study. We believe
that our study could provide evidence for the Ministry of Health,
including China, to develop standards guideline for controlling the
spread of C. auris.
Conclusions
In summary, our study provides a more comprehensive assess-
ment of the effectiveness of different disinfection methods that are
commonly used in hospitals to against C. auris and other Candida
species. It is worth noting that the tested C. auris isolates showed
greater resistance to quaternary ammonium disinfectants, UV-C
(253.7 nm) and ozone. We recommend extending the disinfec-
tion times of UV-C and ozone and emphasizing the effectiveness
of washing hands with soap, drying hands, and then applying an
ethanol-based hand sanitizer gel to inhibit the growth of C. auris
according to the ex vivo skin contamination model in this study.
Funding
This work was supported by the National Natural Science Foun-
dation of China (Grant No. 81373052).
Ethical approval
Not required.
Conflict of interest
None.
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