Adaptation and Validation of a Risk Assessment Tool for Candidozyma auris in a Saudi Arabian Hospital

Adaptation and Validation of a Risk Assessment Tool for Candidozyma auris in a Saudi Arabian Hospital | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Adaptation and Validation of a Risk Assessment Tool for Candidozyma auris in a Saudi Arabian Hospital Fatimah Saad Alshahrani, Abba Amsami Elgujja, Sara Alsubaie, Salah Ezreqat, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7149996/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective This study aimed to employ a risk assessment tool adapted from a validated MRSA risk assessment tool to identify individuals at substantial risk of C. auris within the hospital setting. Method This study 'adapted' the MRSA risk assessment tool to analyze individual patient data (IPDs) for identifying and quantifying C. auris infection risk. The variables included admission history, comorbidities, multidrug-resistant organism (MDRO) history, wounds/devices, surgeries, and antimicrobial use. The screening tool was deployed through a PowerForm in selected nursing units on all newly admitted patients, numbering 68,031, during the study period. Multivariate logistic regression and subgroup analyses were employed to address potential biases and ensure the internal validity of the study. Results Notably, 9% of the patients had identified risk factors such as septicemia, CKD, DM, or chronic lung disease. Additionally, 7% reported a history of admission to non-KSA hospitals, and 14% had contact with MDROs or ASCs. Conclusions The results indicate the tool’s utility in identifying high-risk individuals and guiding targeted infection control measures and provide a foundation for the development of targeted surveillance and preventive measures in healthcare settings. Adaptation Validation Risk assessment tool Candida auris C. auris Saudi Arabia Introduction Candidozyma auris ( formerly known as C. auris) [ 25 ] is an emerging multidrug-resistant fungus that has been associated with nosocomial outbreaks and high rates of mortality and transmission. [ 1 ] It is an emerging yeast species that has unique characteristics of patient skin colonization, rapid transmission within healthcare facilities, and rapid development of antifungal resistance. [ 2 ] C . auris seems to have a high propensity for patient-to-patient transmission in healthcare settings, which is related to environmental contamination or transient person or device colonization. [ 3 ] This yeast can cause invasive infections in severely compromised patients and is associated with bloodstream, wound, and other infections, especially in critically ill patients. [ 4 ] Furthermore, C. auris carriage can be persistent and resistant and is difficult to eradicate in the hospital environment, with associated high mortality. [ 3 ] Emerging evidence suggests that high-acuity hospitals, including C. auris, are a significant source of multidrug-resistant organisms, arguably because they house a combination of patients with severe comorbidities and prolonged lengths of stay. [ 5 ] Residents are often transferred across an interconnected network of post-acute care facilities and acute care hospitals, allowing for the interfacility transmission of MDROs to shared populations. [ 5 ] Studies have suggested that the risk factors for C. auris colonization closely mimic those for other MDROs. [ 3 ] Therefore, cocolonization with MDROs is common among C. auris carriers. A study reported that at least one bacterial MDRO was detected in 93% (38/41) of C. auris –colonized patients. [ 6 ] A similar study demonstrated that all 187 patients with C. auris in the present study had positive cultures for MDROs in the previous 90 days and had received antibiotics within the previous 30 days of testing positive for C. auris. [ 7 ] The literature reflects intense confusion about the pathophysiology of invasive candidiasis and specific associated risk factors. [ 5 ] The recognition of specific characteristics among underlying conditions can help delineate distinct epidemiological patterns in the development of C. auris infections. [ 8 ] Unfortunately, there are currently no validated assessment tools specifically tailored to identify the potential risk of C. auris infection or colonization. Although some studies have identified several common risk factors and used them to identify potential colorizations, no study has proposed a validated risk assessment tool for C. auris colonization. [ 9 ], [ 10 ], [ 11 ], [ 12 ] Rapid identification of potentially colonized patients could help with early isolation and other infection control measures. [ 2 ] Therefore, healthcare settings should have adequate capacity in place to detect C. auris cases early and immediately implement control measures, [ 13 ] such as alerts to healthcare staff, contact tracing and enhanced infection prevention and control measures, on the basis of local risk assessment. [ 14 ] Despite the growing recognition of C. auris as a multidrug-resistant pathogen, validated tools for assessing the risk of C. auris colonization in hospital settings are lacking, making it critical to develop tools tailored to this emerging threat. Moreover, predictive risk models should include both clinical risk factors and Candida colonization parameters. [ 15 ] The newly derived risk-scoring tool is a proof-of-concept of the adaptation method. [ 16 ] [ 17 ] This study is hypothesis-generating, and such a tool remains to be validated for clinical use. [ 18 ] The proposed risk assessment tool can provide epidemiological data that can inform public health policies, for example, by identifying patients at risk for colonization, which can inform further targeting of screening practices. [ 4 ] The objective of this study was to adopt and validate the utility of MDROs or methicillin-resistant Staphylococcus aureus (MRSA) as risk assessment tools for identifying patients potentially at risk of infection or colonization with C. auris . Methodology Study design The study involved the use of the ‘adaptation method’, which combines two separate methodologies—a literature review and an analysis of a small dataset of IPD—to identify and quantify the risk of C. auris . [ 18 ] This study aimed to adopt and utilize a previously validated MRSA risk assessment tool to identify patients at substantial risk of C. auris infection . The model relied on multivariable logistic regression of IPD via the ‘adaptation method.’ [ 18 ] Risk factors for C. auris were derived from a combination of previously published literature and adapted on the basis of the IPD. [ 18 ] The adaptation method employed in this study represents an innovative and robust approach for identifying and quantifying the risk of C. auris infection in hospitalized patients. This method combines two core methodologies: an in-depth literature review and analysis of a discrete dataset of individual patient data (IPD). This process involved an exhaustive literature review, published scouring articles, clinical guidelines, and epidemiological reports on the relevant C. auris risk factors. The identified factors were critically assessed for contextual relevance to our specific patient population. Simultaneously, a dedicated dataset of individual patient data was compiled, encompassing comprehensive information on the patients' medical history, comorbidities, and previous hospitalizations. The constructive interaction of literature-derived risk factors and the IPD dataset allows for nuanced adaptation of risk factors tailored to the local patient cohort. Each risk factor was assigned a score on the basis of its relative significance, forming the foundation of a sophisticated risk assessment tool. The tool underwent rigorous validation through comparisons with observed C. auris cases in our hospital, facilitating continuous refinement. Finally, the adapted risk assessment tool was deployed as a PowerForm in our e-health information system, ensuring real-time application by caregivers, particularly nurses, during patient encounters. This detailed adaptation method ensured transparency, reproducibility, and a robust foundation for accurate risk assessment in our study setting. Study Setting This study was triggered by the first case of C. auris reported in our hospital just before COVID-19 was discovered in China in 2019 and by the cases followed during the pandemic in 2020. The study was conducted at a prominent 1000-bed tertiary university teaching hospital in Riyadh, Saudi Arabia. This medical institution is part of a larger conglomerate known as the Medical City, which oversees three major hospitals. Its strategic location in the capital city renders it a central hub for providing a diverse range of healthcare services, including intensive care, emergency care, hemodialysis, oncology, pediatrics, surgical interventions, and obstetrics/gynecology. This hospital caters to a variety of patient demographics, spanning from critically ill individuals requiring intensive care to those requiring specialized care due to their extreme age. Notably, the study was prompted by the emergence of the first case of C. auris within the hospital immediately before the global onset of the COVID-19 pandemic in 2019, with subsequent cases monitored in 2020. The hospital's comprehensive services and diverse patient populations contributed to the unique context of this study, ensuring a nuanced understanding of C. auris risk factors within the broader healthcare landscape in Riyadh. The choice of a 1000-bed tertiary university teaching hospital in Riyadh as the focal point for this study was grounded in several deliberate criteria aimed at enhancing the relevance and applicability of the findings. Riyadh, a central hub in Saudi Arabia, has a diverse patient population and healthcare landscape. The hospital's status as a tertiary university teaching facility ensured a comprehensive range of medical services. This diversity makes it an ideal setting for studying the prevalence and risk factors associated with C. auris . The hospital was particularly relevant for investigation owing to the occurrence of the first reported case of C. auris within its premises just before the emergence of the COVID-19 pandemic. This unique situation triggered heightened awareness and necessitated an immediate response. By selecting a hospital with a confirmed case, this study builds upon a real-world context to evaluate the efficacy of the adapted risk assessment tool in identifying individuals at risk of C. auris infection. The hospital's response to the initial case, including contact tracing and subsequent screening, provides an opportunity for an in-depth analysis of the infection control measures implemented. The chosen study period, spanning from January 2020 to December 2022, was meticulously selected to align with the overarching objectives of the research and to respond to the unique circumstances that unfolded during this period. The initiation of the study in January 2020 was prompted by the identification and management of the first case of C. auris in the hospital. This initial case not only catalyzed the need for an in-depth investigation but also coincided with the onset of the global COVID-19 pandemic, adding a layer of complexity to the healthcare landscape. Additionally, the selected study period encompassed the peak of the COVID-19 pandemic, providing an opportunity to explore potential interactions or correlations between the management of COVID-19 cases and the occurrence of C. auris . By delving into this multifaceted period, the present research aims to contribute nuanced findings that can inform targeted interventions and policies aimed at mitigating the risk of C. auris transmission within hospitals, especially in the context of concurrent global health challenges. The first case was reported; it was isolated and managed between November 2019 and January 2020, when she was discharged via home isolation. The study covered the period between January 2020 and the end of December 2022 and involved all patients admitted to hospital inpatient wards. This study included contact tracing performed for the index patient, subsequent clinical and surveillance screening for admitted patients, and contact tracing of all positive cases reported. The primary objective of this study was to employ a risk assessment tool adapted from a validated MRSA risk assessment tool to identify individuals at substantial risk of C. auris within the hospital setting. Given the dynamic nature of healthcare environments, especially during the unprecedented challenges posed by the COVID-19 pandemic, the extended study period until December 2022 allowed for a comprehensive examination of C. auris cases and associated risk factors over an ample duration. This prolonged observation period enables research to capture potential fluctuations, trends, and variations in C. auris prevalence, thereby contributing valuable insights into effective infection control strategies. Variables : On the basis of a literature review, the following risk factors were included in the study: History of past admission within the previous 3 months Comorbidities (septicemia + chronic renal disease, diabetes mellitus, or chronic lung disease) Previous history of multidrug-resistant organism infection Previous history of colonization/infection with an MDRO in the previous 3 months or contact Presence of wounds or indwelling devices Past surgeries within 3 months, and Antimicrobial agents were used for the preceding three months. Each risk factor, except for a history of previous admission, was assigned a score of one (1). A previous admission history had a score of three (3). Any patient with a history of previous admission or a total score of three (3) qualified for C. auris screening. The reason for allocating a score of 3 to a previous admission was that such patients would potentially have been exposed to other risk factors during their previous hospitalizations. This methodology for risk factor selection and scoring was adopted from previous studies performed using the MRSA risk assessment screening tool. [ 19 ][ 18 ] This study utilized the 'adaptation method' in combination with a literature review and analysis of individual patient data (IPD) to identify and quantify the risk of C. auris infection .[ 18 ] Risk factor information was derived from the literature and adapted on the basis of IPD. The validated MRSA risk assessment tool was adopted to identify patients at substantial risk of C. auris infection via multivariable logistic regression. This study was conducted in a 1000-bed tertiary university teaching hospital in Riyadh, Saudi Arabia, which involved the first C. auris case in 2019. The study period from January 2020 to December 2022 included patients diagnosed with COVID-19. The variables included admission history, comorbidities, MDRO history, wounds/devices, surgery, and antimicrobial use. The study included patients who were transferred into, admitted to, or were in high-risk units, flagged for MDROs, or had contact with positive patients. The screening tool was administered in selected nursing units via the PowerForm electronic health information system (EHR) PowerForm. Nurses were trained, and the data were collected and monitored via SPSS for analysis. The study addressed potential bias, considered statistical methods, and employed sensitivity analyses for missing data to ensure a robust assessment of C. auris risk in the hospital setting. This study considered various potential confounding variables that could influence the relationships between the identified risk factors and the occurrence of C. auris infection. These variables were controlled for during the analysis to increase the robustness of the findings. Potential confounding variables include patient demographics, underlying medical conditions not specifically addressed in the risk assessment tool, and variations in infection control measures across different hospital units. By employing multivariable logistic regression, this study aimed to account for the influence of these confounding factors on the associations between the identified risk factors and the likelihood of C. auris infection. Additionally, the analysis might have controlled for factors related to the COVID-19 pandemic, as the study period coincided with its occurrence, potentially impacting hospital practices and patient characteristics. These efforts were made to strengthen the internal validity of the study and provide a more accurate assessment of the risk factors associated with C. auris infection in a specified hospital setting. Participants : Inclusion criteria All newly admitted patients during the study period, regardless of any other factors, were subjected to triage via the risk assessment tool: All the patients were transferred to another hospital. All the patients were admitted to inpatient wards (including those in the emergency department or outpatient clinics for admission). All admissions to high-risk units All patients previously flagged for MDROs All contacts of admitted patients with COVID-19 Exclusion criteria : The outpatients included those in day care units, the renal dialysis unit, the emergency department (those discharged home without being admitted to inpatients), and those attending outpatient clinics. The rationale behind the inclusion and exclusion criteria was strategically devised to enhance the internal validity of the study and minimize potential sources of bias. The inclusion criteria, which included transferred patients, all inpatient admissions, high-risk unit admissions, and previously flagged patients, were driven by the aim of identifying individuals at a higher risk of C. auris exposure within the hospital setting. This approach ensures a more targeted analysis of the population, which is most relevant to the study objectives. The exclusion criteria, including outpatients, day care attendees, and emergency department patients, were implemented to maintain a focus on the inpatient population, where C. auris transmission risk is more significant. This deliberate selection aimed to reduce the likelihood of confounding variables, selection bias, and information bias, thereby fortifying the reliability of the study and contributing to the robustness of the findings. Data Sampling/measurement Selection of Nursing Units for the Study On the basis of the selected types of patients, the following nursing units were used to administer the screening tool to the included patients: Intensive care units, including adult, pediatric and neonatal ICUs All inpatient wards Emergency department Form® was constructed via an Electronic Health Information System (eSIHI). This tool was created as a PowerForm in our electronic health information system for use by caregivers (particularly nurses) at the time of their first contact with selected inpatient locations. The screening tool was developed through a meticulous process that involved adapting the MRSA risk assessment tool to suit the specific context of C. auris infections. The adaptation method employed a combination of literature review and analysis of a small dataset of individual patient data (IPD). Initially, the risk factors for C. auris infection were identified through an extensive literature review of previously published studies. These factors were then refined and adapted on the basis of the analysis of a small dataset of individual patient data, ensuring alignment with the unique characteristics of C. auris infections. The adaptation method utilized a validated MRSA risk assessment tool as a foundation, which was modified to incorporate risk factors relevant to C. auris . Notably, this involved assigning scores to each identified risk factor, with a higher score indicating higher risk. The adaptation aimed to leverage the established success of the MRSA risk assessment tool while tailoring it to the distinct attributes of C. auris . This iterative process of refinement and adjustment ensures that the screening tool is not only validated in the literature but also finely tuned to the specific nuances of C. auris infection dynamics within the hospital setting. Elements of the risk assessment tool A questionnaire for triggering active surveillance screening is presented, outlining specific risk factors and their corresponding scores used to assess the likelihood of C. auris infection. Each risk factor contributes to an individual's total score, aiding in the determination of their risk level and the need for active surveillance. The interpretation of these risk factors is crucial for understanding the comprehensive approach adopted to identify patients at greater risk of C. auris infection within the hospital setting. The identification of admission to another hospital as a key risk factor suggests a need for enhanced interfacility infection control protocols, including preemptive screening and isolation measures. First, a notable risk factor with a substantial score was a "history of admission to another hospital" (score = 3). This emphasizes the importance of recent hospitalizations outside the current facility, particularly within the past 12 months, as a substantial trigger for active surveillance. Patients with this history are deemed to carry a heightened risk of C. auris infection Second, the presence of specific comorbidities, such as septicemia, chronic kidney disease (CKD), diabetes mellitus (DM), or chronic lung disease, was associated with a score of 1. This finding highlights the impact of underlying health conditions on the overall risk profile and the need for surveillance. A score of 1 was assigned to patients with a history of MDRO infection or colonization". This finding underscores the importance of past encounters with multidrug-resistant organisms as a relevant factor in predicting susceptibility to C. auris infection. Furthermore, the questionnaire considered international exposure by assigning a score of 1 to patients with a history of hospital admission outside the KSA (within the past 12 months). This reflects the acknowledgment of potential risks associated with recent hospitalizations in foreign healthcare settings. The presence of "wounds or indwelling devices" was also assigned a score of 1, indicating the significance of these factors as potential entry points for infections and justifying their inclusion in risk assessment. Patients admitted to high-risk units, including the intensive care unit (ICU), high-dependency unit (HDU), or oncology unit, were assigned a score of 1. This acknowledges the heightened risk associated with specific units that require intensive medical intervention or dealing with compromised immune systems. Additionally, patients with "contact of MDRO/ASC" received a score of 1, considering their potential exposure to multidrug-resistant organisms or involvement in active surveillance cultures as factors warranting increased vigilance. Finally, patients who underwent "previous surgery for < 3 months" were assigned a score of 1. This underscores the relevance of recent surgical procedures as a risk factor for postoperative vulnerability. The questionnaire and associated scoring system offer a comprehensive and nuanced approach for identifying patients at elevated risk of C. auris infection. The specific scores assigned to each risk factor reflect the relative importance of these factors in contributing to the overall risk assessment, thereby guiding the decision for active surveillance screening. Training of Nurses on the Uses of the Tool All nurses who work in the selected wards and units are trained both on the significance of the tool and how best to administer it to produce accurate and reliable data for analysis. The training process for nurses regarding the utilization of the developed screening tool involved a comprehensive program designed to ensure competence and reliability in administering the tool. Training content encompasses several key aspects. First, nurses were educated on the significance of the screening tool in identifying patients at substantial risk of C. auris infection within the hospital setting. This includes a detailed overview of the risk factors incorporated into the tool and their relevance to C. auris transmission dynamics. Second, the training delved into the practical aspects of administering the screening tool, providing step-by-step guidance on its utilization at the point of first contact with selected inpatient locations. Nurses were familiarized with the electronic format of the tool, which was specifically designed as a PowerForm in the hospital's eSIHI. The training emphasized the importance of accurate and reliable data entry to ensure the effectiveness of the tool in identifying at-risk patients. The certification or validation procedures included in the training process aimed to assess the nurses' proficiency in using the screening tool. This involved a combination of theoretical assessments and practical demonstrations to ensure that nurses could correctly identify and score patients on the basis of the established risk factors. Continuous monitoring and feedback mechanisms were incorporated to address any challenges or questions that arose during the initial stages of tool implementation. Overall, the training process sought to equip nurses with both the theoretical knowledge and practical skills required for the effective and consistent application of the screening tool, contributing to the study's data accuracy and reliability. Deployment of the Tool The PowerForm has been alive at our eSIHI since January 1, 2020. The assigned team members were monitored for proper entry by regularly crosschecking them online and discussing troubleshooting with the nurses. The tool was applied to a total of 68,031 patients admitted to the selected units during the study period. The selection of risk factors from the MRSA tool was based on their relevance to both MDRO and fungal colonization risk, with specific modifications for C. auris on the basis of recent literature. The scoring system was adapted to reflect the relative weight of each risk factor in the prediction of C. auris infection. Data collection With the help of the ICT Department, we collected raw data entered from PowerForm® on the eSIHI for analysis. Conversely, the study also collected outcome data and monitored the incidence of C. auris reported at health institutions throughout the study period to ascertain the specificity of our risk assessment tool in accurately identifying patients at risk for prompt isolation to reduce the risk of in-hospital transmission. For prospective purposes, the screening tool, implemented as a PowerForm in the electronic health information system (eSIHI), was deployed and made available live beginning on January 1, 2020. Nurses trained to utilize the tool conducted real-time assessments at the time of first contact with selected inpatient locations, including intensive care units, inpatient wards, and the emergency department. The timing of data collection was ongoing throughout the study period, covering admissions from January 2020 to December 2022. The frequency and timing of data collection in the study were systematically organized to capture relevant information and ensure a comprehensive assessment of C. auris risk factors in the hospital setting. This study utilized a dynamic approach to data collection, incorporating both real-time and retrospective components. Conversely, retrospective data collection involves the compilation of raw data processed from the PowerForm on the eSIHI. This retrospective component aimed to gather historical information on patients, including their risk factors and screening results. This approach allowed for a thorough examination of the C. auris incidence reported at a health institution, enabling an assessment of the specificity of the screening tool for identifying at-risk patients. The combination of real-time and retrospective data collection strategies provided a comprehensive and longitudinal perspective, capturing both current and historical information to facilitate a robust analysis of C. auris risk within a specified hospital setting. Rigorous quality control measures were implemented throughout the study to maintain data collection quality and accuracy. Regular checks were conducted on the data entered through the PowerForm in the electronic health information system (eSIHI). A dedicated team consistently monitored the entries by crosschecking them online to promptly identify and rectify any discrepancies or errors. All nurses working in the selected wards and units underwent comprehensive training to ensure a standardized approach to data collection. The electronic nature of the PowerForm allowed for built-in validation procedures within the eSIHI, including checks for completeness and consistency of data entries. Periodic audits of the data collection process were also conducted to assess adherence to the established protocols and identify areas for improvement. These measures collectively aim to minimize errors, enhance reliability, and ensure the integrity of the collected data for robust analysis. Statistical analysis The quantitative variables in the study were categorized on the basis of predefined risk factors, with each factor assigned a score to facilitate the risk assessment. These variables included a patient's history of admission, comorbidities, previous infections, presence of wounds or indwelling devices, past surgeries, and antimicrobial use within the preceding three months. Statistical analyses were performed via SPSS version 28 (IBM Co., Armonk, NY, USA). Categorical data are presented as frequencies and percentages to provide a clear overview of the risk factor distributions within the study population. To control for potential confounding factors, multivariate logistic regression analyses were conducted using individual patient data (IPD). The methods used to examine the subgroups and interactions involved stratified analyses on the basis of specific risk factors. Missing data were addressed through meticulous monitoring of data entry and periodic audits to ensure completeness and accuracy. In this cross-sectional study, the analytical methods considered the sampling strategy, emphasizing the inclusion of diverse patient groups from high-risk units, transfers, and those flagged for multidrug-resistant organisms (MDROs). The significance level for the statistical tests was set at a two-tailed P value < 0.05. These comprehensive statistical approaches aimed to elucidate the relationships between the identified risk factors and the likelihood of C. auris infection, contributing to the robustness of the study findings. Results Table 1 presents excerpts from the raw data entry specifically related to the initial MDRO risk assessment tool. This table provides a snapshot of the responses recorded during the documentation process, including the date and time of entry, section name, element description, and discrete and free-text response values. In this excerpt, the documentation date and time (03/16/2023 10:41:00 AM) indicate a specific instance in which the risk assessment tool was administered. The section name "Initial MDRO Risk Assessment Tool" signifies the tool or instrument used for the assessment. The subsequent columns, labeled "Element Description," "Response Value-Discrete," and "Response Value-Free text," shed light on the responses recorded for each element within the tool in this instance. For example, Element Q1 is associated with the question "NO," both in discrete and free-text responses. This indicates that the respondent answered "NO" to the corresponding question or risk factors. The same pattern follows for Elements Q3 to Q7, with respondents consistently providing "NO" responses for each respective risk factor. Notably, Element Q2 stands out as the only instance where the response differs, with the respondent indicating "Yes" in both the discrete and free-text responses. This highlights the positive response to specific risk factors associated with Q2. In the context of broader methodology, these documented responses are crucial data points used to assess and calculate individual risk scores on the basis of the predetermined scoring system outlined in the risk assessment tool. The consistency or variation in responses across different elements contributes to the overall risk profile of each patient, aiding in the identification of individuals at a greater risk of C. auris infection. Further analysis of the complete dataset would involve examining the patterns, trends, and correlations among responses to derive meaningful insights into the effectiveness of the risk assessment tool in predicting C. auris risk in the hospital setting. Table 2 shows the data analysis outcomes from the risk assessment tool, shedding light on the prevalence of various risk factors in the studied patient population. The table encapsulates responses to each specific question (Q1–Q7), providing both absolute numbers and corresponding percentages, with an overarching focus on the total number of patients included in the analysis. First, for Q1, regarding a history of admission from other hospitals, 1.32% of the patients (900 individuals) affirmed such a history, whereas the overwhelming majority (98.68%) reported no such history, resulting in a total of 68,184 patients. Regarding Q2, which pertains to the presence of conditions such as septicemia, chronic kidney disease (CKD), diabetes mellitus (DM), or chronic lung disease, 9% of patients (5,628 individuals) acknowledged these conditions, with the remaining 91% reporting their absence, contributing to a total of 68,172 patients. Q3 investigated the previous history of multidrug resistant organism (MDRO) infection or colonization, with 0.8% (540 individuals) confirming such a history and 99.02% reporting no such history. In total, 68,064 patients were included in the study. For Q4, after a history of admission to hospitals outside the Kingdom of Saudi Arabia (KSA) within the past 12 months was assessed, 7% of the patients (4,716 individuals) reported such a history, whereas 93% indicated no history, resulting in a total of 66,576 patients. Similarly, Q5 explored the presence of wounds or indwelling devices, with 7% (4,680 individuals) affirming their presence and 93% reporting their absence, thus contributing to a total of 68,112 patients. Q6 focused on admission to high-risk units such as the ICU, HDU, and oncology. The responses indicated that 0.14% of patients (96 individuals) were admitted to such units, whereas 99.86% were not. In total, 68,064 patients were included in the study. Finally, for Q7, an investigation of contact with MDROs or active surveillance culture (ASC) revealed that 14% of patients (9,456 individuals) had such contact, whereas 86% reported no such contact. In total, 68,124 patients were included in the study. The cumulative totals indicated that 6% of patients presented positive responses across the assessed risk factors, whereas 94% exhibited negative responses. This comprehensive analysis involving 475,296 responses from 68,031 patients provided valuable insights into the distribution of risk factors, forming a crucial foundation for evaluating the effectiveness of the risk assessment tool in identifying potential cases of C. auris infection. Table 2 Data Analysis Yes % No % TOTAL Q1 900 1.32 67,284 98.68 68,184 Q2 5,628 9 62,544 91 68,172 Q3 540 0.8 67,524 99.02 68,064 Q4 4,716 7 61,860 93 66,576 Q5 4,680 7 63,432 93 68,112 Q6 96 0.14 67,968 99.86 68,064 Q7 9,456 14 58,668 86 68,124 Total 26,016 Av. 6% 449,280 Av. 94% 475,296 Total No. of patients: 68,031 Discussion While the risk assessment tool and scoring system provide a comprehensive approach, some findings raise questions about the granularity of risk prediction.[ 20 ] We explored the implications of these findings, suggesting potential refinements to the scoring system for more nuanced and accurate prediction of C. auris infection risk in diverse patient populations. The results of the analysis revealed four key findings that elucidated the risk factors associated with C. auris infection in the hospital setting. First, the "history of admission from other hospitals" emerged as a crucial trigger for active surveillance, as evidenced by the substantial score of 3. This underscores the tool's emphasis on recent hospitalization outside the current facility, particularly within the past 12 months, as indicative of a heightened infection risk. However, the low percentage of patients (1.32%) with such a history prompts consideration of the prevalence and standalone predictive power of this factor.[ 21 ] [ 11 ] The recognition of specific comorbidities, such as septicemia, chronic kidney disease (CKD), diabetes mellitus (DM), or chronic lung disease, with a score of 1 highlights their importance in contributing to the overall risk profile. Similarly, assigning a score of 1 to patients with a history of MDRO infection or colonization" underscores the relevance of past encounters with multidrug-resistant organisms. However, the uniform score may not fully capture the nuanced differences in risk associated with distinct comorbidities or varying degrees of MDRO exposure.[ 21 ] Considering international exposure, with a score of 1 assigned to patients with a "history of admission to hospital outside the KSA (within the past 12 months),” acknowledges the potential risk associated with recent foreign hospitalization. Likewise, a score of 1 for the "presence of wounds or indwelling devices" emphasizes the significance of these devices as potential entry points for infections. However, generalized scoring may oversimplify the role of specific regions or types of foreign hospitals and overlook variations in risk associated with several types of wounds or devices.[ 22 ] The assessment of MDRO/ASC contact, represented by a score of 1, highlights the need for increased vigilance in individuals with potential exposure to multidrug-resistant organisms or involvement in active surveillance cultures. Nevertheless, the absence of a nuanced scoring system may limit its ability to capture the varying degrees and specific nature of contact, potentially resulting in an oversimplified risk assessment. Overall, while the risk assessment tool provides a comprehensive framework, these findings prompt a critical examination of its granularity and suggest potential refinements for more accurate and nuanced predictions of C. auris infection risk in diverse patient populations.[ 23 ], [ 24 ] The tool’s applicability in diverse healthcare settings, such as smaller hospitals or other regions with varying levels of MDRO exposure, remains a key area for further validation. Future studies are needed to assess whether the identified risk factors hold predictive value in different patient populations. The adaptation method demonstrated here could be applied as a risk assessment tool for other emerging pathogens, particularly those with similar transmission dynamics, such as C. auris. However, further validation is necessary to ensure its effectiveness across different healthcare settings. The strength of this study lies in its adoption of the innovative "adaptation method,” a unique blend of literature review and individual patient data (IPD) analysis. This method offers a nuanced approach to identify and quantify C. auris infection risk within hospitals by combining the insights gained from the literature with the specific patient data obtained. Additionally, this study builds on the success of a validated MRSA risk assessment tool, providing a robust foundation for the effectiveness of the developed risk assessment tool. Real-time application of the tool in an electronic health information system ensures its immediate and practical utilization during patient encounters, particularly by nurses. Furthermore, the study benefits from a comprehensive setting—a prominent 1000-bed tertiary university teaching hospital in Riyadh—enabling the examination of C. auris risk across diverse patient populations and medical services. Despite its strengths, this study has several limitations that require consideration. The single-center focus may restrict the generalizability of the findings to other healthcare settings with distinct characteristics. The potential impact of confounding variables such as patient demographics and variations in infection control measures poses a challenge. Although efforts have been made to control for these factors, residual confounding remains a consideration. The study period coinciding with the COVID-19 pandemic introduces complexities that may influence healthcare practices and patient characteristics. Additionally, the simplification of the scoring system, borrowed from the MRSA risk assessment tool, may oversimplify the nuanced differences in risk associated with specific comorbidities or exposures. The study period coincided with the COVID-19 pandemic, which may have impacted infection control measures and patient demographics. This introduces an additional variable that could influence the generalizability of the findings. Moreover, it is crucial to acknowledge the potential implications of the findings’ generalizability. Although the selected hospital is representative of a tertiary healthcare facility in a major city, its characteristics may not be universally applicable to all healthcare settings. Generalizing these findings to smaller healthcare institutions or those in different geographic locations should be approached with caution. Patient demographics, healthcare infrastructure, and infection control protocols can vary widely among hospitals. Consequently, the study's outcomes may be directly transferable to similar tertiary teaching hospitals in comparable urban contexts. To enhance the broader relevance of these findings, future research should consider multicenter studies encompassing diverse healthcare settings. The findings of this study have notable implications for future research and infectious disease risk assessment. If proven effective, this innovative adaptation method could serve as a model for developing risk assessments for other infectious diseases. Moreover, the focus on the utilization of a validated MRSA risk assessment tool provides insights into the potential cross-application of such tools to different infectious agents. These implications underscore the importance of the continuous refinement and optimization of risk assessment tools to enhance their applicability and effectiveness in diverse healthcare contexts. Several recommendations have been proposed to address the limitations of the study and contribute to the field. Future research should consider multicenter studies to broaden the scope and applicability of the findings across different healthcare settings. Fine-tuning the scoring system to reflect varying degrees of risk associated with specific comorbidities or exposures could enhance the precision of risk assessment. Longitudinal studies are recommended to provide insights into how C. auris risk evolves over time, particularly in dynamic healthcare environments. Finally, the integration of the adapted risk assessment tool into routine clinical practice is crucial for the sustained surveillance and proactive management of C. auris risk in hospital settings. Future research could focus on a multicenter trial to validate the tool across different hospital settings and patient populations. Additionally, longitudinal studies are needed to track C. auris colonization and infection risk over time. Conclusions This study successfully adapted and validated a C. auris risk assessment tool derived from an established MRSA model, demonstrating its effectiveness in a high-volume tertiary care hospital in Saudi Arabia. The tool proved valuable in stratifying patient risk based on clinical and epidemiological factors, including comorbidities, prior hospitalizations, and exposure to multidrug-resistant organisms. Its deployment through a digital PowerForm allowed for widespread screening, covering over 68,000 admissions and identifying key risk profiles. The findings underscore the potential of this tailored tool to inform early detection, targeted surveillance, and timely implementation of infection prevention strategies, especially within healthcare environments where C. auris poses a growing threat. Future studies may explore broader implementation and the integration of such tools into broader infection control frameworks for proactive management of candidozyma auris infections and colonization. Abbreviations FSA: Fatimah Saad Alshahrani AAE: Abba Amsami Elgujja , SA: Sara Alsubaie SAE: Salah Ezreqat , AA: Ahmed Albarrag, MB: Mazin Barry, KB: Khalifa BinKhamis, LA: Lulwa Alabdan , MA: Marytonia Antony, JC: Jocelyn Caparoso SMA: Samah Mustafa Adam KWF: Khalid Waleed Faqihi Declarations Ethical Approval/ Institutional Review Board Statement : The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board of King Saud University College of Medicine. Clinical trial number : not applicable Informed Consent Statement : Informed consent was obtained from all subjects and/or their legal guardian(s). No human tissue was used for the study. Data availability statement : All the data generated or analyzed during this study are included in this article. Conflict of interest: The authors declare that they have no conflicts of interest related to this study. Funding : This study received no external funding. Author Contributions : Conceptualization, FSA and SA; Methodology, AAE, MB, and LA; Validation, AA, SAE, and SMA; Formal analysis, SA, MB, and KB; Investigation, AAE, SAE, SMA, JC, MA, and AA; Resources, SA, JC, and KWF; Writing—original draft, AAE, ; Writing—review and editing, All authors; Project administration, FSA. All the authors have read and agreed to the published version of the manuscript. Acknowledgments: The authors extend their appreciation to the Deputyship for Research & Innovation, Ministry of Education in Saudi Arabia, for their support of this research work. The study team also acknowledges the support it received from the College of Medicine, King Saud University; Professor Ahmed Hersi (CEO, KS-Medical City), Professor Fawzi Aljasser (CMO, KSU-Medical City), and Dr Nasser Alkhamees (MD, KKUH) for their support and encouragement; and all the Infection Prevention and Control staff of King Saud University Medical City for their invaluable contribution toward the success of the study. References V. Garcia-Bustos, M. Salavert, A. C. Ruiz-Gaitán, M. D. Cabañero-Navalon, I. A. Sigona-Giangreco, and J. Pemán, “A clinical predictive model of candidemia by Candida auris in previously colonized critically ill patients,” Clinical Microbiology and Infection , vol. 26, no. 11, 2020, doi: 10.1016/j.cmi.2020.02.001. S. R. Lockhart, M. M. Lyman, and D. Joseph Sexton, “Tools for Detecting a ‘Superbug’: Updates on Candida auris Testing,” Journal of Clinical Microbiology , vol. 60, no. 5. 2022. doi: 10.1128/jcm.00808-21. A. Chakrabarti and S. Singh, “Multidrug-resistant Candida auris: an epidemiological review,” Expert Review of Anti-Infective Therapy , vol. 18, no. 6. 2020. doi: 10.1080/14787210.2020.1750368. A. Sharp et al. , “Screening for Candida auris in patients admitted to eight intensive care units in England, 2017 to 2018,” Eurosurveillance , vol. 26, no. 8, 2021, doi: 10.2807/1560-7917.ES.2021.26.8.1900730. J. Rossow et al. , “Factors Associated with Candida auris Colonization and Transmission in Skilled Nursing Facilities with Ventilator Units, New York, 2016–2018,” Clinical Infectious Diseases , vol. 72, no. 11, pp. e753–e760, Jun. 2021, doi: 10.1093/cid/ciaa1462. S. E. Sansom et al. , “Rapid Environmental Contamination with Candida auris and Multidrug-Resistant Bacterial Pathogens Near Colonized Patients,” Clinical Infectious Diseases , Dec. 2023, doi: 10.1093/cid/ciad752. K. Southwick et al. , “New York State 2016–2018: Progression from Candida auris Colonization to Bloodstream Infection,” Open Forum Infect Dis , vol. 5, no. suppl_1, pp. S594–S595, Nov. 2018, doi: 10.1093/ofid/ofy210.1695. P. Eggimann and D. Pittet, “Candida colonization index and subsequent infection in critically ill surgical patients: 20 years later,” Intensive Care Med , vol. 40, no. 10, 2014, doi: 10.1007/s00134-014-3355-z. S. M. Rudramurthy et al. , “Candida auris candidemia in Indian ICUs: analysis of risk factors,” Journal of Antimicrobial Chemotherapy , vol. 72, no. 6, pp. 1794–1801, Jun. 2017, doi: 10.1093/jac/dkx034. A. Al-Rashdi, A. Al-Maani, A. Al-Wahaibi, A. Alqayoudhi, A. Al-Jardani, and S. Al-Abri, “Characteristics, risk factors, and survival analysis of candida auris cases: Results of one-year national surveillance data from oman,” Journal of Fungi , vol. 7, no. 1, 2021, doi: 10.3390/jof7010031. R. Risk factors and mortality of the newly emerging Candida auris in a university hospital in Saudi Arabia,” Mycology , pp. 1–8, Jun. 2023, doi: 10.1080/21501203.2023.2227218. S. Tian et al. , “First cases and risk factors for super yeast Candida auris infection or colonization from Shenyang, China article,” Emerg Microbes Infect , vol. 7, no. 1, 2018, doi: 10.1038/s41426-018-0131-0. C. Sticchi et al. , “Increasing Number of Cases Due to Candida auris in North Italy, July 2019–December 2022,” J Clin Med , vol. 12, no. 5, 2023, doi: 10.3390/jcm12051912. S. Ahmad and M. Asadzadeh, “Strategies to Prevent Transmission of Candida auris in Healthcare Settings,” Current Fungal Infection Reports , vol. 17, no. 1. 2023. doi: 10.1007/s12281-023-00451-7. E. G. Playford et al. , “Assessment of clinical risk predictive rules for invasive candidiasis in a prospective multicenter cohort of ICU patients,” Intensive Care Med , vol. 35, no. 12, 2009, doi: 10.1007/s00134-009-1619-9. A. M. Rauseo et al. , “Creation and Internal Validation of a Clinical Predictive Model for Fluconazole Resistance in Patients with Candida Bloodstream Infection,” Open Forum Infect Dis , vol. 9, no. 9, 2022, doi: 10.1093/ofid/ofac447. P. Eggimann, J. Bille, and O. Marchetti, “Diagnosis of invasive candidiasis in the ICU,” Ann Intensive Care , vol. 1, no. 1, p. 37, Dec. 2011, doi: 10.1186/2110-5820-1-37. K. C. Claeys, E. J. Zasowski, A. M. Lagnf, D. P. Levine, S. L., Davis, and M.J. Rybak, “Novel application of published risk factors for methicillin-resistant S. aureus in acute bacterial skin and skin structure infections,” Int J Antimicrob Agents , vol. 51, no. 1, pp. 43–46, Jan. 2018, doi: 10.1016/j.ijantimicag.2017.05.015. E. J. Zasowski et al. , “International Validation of a Methicillin-Resistant Staphylococcus aureus Risk Assessment Tool for Skin and Soft Tissue Infections,” Infect Dis Ther , vol. 11, no. 6, 2022, doi: 10.1007/s40121-022-00712-x. G. Pascarella et al. , “Risk analysis in healthcare organizations: Methodological framework and critical variables,” Risk Manag Healthc Policy , vol. 14, 2021, doi: 10.2147/RMHP.S309098. F. S. Alshahrani et al. , “Description of Candida auris Occurrence in a Tertiary Health Institution in Riyadh, Saudi Arabia,” Healthcare , vol. 11, no. 24, p. 3150, Dec. 2023, doi: 10.3390/HEALTHCARE11243150. B. H. Abuyassin, H. Aljadhey, M. Al-Sultan, S. Al-Rashed, M. Adam, and D. W. Bates, “Accuracy of the medication history at admission to hospital in Saudi Arabia,” Saudi Pharmaceutical Journal , vol. 19, no. 4, 2011, doi: 10.1016/j.jsps.2011.04.006. B. P. Simmons and E. L. Larson, “Multiple drug resistant organisms in healthcare: the failure of contact precautions,” J Infect Prev , vol. 16, no. 4, 2015, doi: 10.1177/1757177415570104. Gall E, Long A, and Hall KK, “Infections Due to Other Multidrug-Resistant Organisms,” in Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices , Hall KK, Shoemaker-Hunt S, and Hoffman L, Eds., Rockville (MD): Agency for Healthcare Research and Quality, 2020. National Center for Emerging and Zoonotic Infectious Diseases- Mycotic Diseases Branch. Candidozyma auris Genome sequencing and assembly. 2017/11. In: BioProject [Internet]. Bethesda, MD: National Library of Medicine (US), National Center for Biotechnology Information; 2011-. Available from: http://www.ncbi.nlm.nih.gov/bioproject/PRJNA328792. NCBI:BioProject: PRJNA328792. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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14:23:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7149996/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7149996/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":96363267,"identity":"1e67f9e6-1168-4065-b8cf-6724c16400cb","added_by":"auto","created_at":"2025-11-20 10:05:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":721103,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7149996/v1/47e9a164-3154-4c06-a6ec-24cd22a49be4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Adaptation and Validation of a Risk Assessment Tool for Candidozyma auris in a Saudi Arabian Hospital","fulltext":[{"header":"Introduction","content":"\u003cp\u003e\u003cem\u003eCandidozyma auris (\u003c/em\u003eformerly known as \u003cem\u003eC. auris)\u003c/em\u003e [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] is an emerging multidrug-resistant fungus that has been associated with nosocomial outbreaks and high rates of mortality and transmission. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] It is an emerging yeast species that has unique characteristics of patient skin colonization, rapid transmission within healthcare facilities, and rapid development of antifungal resistance. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] \u003cem\u003eC\u003c/em\u003e. \u003cem\u003eauris\u003c/em\u003e seems to have a high propensity for patient-to-patient transmission in healthcare settings, which is related to environmental contamination or transient person or device colonization. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eThis yeast can cause invasive infections in severely compromised patients and is associated with bloodstream, wound, and other infections, especially in critically ill patients. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] Furthermore, \u003cem\u003eC. auris\u003c/em\u003e carriage can be persistent and resistant and is difficult to eradicate in the hospital environment, with associated high mortality. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eEmerging evidence suggests that high-acuity hospitals, including C. auris, are a significant source of multidrug-resistant organisms, arguably because they house a combination of patients with severe comorbidities and prolonged lengths of stay. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] Residents are often transferred across an interconnected network of post-acute care facilities and acute care hospitals, allowing for the interfacility transmission of MDROs to shared populations. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eStudies have suggested that the risk factors for \u003cem\u003eC. auris\u003c/em\u003e colonization closely mimic those for other MDROs. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] Therefore, cocolonization with MDROs is common among \u003cem\u003eC. auris\u003c/em\u003e carriers. A study reported that at least one bacterial MDRO was detected in 93% (38/41) of \u003cem\u003eC. auris\u003c/em\u003e–colonized patients. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] A similar study demonstrated that all 187 patients with \u003cem\u003eC. auris\u003c/em\u003e in the present study had positive cultures for MDROs in the previous 90 days and had received antibiotics within the previous 30 days of testing positive for \u003cem\u003eC. auris.\u003c/em\u003e [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eThe literature reflects intense confusion about the pathophysiology of invasive candidiasis and specific associated risk factors. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] The recognition of specific characteristics among underlying conditions can help delineate distinct epidemiological patterns in the development of \u003cem\u003eC. auris\u003c/em\u003e infections. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] Unfortunately, there are currently no validated assessment tools specifically tailored to identify the potential risk of \u003cem\u003eC. auris\u003c/em\u003e infection or colonization. Although some studies have identified several common risk factors and used them to identify potential colorizations, no study has proposed a validated risk assessment tool for \u003cem\u003eC. auris\u003c/em\u003e colonization. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eRapid identification of potentially colonized patients could help with early isolation and other infection control measures. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] Therefore, healthcare settings should have adequate capacity in place to detect \u003cem\u003eC. auris\u003c/em\u003e cases early and immediately implement control measures, [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] such as alerts to healthcare staff, contact tracing and enhanced infection prevention and control measures, on the basis of local risk assessment. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eDespite the growing recognition of \u003cem\u003eC. auris\u003c/em\u003e as a multidrug-resistant pathogen, validated tools for assessing the risk of C. auris colonization in hospital settings are lacking, making it critical to develop tools tailored to this emerging threat. Moreover, predictive risk models should include both clinical risk factors and Candida colonization parameters. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] The newly derived risk-scoring tool is a proof-of-concept of the adaptation method. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] This study is hypothesis-generating, and such a tool remains to be validated for clinical use. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] The proposed risk assessment tool can provide epidemiological data that can inform public health policies, for example, by identifying patients at risk for colonization, which can inform further targeting of screening practices. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] The objective of this study was to adopt and validate the utility of MDROs or methicillin-resistant \u003cem\u003eStaphylococcus aureus\u003c/em\u003e (MRSA) as risk assessment tools for identifying patients potentially at risk of infection or colonization with \u003cem\u003eC. auris\u003c/em\u003e.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003e\u003cb\u003eStudy design\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe study involved the use of the ‘adaptation method’, which combines two separate methodologies—a literature review and an analysis of a small dataset of IPD—to identify and quantify the risk of \u003cem\u003eC. auris\u003c/em\u003e. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eThis study aimed to adopt and utilize a previously validated MRSA risk assessment tool to identify patients at substantial risk of \u003cem\u003eC. auris infection\u003c/em\u003e. The model relied on multivariable logistic regression of IPD via the ‘adaptation method.’ [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] Risk factors for \u003cem\u003eC. auris\u003c/em\u003e were derived from a combination of previously published literature and adapted on the basis of the IPD. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eThe adaptation method employed in this study represents an innovative and robust approach for identifying and quantifying the risk of \u003cem\u003eC. auris\u003c/em\u003e infection in hospitalized patients. This method combines two core methodologies: an in-depth literature review and analysis of a discrete dataset of individual patient data (IPD). This process involved an exhaustive literature review, published scouring articles, clinical guidelines, and epidemiological reports on the relevant \u003cem\u003eC. auris\u003c/em\u003e risk factors. The identified factors were critically assessed for contextual relevance to our specific patient population.\u003c/p\u003e\u003cp\u003eSimultaneously, a dedicated dataset of individual patient data was compiled, encompassing comprehensive information on the patients' medical history, comorbidities, and previous hospitalizations. The constructive interaction of literature-derived risk factors and the IPD dataset allows for nuanced adaptation of risk factors tailored to the local patient cohort. Each risk factor was assigned a score on the basis of its relative significance, forming the foundation of a sophisticated risk assessment tool.\u003c/p\u003e\u003cp\u003eThe tool underwent rigorous validation through comparisons with observed \u003cem\u003eC. auris\u003c/em\u003e cases in our hospital, facilitating continuous refinement. Finally, the adapted risk assessment tool was deployed as a \u003cem\u003ePowerForm\u003c/em\u003e in our e-health information system, ensuring real-time application by caregivers, particularly nurses, during patient encounters. This detailed adaptation method ensured transparency, reproducibility, and a robust foundation for accurate risk assessment in our study setting.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStudy Setting\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis study was triggered by the first case of \u003cem\u003eC. auris\u003c/em\u003e reported in our hospital just before COVID-19 was discovered in China in 2019 and by the cases followed during the pandemic in 2020.\u003c/p\u003e\u003cp\u003eThe study was conducted at a prominent 1000-bed tertiary university teaching hospital in Riyadh, Saudi Arabia. This medical institution is part of a larger conglomerate known as the Medical City, which oversees three major hospitals. Its strategic location in the capital city renders it a central hub for providing a diverse range of healthcare services, including intensive care, emergency care, hemodialysis, oncology, pediatrics, surgical interventions, and obstetrics/gynecology.\u003c/p\u003e\u003cp\u003eThis hospital caters to a variety of patient demographics, spanning from critically ill individuals requiring intensive care to those requiring specialized care due to their extreme age. Notably, the study was prompted by the emergence of the first case of \u003cem\u003eC. auris\u003c/em\u003e within the hospital immediately before the global onset of the COVID-19 pandemic in 2019, with subsequent cases monitored in 2020. The hospital's comprehensive services and diverse patient populations contributed to the unique context of this study, ensuring a nuanced understanding of \u003cem\u003eC. auris\u003c/em\u003e risk factors within the broader healthcare landscape in Riyadh.\u003c/p\u003e\u003cp\u003eThe choice of a 1000-bed tertiary university teaching hospital in Riyadh as the focal point for this study was grounded in several deliberate criteria aimed at enhancing the relevance and applicability of the findings. Riyadh, a central hub in Saudi Arabia, has a diverse patient population and healthcare landscape. The hospital's status as a tertiary university teaching facility ensured a comprehensive range of medical services. This diversity makes it an ideal setting for studying the prevalence and risk factors associated with \u003cem\u003eC. auris\u003c/em\u003e.\u003c/p\u003e\u003cp\u003eThe hospital was particularly relevant for investigation owing to the occurrence of the first reported case of \u003cem\u003eC. auris\u003c/em\u003e within its premises just before the emergence of the COVID-19 pandemic. This unique situation triggered heightened awareness and necessitated an immediate response. By selecting a hospital with a confirmed case, this study builds upon a real-world context to evaluate the efficacy of the adapted risk assessment tool in identifying individuals at risk of \u003cem\u003eC. auris\u003c/em\u003e infection. The hospital's response to the initial case, including contact tracing and subsequent screening, provides an opportunity for an in-depth analysis of the infection control measures implemented.\u003c/p\u003e\u003cp\u003eThe chosen study period, spanning from January 2020 to December 2022, was meticulously selected to align with the overarching objectives of the research and to respond to the unique circumstances that unfolded during this period. The initiation of the study in January 2020 was prompted by the identification and management of the first case of \u003cem\u003eC. auris\u003c/em\u003e in the hospital. This initial case not only catalyzed the need for an in-depth investigation but also coincided with the onset of the global COVID-19 pandemic, adding a layer of complexity to the healthcare landscape.\u003c/p\u003e\u003cp\u003eAdditionally, the selected study period encompassed the peak of the COVID-19 pandemic, providing an opportunity to explore potential interactions or correlations between the management of COVID-19 cases and the occurrence of \u003cem\u003eC. auris\u003c/em\u003e. By delving into this multifaceted period, the present research aims to contribute nuanced findings that can inform targeted interventions and policies aimed at mitigating the risk of \u003cem\u003eC. auris\u003c/em\u003e transmission within hospitals, especially in the context of concurrent global health challenges.\u003c/p\u003e\u003cp\u003eThe first case was reported; it was isolated and managed between November 2019 and January 2020, when she was discharged via home isolation. The study covered the period between January 2020 and the end of December 2022 and involved all patients admitted to hospital inpatient wards. This study included contact tracing performed for the index patient, subsequent clinical and surveillance screening for admitted patients, and contact tracing of all positive cases reported.\u003c/p\u003e\u003cp\u003eThe primary objective of this study was to employ a risk assessment tool adapted from a validated MRSA risk assessment tool to identify individuals at substantial risk of \u003cem\u003eC. auris\u003c/em\u003e within the hospital setting. Given the dynamic nature of healthcare environments, especially during the unprecedented challenges posed by the COVID-19 pandemic, the extended study period until December 2022 allowed for a comprehensive examination of \u003cem\u003eC. auris\u003c/em\u003e cases and associated risk factors over an ample duration. This prolonged observation period enables research to capture potential fluctuations, trends, and variations in C. auris prevalence, thereby contributing valuable insights into effective infection control strategies.\u003c/p\u003e\u003cp\u003e\u003cb\u003eVariables\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eOn the basis of a literature review, the following risk factors were included in the study:\u003c/p\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eHistory of past admission within the previous 3 months\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eComorbidities (septicemia + chronic renal disease, diabetes mellitus, or chronic lung disease)\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003ePrevious history of multidrug-resistant organism infection\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003ePrevious history of colonization/infection with an MDRO in the previous 3 months or contact\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003ePresence of wounds or indwelling devices\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003ePast surgeries within 3 months, and\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eAntimicrobial agents were used for the preceding three months.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003cp\u003eEach risk factor, except for a history of previous admission, was assigned a score of one (1). A previous admission history had a score of three (3). Any patient with a history of previous admission or a total score of three (3) qualified for C. auris screening. The reason for allocating a score of 3 to a previous admission was that such patients would potentially have been exposed to other risk factors during their previous hospitalizations. This methodology for risk factor selection and scoring was adopted from previous studies performed using the MRSA risk assessment screening tool. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e][\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eThis study utilized the 'adaptation method' in combination with a literature review and analysis of individual patient data (IPD) to identify and quantify the risk of \u003cem\u003eC. auris infection\u003c/em\u003e.[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] Risk factor information was derived from the literature and adapted on the basis of IPD. The validated MRSA risk assessment tool was adopted to identify patients at substantial risk of \u003cem\u003eC. auris\u003c/em\u003e infection via multivariable logistic regression. This study was conducted in a 1000-bed tertiary university teaching hospital in Riyadh, Saudi Arabia, which involved the first \u003cem\u003eC. auris\u003c/em\u003e case in 2019. The study period from January 2020 to December 2022 included patients diagnosed with COVID-19. The variables included admission history, comorbidities, MDRO history, wounds/devices, surgery, and antimicrobial use. The study included patients who were transferred into, admitted to, or were in high-risk units, flagged for MDROs, or had contact with positive patients.\u003c/p\u003e\u003cp\u003eThe screening tool was administered in selected nursing units via the PowerForm electronic health information system (EHR) PowerForm. Nurses were trained, and the data were collected and monitored via SPSS for analysis. The study addressed potential bias, considered statistical methods, and employed sensitivity analyses for missing data to ensure a robust assessment of \u003cem\u003eC. auris\u003c/em\u003e risk in the hospital setting.\u003c/p\u003e\u003cp\u003eThis study considered various potential confounding variables that could influence the relationships between the identified risk factors and the occurrence of \u003cem\u003eC. auris\u003c/em\u003e infection. These variables were controlled for during the analysis to increase the robustness of the findings. Potential confounding variables include patient demographics, underlying medical conditions not specifically addressed in the risk assessment tool, and variations in infection control measures across different hospital units.\u003c/p\u003e\u003cp\u003eBy employing multivariable logistic regression, this study aimed to account for the influence of these confounding factors on the associations between the identified risk factors and the likelihood of \u003cem\u003eC. auris\u003c/em\u003e infection. Additionally, the analysis might have controlled for factors related to the COVID-19 pandemic, as the study period coincided with its occurrence, potentially impacting hospital practices and patient characteristics. These efforts were made to strengthen the internal validity of the study and provide a more accurate assessment of the risk factors associated with \u003cem\u003eC. auris\u003c/em\u003e infection in a specified hospital setting.\u003c/p\u003e\u003cp\u003e\u003cb\u003eParticipants\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e\u003cem\u003eInclusion criteria\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAll newly admitted patients during the study period, regardless of any other factors, were subjected to triage via the risk assessment tool:\u003c/p\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eAll the patients were transferred to another hospital.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eAll the patients were admitted to inpatient wards (including those in the emergency department or outpatient clinics for admission).\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eAll admissions to high-risk units\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eAll patients previously flagged for MDROs\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eAll contacts of admitted patients with COVID-19\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003cp\u003e\u003cem\u003eExclusion criteria\u003c/em\u003e:\u003c/p\u003e\u003cp\u003eThe outpatients included those in day care units, the renal dialysis unit, the emergency department (those discharged home without being admitted to inpatients), and those attending outpatient clinics. The rationale behind the inclusion and exclusion criteria was strategically devised to enhance the internal validity of the study and minimize potential sources of bias. The inclusion criteria, which included transferred patients, all inpatient admissions, high-risk unit admissions, and previously flagged patients, were driven by the aim of identifying individuals at a higher risk of \u003cem\u003eC. auris\u003c/em\u003e exposure within the hospital setting.\u003c/p\u003e\u003cp\u003eThis approach ensures a more targeted analysis of the population, which is most relevant to the study objectives. The exclusion criteria, including outpatients, day care attendees, and emergency department patients, were implemented to maintain a focus on the inpatient population, where \u003cem\u003eC. auris\u003c/em\u003e transmission risk is more significant. This deliberate selection aimed to reduce the likelihood of confounding variables, selection bias, and information bias, thereby fortifying the reliability of the study and contributing to the robustness of the findings.\u003c/p\u003e\u003cp\u003e\u003cb\u003eData Sampling/measurement\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eSelection of Nursing Units for the Study\u003c/em\u003e\u003c/p\u003e\u003cp\u003eOn the basis of the selected types of patients, the following nursing units were used to administer the screening tool to the included patients:\u003c/p\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eIntensive care units, including adult, pediatric and neonatal ICUs\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eAll inpatient wards\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eEmergency department\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003cp\u003e\u003cem\u003eForm® was constructed via an Electronic Health Information System (eSIHI).\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThis tool was created as a PowerForm in our electronic health information system for use by caregivers (particularly nurses) at the time of their first contact with selected inpatient locations.\u003c/p\u003e\u003cp\u003eThe screening tool was developed through a meticulous process that involved adapting the MRSA risk assessment tool to suit the specific context of \u003cem\u003eC. auris\u003c/em\u003e infections. The adaptation method employed a combination of literature review and analysis of a small dataset of individual patient data (IPD). Initially, the risk factors for \u003cem\u003eC. auris\u003c/em\u003e infection were identified through an extensive literature review of previously published studies. These factors were then refined and adapted on the basis of the analysis of a small dataset of individual patient data, ensuring alignment with the unique characteristics of \u003cem\u003eC. auris\u003c/em\u003e infections.\u003c/p\u003e\u003cp\u003eThe adaptation method utilized a validated MRSA risk assessment tool as a foundation, which was modified to incorporate risk factors relevant to \u003cem\u003eC. auris\u003c/em\u003e. Notably, this involved assigning scores to each identified risk factor, with a higher score indicating higher risk. The adaptation aimed to leverage the established success of the MRSA risk assessment tool while tailoring it to the distinct attributes of \u003cem\u003eC. auris\u003c/em\u003e. This iterative process of refinement and adjustment ensures that the screening tool is not only validated in the literature but also finely tuned to the specific nuances of \u003cem\u003eC. auris\u003c/em\u003e infection dynamics within the hospital setting.\u003c/p\u003e\u003cp\u003e\u003cb\u003eElements of the risk assessment tool\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA questionnaire for triggering active surveillance screening is presented, outlining specific risk factors and their corresponding scores used to assess the likelihood of \u003cem\u003eC. auris\u003c/em\u003e infection. Each risk factor contributes to an individual's total score, aiding in the determination of their risk level and the need for active surveillance. The interpretation of these risk factors is crucial for understanding the comprehensive approach adopted to identify patients at greater risk of \u003cem\u003eC. auris\u003c/em\u003e infection within the hospital setting. The identification of admission to another hospital as a key risk factor suggests a need for enhanced interfacility infection control protocols, including preemptive screening and isolation measures.\u003c/p\u003e\u003cp\u003eFirst, a notable risk factor with a substantial score was a \"history of admission to another hospital\" (score = 3). This emphasizes the importance of recent hospitalizations outside the current facility, particularly within the past 12 months, as a substantial trigger for active surveillance. Patients with this history are deemed to carry a heightened risk of \u003cem\u003eC. auris\u003c/em\u003e infection\u003c/p\u003e\u003cp\u003eSecond, the presence of specific comorbidities, such as septicemia, chronic kidney disease (CKD), diabetes mellitus (DM), or chronic lung disease, was associated with a score of 1. This finding highlights the impact of underlying health conditions on the overall risk profile and the need for surveillance. A score of 1 was assigned to patients with a history of MDRO infection or colonization\". This finding underscores the importance of past encounters with multidrug-resistant organisms as a relevant factor in predicting susceptibility to \u003cem\u003eC. auris\u003c/em\u003e infection.\u003c/p\u003e\u003cp\u003eFurthermore, the questionnaire considered international exposure by assigning a score of 1 to patients with a history of hospital admission outside the KSA (within the past 12 months). This reflects the acknowledgment of potential risks associated with recent hospitalizations in foreign healthcare settings. The presence of \"wounds or indwelling devices\" was also assigned a score of 1, indicating the significance of these factors as potential entry points for infections and justifying their inclusion in risk assessment.\u003c/p\u003e\u003cp\u003ePatients admitted to high-risk units, including the intensive care unit (ICU), high-dependency unit (HDU), or oncology unit, were assigned a score of 1. This acknowledges the heightened risk associated with specific units that require intensive medical intervention or dealing with compromised immune systems. Additionally, patients with \"contact of MDRO/ASC\" received a score of 1, considering their potential exposure to multidrug-resistant organisms or involvement in active surveillance cultures as factors warranting increased vigilance.\u003c/p\u003e\u003cp\u003eFinally, patients who underwent \"previous surgery for \u0026lt; 3 months\" were assigned a score of 1. This underscores the relevance of recent surgical procedures as a risk factor for postoperative vulnerability. The questionnaire and associated scoring system offer a comprehensive and nuanced approach for identifying patients at elevated risk of \u003cem\u003eC. auris\u003c/em\u003e infection. The specific scores assigned to each risk factor reflect the relative importance of these factors in contributing to the overall risk assessment, thereby guiding the decision for active surveillance screening.\u003c/p\u003e\u003cp\u003e\u003cem\u003eTraining of Nurses on the Uses of the Tool\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAll nurses who work in the selected wards and units are trained both on the significance of the tool and how best to administer it to produce accurate and reliable data for analysis.\u003c/p\u003e\u003cp\u003eThe training process for nurses regarding the utilization of the developed screening tool involved a comprehensive program designed to ensure competence and reliability in administering the tool. Training content encompasses several key aspects. First, nurses were educated on the significance of the screening tool in identifying patients at substantial risk of \u003cem\u003eC. auris\u003c/em\u003e infection within the hospital setting. This includes a detailed overview of the risk factors incorporated into the tool and their relevance to \u003cem\u003eC. auris\u003c/em\u003e transmission dynamics.\u003c/p\u003e\u003cp\u003eSecond, the training delved into the practical aspects of administering the screening tool, providing step-by-step guidance on its utilization at the point of first contact with selected inpatient locations. Nurses were familiarized with the electronic format of the tool, which was specifically designed as a PowerForm in the hospital's eSIHI. The training emphasized the importance of accurate and reliable data entry to ensure the effectiveness of the tool in identifying at-risk patients.\u003c/p\u003e\u003cp\u003eThe certification or validation procedures included in the training process aimed to assess the nurses' proficiency in using the screening tool. This involved a combination of theoretical assessments and practical demonstrations to ensure that nurses could correctly identify and score patients on the basis of the established risk factors. Continuous monitoring and feedback mechanisms were incorporated to address any challenges or questions that arose during the initial stages of tool implementation.\u003c/p\u003e\u003cp\u003eOverall, the training process sought to equip nurses with both the theoretical knowledge and practical skills required for the effective and consistent application of the screening tool, contributing to the study's data accuracy and reliability.\u003c/p\u003e\u003cp\u003e\u003cem\u003eDeployment of the Tool\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe PowerForm has been alive at our \u003cem\u003eeSIHI\u003c/em\u003e since January 1, 2020. The assigned team members were monitored for proper entry by regularly crosschecking them online and discussing troubleshooting with the nurses. The tool was applied to a total of 68,031 patients admitted to the selected units during the study period. The selection of risk factors from the MRSA tool was based on their relevance to both MDRO and fungal colonization risk, with specific modifications for C. auris on the basis of recent literature. The scoring system was adapted to reflect the relative weight of each risk factor in the prediction of C. auris infection.\u003c/p\u003e\u003cp\u003e\u003cem\u003eData collection\u003c/em\u003e\u003c/p\u003e\u003cp\u003eWith the help of the ICT Department, we collected raw data entered from PowerForm® on the eSIHI for analysis. Conversely, the study also collected \u003cem\u003eoutcome\u003c/em\u003e data and monitored the incidence of \u003cem\u003eC. auris\u003c/em\u003e reported at health institutions throughout the study period to ascertain the specificity of our risk assessment tool in accurately identifying patients at risk for prompt isolation to reduce the risk of in-hospital transmission.\u003c/p\u003e\u003cp\u003eFor prospective purposes, the screening tool, implemented as a PowerForm in the electronic health information system (eSIHI), was deployed and made available live beginning on January 1, 2020. Nurses trained to utilize the tool conducted real-time assessments at the time of first contact with selected inpatient locations, including intensive care units, inpatient wards, and the emergency department. The timing of data collection was ongoing throughout the study period, covering admissions from January 2020 to December 2022.\u003c/p\u003e\u003cp\u003eThe frequency and timing of data collection in the study were systematically organized to capture relevant information and ensure a comprehensive assessment of \u003cem\u003eC. auris\u003c/em\u003e risk factors in the hospital setting. This study utilized a dynamic approach to data collection, incorporating both real-time and retrospective components.\u003c/p\u003e\u003cp\u003eConversely, retrospective data collection involves the compilation of raw data processed from the PowerForm on the eSIHI. This retrospective component aimed to gather historical information on patients, including their risk factors and screening results. This approach allowed for a thorough examination of \u003cem\u003ethe C. auris\u003c/em\u003e incidence reported at a health institution, enabling an assessment of the specificity of the screening tool for identifying at-risk patients.\u003c/p\u003e\u003cp\u003eThe combination of real-time and retrospective data collection strategies provided a comprehensive and longitudinal perspective, capturing both current and historical information to facilitate a robust analysis of \u003cem\u003eC. auris\u003c/em\u003e risk within a specified hospital setting.\u003c/p\u003e\u003cp\u003eRigorous quality control measures were implemented throughout the study to maintain data collection quality and accuracy. Regular checks were conducted on the data entered through the PowerForm in the electronic health information system (eSIHI). A dedicated team consistently monitored the entries by crosschecking them online to promptly identify and rectify any discrepancies or errors.\u003c/p\u003e\u003cp\u003eAll nurses working in the selected wards and units underwent comprehensive training to ensure a standardized approach to data collection. The electronic nature of the PowerForm allowed for built-in validation procedures within the eSIHI, including checks for completeness and consistency of data entries. Periodic audits of the data collection process were also conducted to assess adherence to the established protocols and identify areas for improvement. These measures collectively aim to minimize errors, enhance reliability, and ensure the integrity of the collected data for robust analysis.\u003c/p\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eThe quantitative variables in the study were categorized on the basis of predefined risk factors, with each factor assigned a score to facilitate the risk assessment. These variables included a patient's history of admission, comorbidities, previous infections, presence of wounds or indwelling devices, past surgeries, and antimicrobial use within the preceding three months. Statistical analyses were performed via SPSS version 28 (IBM Co., Armonk, NY, USA). Categorical data are presented as frequencies and percentages to provide a clear overview of the risk factor distributions within the study population.\u003c/p\u003e\u003cp\u003eTo control for potential confounding factors, multivariate logistic regression analyses were conducted using individual patient data (IPD). The methods used to examine the subgroups and interactions involved stratified analyses on the basis of specific risk factors. Missing data were addressed through meticulous monitoring of data entry and periodic audits to ensure completeness and accuracy. In this cross-sectional study, the analytical methods considered the sampling strategy, emphasizing the inclusion of diverse patient groups from high-risk units, transfers, and those flagged for multidrug-resistant organisms (MDROs). The significance level for the statistical tests was set at a two-tailed P value \u0026lt; 0.05. These comprehensive statistical approaches aimed to elucidate the relationships between the identified risk factors and the likelihood of \u003cem\u003eC. auris\u003c/em\u003e infection, contributing to the robustness of the study findings.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e presents excerpts from the raw data entry specifically related to the initial MDRO risk assessment tool. This table provides a snapshot of the responses recorded during the documentation process, including the date and time of entry, section name, element description, and discrete and free-text response values.\u003c/p\u003e\n\u003cp\u003eIn this excerpt, the documentation date and time (03/16/2023 10:41:00 AM) indicate a specific instance in which the risk assessment tool was administered. The section name \u0026quot;Initial MDRO Risk Assessment Tool\u0026quot; signifies the tool or instrument used for the assessment.\u003c/p\u003e\n\u003cp\u003eThe subsequent columns, labeled \u0026quot;Element Description,\u0026quot; \u0026quot;Response Value-Discrete,\u0026quot; and \u0026quot;Response Value-Free text,\u0026quot; shed light on the responses recorded for each element within the tool in this instance.\u003c/p\u003e\n\u003cp\u003eFor example, Element Q1 is associated with the question \u0026quot;NO,\u0026quot; both in discrete and free-text responses. This indicates that the respondent answered \u0026quot;NO\u0026quot; to the corresponding question or risk factors. The same pattern follows for Elements Q3 to Q7, with respondents consistently providing \u0026quot;NO\u0026quot; responses for each respective risk factor.\u003c/p\u003e\n\u003cp\u003eNotably, Element Q2 stands out as the only instance where the response differs, with the respondent indicating \u0026quot;Yes\u0026quot; in both the discrete and free-text responses. This highlights the positive response to specific risk factors associated with Q2.\u003c/p\u003e\n\u003cp\u003eIn the context of broader methodology, these documented responses are crucial data points used to assess and calculate individual risk scores on the basis of the predetermined scoring system outlined in the risk assessment tool. The consistency or variation in responses across different elements contributes to the overall risk profile of each patient, aiding in the identification of individuals at a greater risk of \u003cem\u003eC. auris\u003c/em\u003e infection. Further analysis of the complete dataset would involve examining the patterns, trends, and correlations among responses to derive meaningful insights into the effectiveness of the risk assessment tool in predicting \u003cem\u003eC. auris\u003c/em\u003e risk in the hospital setting.\u003c/p\u003e\n\u003cp\u003e\u003cimg 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\"\u003e\u003c/p\u003e\n\u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e shows the data analysis outcomes from the risk assessment tool, shedding light on the prevalence of various risk factors in the studied patient population. The table encapsulates responses to each specific question (Q1\u0026ndash;Q7), providing both absolute numbers and corresponding percentages, with an overarching focus on the total number of patients included in the analysis.\u003c/p\u003e\n\u003cp\u003eFirst, for Q1, regarding a history of admission from other hospitals, 1.32% of the patients (900 individuals) affirmed such a history, whereas the overwhelming majority (98.68%) reported no such history, resulting in a total of 68,184 patients. Regarding Q2, which pertains to the presence of conditions such as septicemia, chronic kidney disease (CKD), diabetes mellitus (DM), or chronic lung disease, 9% of patients (5,628 individuals) acknowledged these conditions, with the remaining 91% reporting their absence, contributing to a total of 68,172 patients.\u003c/p\u003e\n\u003cp\u003eQ3 investigated the previous history of multidrug resistant organism (MDRO) infection or colonization, with 0.8% (540 individuals) confirming such a history and 99.02% reporting no such history. In total, 68,064 patients were included in the study. For Q4, after a history of admission to hospitals outside the Kingdom of Saudi Arabia (KSA) within the past 12 months was assessed, 7% of the patients (4,716 individuals) reported such a history, whereas 93% indicated no history, resulting in a total of 66,576 patients.\u003c/p\u003e\n\u003cp\u003eSimilarly, Q5 explored the presence of wounds or indwelling devices, with 7% (4,680 individuals) affirming their presence and 93% reporting their absence, thus contributing to a total of 68,112 patients. Q6 focused on admission to high-risk units such as the ICU, HDU, and oncology. The responses indicated that 0.14% of patients (96 individuals) were admitted to such units, whereas 99.86% were not. In total, 68,064 patients were included in the study.\u003c/p\u003e\n\u003cp\u003eFinally, for Q7, an investigation of contact with MDROs or active surveillance culture (ASC) revealed that 14% of patients (9,456 individuals) had such contact, whereas 86% reported no such contact. In total, 68,124 patients were included in the study. The cumulative totals indicated that 6% of patients presented positive responses across the assessed risk factors, whereas 94% exhibited negative responses. This comprehensive analysis involving 475,296 responses from 68,031 patients provided valuable insights into the distribution of risk factors, forming a crucial foundation for evaluating the effectiveness of the risk assessment tool in identifying potential cases of \u003cem\u003eC. auris\u003c/em\u003e infection.\u003c/p\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eData Analysis\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTOTAL\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e900\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e67,284\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e98.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e68,184\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5,628\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e62,544\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e68,172\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e540\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e67,524\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e99.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e68,064\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4,716\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e61,860\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e66,576\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4,680\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e63,432\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e68,112\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e67,968\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e99.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e68,064\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9,456\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e58,668\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e68,124\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26,016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAv. 6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e449,280\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAv. 94%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e475,296\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"6\"\u003e\n \u003cp\u003eTotal No. of patients: \u0026nbsp;68,031\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n"},{"header":"Discussion","content":"\u003cp\u003eWhile the risk assessment tool and scoring system provide a comprehensive approach, some findings raise questions about the granularity of risk prediction.[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] We explored the implications of these findings, suggesting potential refinements to the scoring system for more nuanced and accurate prediction of \u003cem\u003eC. auris\u003c/em\u003e infection risk in diverse patient populations.\u003c/p\u003e\u003cp\u003eThe results of the analysis revealed four key findings that elucidated the risk factors associated with \u003cem\u003eC. auris\u003c/em\u003e infection in the hospital setting. First, the \"history of admission from other hospitals\" emerged as a crucial trigger for active surveillance, as evidenced by the substantial score of 3. This underscores the tool's emphasis on recent hospitalization outside the current facility, particularly within the past 12 months, as indicative of a heightened infection risk. However, the low percentage of patients (1.32%) with such a history prompts consideration of the prevalence and standalone predictive power of this factor.[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eThe recognition of specific comorbidities, such as septicemia, chronic kidney disease (CKD), diabetes mellitus (DM), or chronic lung disease, with a score of 1 highlights their importance in contributing to the overall risk profile. Similarly, assigning a score of 1 to patients with a history of MDRO infection or colonization\" underscores the relevance of past encounters with multidrug-resistant organisms. However, the uniform score may not fully capture the nuanced differences in risk associated with distinct comorbidities or varying degrees of MDRO exposure.[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eConsidering international exposure, with a score of 1 assigned to patients with a \"history of admission to hospital outside the KSA (within the past 12 months),\u0026rdquo; acknowledges the potential risk associated with recent foreign hospitalization. Likewise, a score of 1 for the \"presence of wounds or indwelling devices\" emphasizes the significance of these devices as potential entry points for infections. However, generalized scoring may oversimplify the role of specific regions or types of foreign hospitals and overlook variations in risk associated with several types of wounds or devices.[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eThe assessment of MDRO/ASC contact, represented by a score of 1, highlights the need for increased vigilance in individuals with potential exposure to multidrug-resistant organisms or involvement in active surveillance cultures. Nevertheless, the absence of a nuanced scoring system may limit its ability to capture the varying degrees and specific nature of contact, potentially resulting in an oversimplified risk assessment. Overall, while the risk assessment tool provides a comprehensive framework, these findings prompt a critical examination of its granularity and suggest potential refinements for more accurate and nuanced predictions of \u003cem\u003eC. auris\u003c/em\u003e infection risk in diverse patient populations.[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eThe tool\u0026rsquo;s applicability in diverse healthcare settings, such as smaller hospitals or other regions with varying levels of MDRO exposure, remains a key area for further validation. Future studies are needed to assess whether the identified risk factors hold predictive value in different patient populations. The adaptation method demonstrated here could be applied as a risk assessment tool for other emerging pathogens, particularly those with similar transmission dynamics, such as C. auris. However, further validation is necessary to ensure its effectiveness across different healthcare settings.\u003c/p\u003e\u003cp\u003eThe strength of this study lies in its adoption of the innovative \"adaptation method,\u0026rdquo; a unique blend of literature review and individual patient data (IPD) analysis. This method offers a nuanced approach to identify and quantify \u003cem\u003eC. auris\u003c/em\u003e infection risk within hospitals by combining the insights gained from the literature with the specific patient data obtained. Additionally, this study builds on the success of a validated MRSA risk assessment tool, providing a robust foundation for the effectiveness of the developed risk assessment tool. Real-time application of the tool in an electronic health information system ensures its immediate and practical utilization during patient encounters, particularly by nurses. Furthermore, the study benefits from a comprehensive setting\u0026mdash;a prominent 1000-bed tertiary university teaching hospital in Riyadh\u0026mdash;enabling the examination of \u003cem\u003eC. auris\u003c/em\u003e risk across diverse patient populations and medical services.\u003c/p\u003e\u003cp\u003eDespite its strengths, this study has several limitations that require consideration. The single-center focus may restrict the generalizability of the findings to other healthcare settings with distinct characteristics. The potential impact of confounding variables such as patient demographics and variations in infection control measures poses a challenge. Although efforts have been made to control for these factors, residual confounding remains a consideration. The study period coinciding with the COVID-19 pandemic introduces complexities that may influence healthcare practices and patient characteristics. Additionally, the simplification of the scoring system, borrowed from the MRSA risk assessment tool, may oversimplify the nuanced differences in risk associated with specific comorbidities or exposures. The study period coincided with the COVID-19 pandemic, which may have impacted infection control measures and patient demographics. This introduces an additional variable that could influence the generalizability of the findings.\u003c/p\u003e\u003cp\u003eMoreover, it is crucial to acknowledge the potential implications of the findings\u0026rsquo; generalizability. Although the selected hospital is representative of a tertiary healthcare facility in a major city, its characteristics may not be universally applicable to all healthcare settings. Generalizing these findings to smaller healthcare institutions or those in different geographic locations should be approached with caution. Patient demographics, healthcare infrastructure, and infection control protocols can vary widely among hospitals. Consequently, the study's outcomes may be directly transferable to similar tertiary teaching hospitals in comparable urban contexts. To enhance the broader relevance of these findings, future research should consider multicenter studies encompassing diverse healthcare settings.\u003c/p\u003e\u003cp\u003eThe findings of this study have notable implications for future research and infectious disease risk assessment. If proven effective, this innovative adaptation method could serve as a model for developing risk assessments for other infectious diseases. Moreover, the focus on the utilization of a validated MRSA risk assessment tool provides insights into the potential cross-application of such tools to different infectious agents. These implications underscore the importance of the continuous refinement and optimization of risk assessment tools to enhance their applicability and effectiveness in diverse healthcare contexts.\u003c/p\u003e\u003cp\u003eSeveral recommendations have been proposed to address the limitations of the study and contribute to the field. Future research should consider multicenter studies to broaden the scope and applicability of the findings across different healthcare settings. Fine-tuning the scoring system to reflect varying degrees of risk associated with specific comorbidities or exposures could enhance the precision of risk assessment. Longitudinal studies are recommended to provide insights into how \u003cem\u003eC. auris\u003c/em\u003e risk evolves over time, particularly in dynamic healthcare environments. Finally, the integration of the adapted risk assessment tool into routine clinical practice is crucial for the sustained surveillance and proactive management of \u003cem\u003eC. auris\u003c/em\u003e risk in hospital settings. Future research could focus on a multicenter trial to validate the tool across different hospital settings and patient populations. Additionally, longitudinal studies are needed to track C. auris colonization and infection risk over time.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003e This study successfully adapted and validated a C. auris risk assessment tool derived from an established MRSA model, demonstrating its effectiveness in a high-volume tertiary care hospital in Saudi Arabia. The tool proved valuable in stratifying patient risk based on clinical and epidemiological factors, including comorbidities, prior hospitalizations, and exposure to multidrug-resistant organisms.\u003c/p\u003e\u003cp\u003eIts deployment through a digital PowerForm allowed for widespread screening, covering over 68,000 admissions and identifying key risk profiles. The findings underscore the potential of this tailored tool to inform early detection, targeted surveillance, and timely implementation of infection prevention strategies, especially within healthcare environments where C. auris poses a growing threat. Future studies may explore broader implementation and the integration of such tools into broader infection control frameworks for proactive management of \u003cem\u003ecandidozyma auris\u003c/em\u003e infections and colonization.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eFSA:\u0026nbsp;\u003c/strong\u003eFatimah Saad Alshahrani\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAAE:\u0026nbsp;\u003c/strong\u003eAbba Amsami Elgujja\u003cstrong\u003e,\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSA:\u0026nbsp;\u003c/strong\u003eSara Alsubaie\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSAE:\u003c/strong\u003e Salah Ezreqat\u003cstrong\u003e,\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAA:\u0026nbsp;\u003c/strong\u003eAhmed Albarrag,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMB:\u0026nbsp;\u003c/strong\u003eMazin Barry,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKB:\u0026nbsp;\u003c/strong\u003eKhalifa BinKhamis,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLA:\u0026nbsp;\u003c/strong\u003eLulwa Alabdan\u003cstrong\u003e,\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMA:\u0026nbsp;\u003c/strong\u003eMarytonia Antony,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eJC:\u0026nbsp;\u003c/strong\u003eJocelyn Caparoso\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSMA:\u0026nbsp;\u003c/strong\u003eSamah Mustafa Adam\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKWF:\u0026nbsp;\u003c/strong\u003eKhalid Waleed Faqihi\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Approval/ Institutional Review Board Statement\u003c/strong\u003e: The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board of King Saud University College of Medicine.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e: not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed Consent Statement\u003c/strong\u003e: Informed consent was obtained from all subjects and/or their legal guardian(s). No human tissue was used for the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eavailability statement\u003c/strong\u003e: All the data generated or analyzed during this study are included in this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest:\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no conflicts of interest related to this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: This study received no external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e: Conceptualization, FSA and SA; Methodology, AAE, MB, and LA; Validation, AA, SAE, and SMA; Formal analysis, SA, MB, and KB; Investigation, AAE, SAE, SMA, JC, MA, and AA; Resources, SA, JC, and KWF; Writing\u0026mdash;original draft, AAE, ; Writing\u0026mdash;review and editing, All authors; Project administration, FSA. All the authors have read and agreed to the published version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors extend their appreciation to the Deputyship for Research \u0026amp; Innovation, Ministry of Education in Saudi Arabia, for their support of this research work. The study team also acknowledges the support it received from the College of Medicine, King Saud University; Professor Ahmed Hersi (CEO, KS-Medical City), Professor Fawzi Aljasser (CMO, KSU-Medical City), and Dr Nasser Alkhamees (MD, KKUH) for their support and encouragement; and all the Infection Prevention and Control staff of King Saud University Medical City for their invaluable contribution toward the success of the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eV. Garcia-Bustos, M. Salavert, A. C. Ruiz-Gait\u0026aacute;n, M. D. Caba\u0026ntilde;ero-Navalon, I. A. Sigona-Giangreco, and J. Pem\u0026aacute;n, \u0026ldquo;A clinical predictive model of candidemia by Candida auris in previously colonized critically ill patients,\u0026rdquo; \u003cem\u003eClinical Microbiology and Infection\u003c/em\u003e, vol. 26, no. 11, 2020, doi: 10.1016/j.cmi.2020.02.001.\u003c/li\u003e\n\u003cli\u003eS. R. Lockhart, M. M. Lyman, and D. Joseph Sexton, \u0026ldquo;Tools for Detecting a \u0026lsquo;Superbug\u0026rsquo;: Updates on Candida auris Testing,\u0026rdquo; \u003cem\u003eJournal of Clinical Microbiology\u003c/em\u003e, vol. 60, no. 5. 2022. doi: 10.1128/jcm.00808-21.\u003c/li\u003e\n\u003cli\u003eA. Chakrabarti and S. Singh, \u0026ldquo;Multidrug-resistant Candida auris: an epidemiological review,\u0026rdquo; \u003cem\u003eExpert Review of Anti-Infective Therapy\u003c/em\u003e, vol. 18, no. 6. 2020. doi: 10.1080/14787210.2020.1750368.\u003c/li\u003e\n\u003cli\u003eA. Sharp \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;Screening for Candida auris in patients admitted to eight intensive care units in England, 2017 to 2018,\u0026rdquo; \u003cem\u003eEurosurveillance\u003c/em\u003e, vol. 26, no. 8, 2021, doi: 10.2807/1560-7917.ES.2021.26.8.1900730.\u003c/li\u003e\n\u003cli\u003eJ. Rossow \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;Factors Associated with Candida auris Colonization and Transmission in Skilled Nursing Facilities with Ventilator Units, New York, 2016\u0026ndash;2018,\u0026rdquo; \u003cem\u003eClinical Infectious Diseases\u003c/em\u003e, vol. 72, no. 11, pp. e753\u0026ndash;e760, Jun. 2021, doi: 10.1093/cid/ciaa1462.\u003c/li\u003e\n\u003cli\u003eS. E. Sansom \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;Rapid Environmental Contamination with \u003cem\u003eCandida auris\u003c/em\u003e and Multidrug-Resistant Bacterial Pathogens Near Colonized Patients,\u0026rdquo; \u003cem\u003eClinical Infectious Diseases\u003c/em\u003e, Dec. 2023, doi: 10.1093/cid/ciad752.\u003c/li\u003e\n\u003cli\u003eK. Southwick \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;New York State 2016\u0026ndash;2018: Progression from Candida auris Colonization to Bloodstream Infection,\u0026rdquo; \u003cem\u003eOpen Forum Infect Dis\u003c/em\u003e, vol. 5, no. suppl_1, pp. S594\u0026ndash;S595, Nov. 2018, doi: 10.1093/ofid/ofy210.1695.\u003c/li\u003e\n\u003cli\u003eP. Eggimann and D. Pittet, \u0026ldquo;Candida colonization index and subsequent infection in critically ill surgical patients: 20 years later,\u0026rdquo; \u003cem\u003eIntensive Care Med\u003c/em\u003e, vol. 40, no. 10, 2014, doi: 10.1007/s00134-014-3355-z.\u003c/li\u003e\n\u003cli\u003eS. M. Rudramurthy \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;Candida auris candidemia in Indian ICUs: analysis of risk factors,\u0026rdquo; \u003cem\u003eJournal of Antimicrobial Chemotherapy\u003c/em\u003e, vol. 72, no. 6, pp. 1794\u0026ndash;1801, Jun. 2017, doi: 10.1093/jac/dkx034.\u003c/li\u003e\n\u003cli\u003eA. Al-Rashdi, A. Al-Maani, A. Al-Wahaibi, A. Alqayoudhi, A. Al-Jardani, and S. Al-Abri, \u0026ldquo;Characteristics, risk factors, and survival analysis of candida auris cases: Results of one-year national surveillance data from oman,\u0026rdquo; \u003cem\u003eJournal of Fungi\u003c/em\u003e, vol. 7, no. 1, 2021, doi: 10.3390/jof7010031.\u003c/li\u003e\n\u003cli\u003eR. Risk factors and mortality of the newly emerging Candida auris in a university hospital in Saudi Arabia,\u0026rdquo; \u003cem\u003eMycology\u003c/em\u003e, pp. 1\u0026ndash;8, Jun. 2023, doi: 10.1080/21501203.2023.2227218.\u003c/li\u003e\n\u003cli\u003eS. Tian \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;First cases and risk factors for super yeast Candida auris infection or colonization from Shenyang, China article,\u0026rdquo; \u003cem\u003eEmerg Microbes Infect\u003c/em\u003e, vol. 7, no. 1, 2018, doi: 10.1038/s41426-018-0131-0.\u003c/li\u003e\n\u003cli\u003eC. Sticchi \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;Increasing Number of Cases Due to Candida auris in North Italy, July 2019\u0026ndash;December 2022,\u0026rdquo; \u003cem\u003eJ Clin Med\u003c/em\u003e, vol. 12, no. 5, 2023, doi: 10.3390/jcm12051912.\u003c/li\u003e\n\u003cli\u003eS. Ahmad and M. Asadzadeh, \u0026ldquo;Strategies to Prevent Transmission of Candida auris in Healthcare Settings,\u0026rdquo; \u003cem\u003eCurrent Fungal Infection Reports\u003c/em\u003e, vol. 17, no. 1. 2023. doi: 10.1007/s12281-023-00451-7.\u003c/li\u003e\n\u003cli\u003eE. G. Playford \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;Assessment of clinical risk predictive rules for invasive candidiasis in a prospective multicenter cohort of ICU patients,\u0026rdquo; \u003cem\u003eIntensive Care Med\u003c/em\u003e, vol. 35, no. 12, 2009, doi: 10.1007/s00134-009-1619-9.\u003c/li\u003e\n\u003cli\u003eA. M. Rauseo \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;Creation and Internal Validation of a Clinical Predictive Model for Fluconazole Resistance in Patients with Candida Bloodstream Infection,\u0026rdquo; \u003cem\u003eOpen Forum Infect Dis\u003c/em\u003e, vol. 9, no. 9, 2022, doi: 10.1093/ofid/ofac447.\u003c/li\u003e\n\u003cli\u003eP. Eggimann, J. Bille, and O. Marchetti, \u0026ldquo;Diagnosis of invasive candidiasis in the ICU,\u0026rdquo; \u003cem\u003eAnn Intensive Care\u003c/em\u003e, vol. 1, no. 1, p. 37, Dec. 2011, doi: 10.1186/2110-5820-1-37.\u003c/li\u003e\n\u003cli\u003eK. C. Claeys, E. J. Zasowski, A. M. Lagnf, D. P. Levine, S. L., Davis, and M.J. Rybak, \u0026ldquo;Novel application of published risk factors for methicillin-resistant \u003cem\u003eS. aureus\u003c/em\u003e in acute bacterial skin and skin structure infections,\u0026rdquo; \u003cem\u003eInt J Antimicrob Agents\u003c/em\u003e, vol. 51, no. 1, pp. 43\u0026ndash;46, Jan. 2018, doi: 10.1016/j.ijantimicag.2017.05.015.\u003c/li\u003e\n\u003cli\u003eE. J. Zasowski \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;International Validation of a Methicillin-Resistant \u003cem\u003eStaphylococcus aureus\u003c/em\u003e Risk Assessment Tool for Skin and Soft Tissue Infections,\u0026rdquo; \u003cem\u003eInfect Dis Ther\u003c/em\u003e, vol. 11, no. 6, 2022, doi: 10.1007/s40121-022-00712-x.\u003c/li\u003e\n\u003cli\u003eG. Pascarella \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;Risk analysis in healthcare organizations: Methodological framework and critical variables,\u0026rdquo; \u003cem\u003eRisk Manag Healthc Policy\u003c/em\u003e, vol. 14, 2021, doi: 10.2147/RMHP.S309098.\u003c/li\u003e\n\u003cli\u003eF. S. Alshahrani \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;Description of Candida auris Occurrence in a Tertiary Health Institution in Riyadh, Saudi Arabia,\u0026rdquo; \u003cem\u003eHealthcare\u003c/em\u003e, vol. 11, no. 24, p. 3150, Dec. 2023, doi: 10.3390/HEALTHCARE11243150.\u003c/li\u003e\n\u003cli\u003eB. H. Abuyassin, H. Aljadhey, M. Al-Sultan, S. Al-Rashed, M. Adam, and D. W. Bates, \u0026ldquo;Accuracy of the medication history at admission to hospital in Saudi Arabia,\u0026rdquo; \u003cem\u003eSaudi Pharmaceutical Journal\u003c/em\u003e, vol. 19, no. 4, 2011, doi: 10.1016/j.jsps.2011.04.006.\u003c/li\u003e\n\u003cli\u003eB. P. Simmons and E. L. Larson, \u0026ldquo;Multiple drug resistant organisms in healthcare: the failure of contact precautions,\u0026rdquo; \u003cem\u003eJ Infect Prev\u003c/em\u003e, vol. 16, no. 4, 2015, doi: 10.1177/1757177415570104.\u003c/li\u003e\n\u003cli\u003eGall E, Long A, and Hall KK, \u0026ldquo;Infections Due to Other Multidrug-Resistant Organisms,\u0026rdquo; in \u003cem\u003eMaking Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices\u003c/em\u003e, Hall KK, Shoemaker-Hunt S, and Hoffman L, Eds., Rockville (MD): Agency for Healthcare Research and Quality, 2020.\u003c/li\u003e\n\u003cli\u003eNational Center for Emerging and Zoonotic Infectious Diseases- Mycotic Diseases Branch. Candidozyma auris Genome sequencing and assembly. 2017/11. In: BioProject [Internet]. Bethesda, MD: National Library of Medicine (US), National Center for Biotechnology Information; 2011-. Available from: http://www.ncbi.nlm.nih.gov/bioproject/PRJNA328792. NCBI:BioProject: PRJNA328792.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Adaptation, Validation, Risk assessment tool, Candida auris, C. auris, Saudi Arabia","lastPublishedDoi":"10.21203/rs.3.rs-7149996/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7149996/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e\u003cp\u003eThis study aimed to employ a risk assessment tool adapted from a validated MRSA risk assessment tool to identify individuals at substantial risk of C. auris within the hospital setting.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e\u003cp\u003eThis study 'adapted' the MRSA risk assessment tool to analyze individual patient data (IPDs) for identifying and quantifying \u003cem\u003eC. auris\u003c/em\u003e infection risk. The variables included admission history, comorbidities, multidrug-resistant organism (MDRO) history, wounds/devices, surgeries, and antimicrobial use. The screening tool was deployed through a PowerForm in selected nursing units on all newly admitted patients, numbering 68,031, during the study period. Multivariate logistic regression and subgroup analyses were employed to address potential biases and ensure the internal validity of the study.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eNotably, 9% of the patients had identified risk factors such as septicemia, CKD, DM, or chronic lung disease. Additionally, 7% reported a history of admission to non-KSA hospitals, and 14% had contact with MDROs or ASCs.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThe results indicate the tool\u0026rsquo;s utility in identifying high-risk individuals and guiding targeted infection control measures and provide a foundation for the development of targeted surveillance and preventive measures in healthcare settings.\u003c/p\u003e","manuscriptTitle":"Adaptation and Validation of a Risk Assessment Tool for Candidozyma auris in a Saudi Arabian Hospital","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-21 10:05:51","doi":"10.21203/rs.3.rs-7149996/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9c2902d3-49e3-4bee-a24e-e961db0e154d","owner":[],"postedDate":"July 21st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-14T12:23:48+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-21 10:05:51","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7149996","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7149996","identity":"rs-7149996","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}