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Received 30 August 2017 Candida aurisis an emerging multidrug-resistant pathogen that can be difcult to identify using
Accepted 30 August 2017 traditional biochemical methods. C. auris is capable of causing invasive fungal infections, particularly
Corresponding Editor: Eskild Petersen, Aar- among hospitalized patients with signicant medical comorbidities. Echinocandins are the empiric drugs
hus, Denmark of choice for C. auris, although not all isolates are susceptible and resistance may develop on therapy.
Nosocomial C. auris outbreaks have been reported in a number of countries and aggressive infection
Keywords: control measures are paramount to stopping transmission.
Candida auris 2017 The Author(s). Published by Elsevier Ltd on behalf of International Society for Infectious Diseases.
Multidrug-resistance
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
Healthcare-associated
nc-nd/4.0/).
Outbreak
Infection control
Candida auris was rst identied from samples of external ear C. auris is phylogenetically related to Candida haemulonii and
drainage from one Japanese patient (Satoh et al., 2009) and Candida ruelliae (Satoh et al., 2009). Four distinct clades have been
15 Korean patients in 2009 (Kim et al., 2009). This organism can be identied from separate geographic origins, suggesting a recent
challenging to identify using standard microbiologic techniques and nearly simultaneous emergence of different clonal populations
and frequently exhibits multidrug-resistance. In the eight years (Lockhart et al., 2017). C. auris grows readily at 3742 C and forms
since these initial cases, C. auris has become an emerging global light pink colonies on chromogenic media (Chowdhary et al., 2014;
health threat, implicated in a host of invasive infections and Kathuria et al., 2015). Unlike C. haemulonii,C. auris does not form
outbreaks in healthcare facilities. To date, cases have now been pseudohyphae. Only some C. auris strains produce the virulence
identied in India (Sarma et al., 2013; Chowdhary et al., 2013), factors phospholipase and proteinase, which may account for the
South Africa (Magobo et al., 2014), Kuwait (Emara et al., 2015), the variability in pathogenicity demonstrated in a murine model
United Kingdom (Schelenz et al., 2016), Venezuela (Calvo et al., (Borman et al., 2016; Larkin et al., 2017). C. auris is capable of
2016), Brazil (Prakash et al., 2016), the United States (Vallabhaneni forming biolms (Oh et al., 2011) and adhering to catheter
et al., 2016), Colombia (Morales-Lpez et al., 2017), Pakistan material, although not to the same degree as Candida albicans
(Lockhart et al., 2017), Spain (Ruiz Gaitn et al., 2017), Germany (Larkin et al., 2017).
(European Centre for Disease Prevention and Control, 2016), Israel Traditional biochemical methods of identication commonly
(Ben-Ami et al., 2017), Norway (European Centre for Disease misdiagnose C. auris as other yeast. The United States Centers for
Prevention and Control, 2016), and Oman (Al-Siyabi et al., 2017). Disease Control and Prevention (CDC) recommends further testing
This review will detail the microbiology, clinical features, for C. auris whenever C. haemulonii is identied or in a number of
therapeutic options, and infection control measures relevant to other scenarios depending on the organism reported and the
C. auris infection. method of identication (Table 1). Accurate identication can be
performed with VITEK MS and Bruker Biotyper matrix-assisted
laser desorption/ionization time-of-ight (MALDI-TOF) devices
using their research use only databases. Molecular sequencing of
the D1D2 domain of the 28s rDNA can also identify C. auris (CDC,
2017). For laboratories without the capability to perform these
tests, Kumar et al. propose a low-cost alternative that can
* Corresponding author at: 513 Parnassus Ave., Box 0654, San Francisco, CA accurately distinguish C. auris from C. haemulonii using CHROMa-
94143, USA. Fax: +1 415 476 9364. gar medium supplemented with Pals medium (Kumar et al., 2017).
E-mail address: david.sears@ucsf.edu (D. Sears).
http://dx.doi.org/10.1016/j.ijid.2017.08.017
1201-9712/ 2017 The Author(s). Published by Elsevier Ltd on behalf of International Society for Infectious Diseases. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
96 D. Sears, B.S. Schwartz / International Journal of Infectious Diseases 63 (2017) 9598
Table 2
Tentative MIC (mg/L) breakpoints for Candida auris susceptibility (CDC, 2017) and published MIC ranges by CLSI microbroth dilution (Prakash et al., 2016; Lockhart et al., 2017;
Kathuria et al., 2015; Arendrup et al., 2017).
Antifungal drug Tentative MIC breakpoint Published MIC50 range Published MIC90 range
Fluconazole 32 64128 64256
Voriconazolea N/Ab 0.52 48
Amphotericin B 2 0.51 24
Anidulafungin 4 0.1250.5 0.51
Caspofungin 2 0.250.5 1
Micafungin 4 0.1250.25 0.252
a
Also applies to other second generation triazole antifungals.
b
Consider using uconazole susceptibility as a surrogate, although uconazole-resistant isolates may occasionally respond to other triazole antifungals.
D. Sears, B.S. Schwartz / International Journal of Infectious Diseases 63 (2017) 9598 97
Much like colonization with other multidrug-resistant species, facilities which have served as sites of ongoing transmission of
CDC does not recommend systemic antifungal therapy for patients this emerging pathogen.
who are colonized with C. auris (CDC, 2017).
Funding sources
Infection control
This research did not receive any specic grant from funding
C. auris can cause widespread and persistent contamination of agencies in the public, commercial, or not-for-prot sectors.
environmental surfaces within healthcare facilities and has been
associated with both intra-hospital and inter-hospital transmis- Conict of interest
sion of clonal strains in multiple countries (Kim et al., 2009;
Chowdhary et al., 2013; Schelenz et al., 2016; Calvo et al., 2016; The authors report no conicts of interest.
Morales-Lpez et al., 2017; European Centre for Disease Prevention
and Control, 2016; Ben-Ami et al., 2017; Tsay et al., 2017; Piedrahita References
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