SRI WAHYUNI

P06219005
 INTRODUCTION

Candida bloodstream infections (BSIs) are the third to fourth most
common cause of health care-associated BSIs. Candida albicans has
historically been considered the most pathogenic species in the genus and
remains the most common cause of candidemia. In 2009, a new
fluconazole-resistant species, Candida auris, was identified in East Asia
and has now been isolated on five continents. This global emergence has
been attributed to the near-simultaneous appearance of at least 4
geographically restricted clades, with clonal transmission identified both
within and across health care facilities. C. auris can be challenging to
identify in the clinical laboratory, and this species frequently exhibits
multidrug resistance. Alarmingly, invasive infections have been difficult
to treat and are associated with high rates of treatment failure. This
minireview summarizes what is currently known about C. auris infection
epidemiology, pathogenesis, diagnosis, and management.
 EPIDEMIOLOGY

C. auris was first isolated in 2009 from the external ear canal of a
patient in Japan, with ribosomal DNA (rDNA) sequencing and
biochemical analyses indicating identification of a novel Candida
species. C. auris was subsequently reported the same year from 15
patients with chronic otitis media in South Korea. The first three
cases of C. auris bloodstream infection (BSI) were also reported in
South Korea in 2011. A retrospective review of South Korean
Candida isolates, however, showed that the earliest strain of
C. auris actually dated back to 1996 and was identified from a BSI
in a child. The majority of the South Korean isolates displayed
elevated fluconazole MICs, which suggested that this new species
is largely resistant to fluconazole.
 
Ensuing reports of C. auris infections have come from
multiple countries around the world, including India, South
Africa, Kuwait, Malaysia, the United Kingdom, Pakistan,
Kenya, Norway, Germany, Oman, Spain, Israel, Venezuela,
Columbia, Panama, Brazil, the United States, and Canada.
 
BSI is the most commonly observed invasive infection, with in-
hospital mortality rates reported on the order of 30 to 60%. Cases
have mainly involved patients with underlying medical
comorbidities and significant health care exposure, with infection
typically occurring weeks after hospital admission. Overlapping
contact with long-term-care facilities or acute-care hospitals in the
same geographic region was also common among cases. In a recent
report from India, the risk for the development of C. auris BSI
compared to other Candida spp. was associated with longer
intensive care unit (ICU) stays, underlying respiratory illness,
vascular surgery, prior antifungal drug exposure, and lower acute
physiology and chronic health evaluation II (APACHE II) scores.
The majority of the C. auris isolates in this study were clonal and
came from public hospitals in the northern portion of the country.
 MICROBIOLOGY

C. auris isolates have been analyzed using a variety of
laboratory methods in an attempt to
(i) Establish phylogenetic relationships with other
pathogenic yeasts,
(ii) Evaluate potential relatedness across strains,
(iii) Determine virulence, and
(iv) Characterize antifungal susceptibility profiles.
 TAXONOMY

rDNA sequencing of the 26S D1/D2 and 18S internal transcribed
spacer (ITS) regions placed the initial Japanese isolate within the
Metschnikowiaceae family, most closely related to species of the
Clavispora clade. D1/D2 sequences from the initial isolate
clustered most closely with Candida haemulonii, Candida
pseudohaemulonii, and Candida ruelliae (85.7, 83.0%, and 82.4%
similarity, respectively), and the ITS 1/2 region most closely
matched C. haemulonii, C. pseudohaemulonii, and C. heveicola
(87.5, 81.4, and 81.3% sequence similarity, respectively). A
phylogenetic tree based on ITS 1/2 and D1/D2 sequences deposited
in publically available databases illustrates the position of C. auris
within the Clavispora/Candida clade (Fig. 1).

 
C. auris isolates from India, South Africa, Brazil, and/or
South Korea have also been analyzed with classical typing
methods, including pulsed-field gel electrophoresis, M13
phage typing, multilocus sequence typing (MLST), and/or
amplified fragment length polymorphism (AFLP)
fingerprinting. These were the first studies to suggest
geographical strain clustering, but the inherently low
discriminatory power of traditional molecular typing methods
precluded comparisons of relatedness among isolates with
identical fingerprints.
 
WGS has also been applied to an international collection of isolates in an
effort to better assess the relatedness to other Candida species and evaluate
clonality among strains. The assembled C. auris genome is diploid and has a
size range between 12.3 and 12.5 Mb, a GC content of 44.5 to 44.8%, and
approximately 6,600 to 8,300 coding sequences. Draft genome comparisons
revealed that the majority (99.5%) of C. auris genomic reads did not
align with previously sequenced C. albicans, Candida glabrata,
Candida lusitaniae, and Saccharomyces cerevisiae strains, which suggests
that C. auris is highly divergent at the whole-genome level. However,
compared to each other, C. auris isolates can be grouped into geographic-
specific clusters, with unique South Asian (India and Pakistan), South African,
South American (Venezuela), and East Asian (Japan) clades identified. Each
of the 4 geographically distinct clades was separated by tens of thousands of
single-nucleotide polymorphisms (SNPs), while the isolates that grouped
within each geospatial clade appeared to be clonal.
 
Matrix-assisted laser desorption ionization–time of flight
mass spectrometry (MALDI TOF MS) has also been used to
examine strain relatedness. Protein profiling with cluster
analysis also showed evidence of geographically distinct
groups, but this did not correlate perfectly with the results of
standard genotyping methods. It should be noted that MALDI
TOF MS has not necessarily been validated or optimized as a
tool for strain typing and is limited in the number of proteins
that can be detected for strain characterization relative to
higher-resolution MS methods.

 VIRULENCE FACTORS

Several studies have been conducted to characterize C. Auris virulence determinants.
Germination, adherence, biofilm formation, phospholipase, and proteinase production
are all known to contribute to Candida pathogenesis. C. auris does not appear to form
germ tubes, pseudohyphae, or chlamydospores in vitro, but may produce
phospholipase and proteinase in a strain-dependent manner . Although C. auris is able
to adhere to plastics and form biofilms, these capabilities are significantly reduced
relative to those of C. Albicans. An additional intriguing observation is that some C.
auris isolates grow in clumps (i.e., budding occurs but daughter cells are not released),
which results in large aggregates of organisms that cannot be easily disrupted in vitro.
In the Galleria mellonella insect model, aggregate-forming strains were found to be
significantly less pathogenic than nonaggregating isolates. Interestingly, the most
virulent nonaggregative forms exhibited pathogenicity on par with C. albicans, despite
the fact they did not form hyphal or pseudohyphal elements in G. mellonella larvae. In
a murine model of hematogenous disseminated candidiasis, C. auris cell aggregates
were also observed in the kidneys of infected animals compared to the invasive hyphal
forms of C. albicans. Additionally, inoculation with C. auris was associated with
longer median survival than with C. albicans. Whether these growth characteristics
affect the course of infection in other animal models or humans is not known.
 IDENTIFICATION IN THE
CLINICAL LABORATORY

Candida isolates from normally sterile body sites should be
identified to the species level in order to guide initial therapy based
on predictable species-specific susceptibility. Additionally, the
CDC recommends considering identifying Candida isolates from
nonsterile sites in select situations, such as when a case of C. auris
has been identified in a health care facility or when a patient has
health care exposure in a location outside the United States where
C. auris has been reported. Laboratories should also review past
records to identify confirmed or suspected cases as well as conduct
prospective surveillance. However, accurate identification of
C. auris infection in the clinical laboratory can be problematic
especially when relying on phenotypic characteristics.
 PHENOTYPIC
CHARACTERISTICS

C. auris strains have been described as nondescript white- to
cream-colored colonies on Sabouraud dextrose agar (SDA) and
pink to beige on CHROMagar. They form ovoid to elongated
budding yeast cells without pseudohyphae on corn meal or rice
Tween 80 agar, grow well at 37°C and 42°C, and assimilate N-
acetylglucosamine, succinate, and gluconate. In contrast,
C. haemulonii and C. duobushaemulonii strains produce
pseudohyphae, do not grow well at 42°C, and do not assimilate the
same sugars. Based on these observations, a small study proposed
using temperature tolerance and CHROMagar supplemented with
Pal’s medium as a means to morphologically separate C. auris
from members of the closely related C. haemulonii complex.
 BIOCHEMICAL METHODS

Misidentifications of C. auris as other Candida species by
commercial biochemical methods have been widely reported,
likely because of a lack of representative organisms in
currently available databases. Clinical laboratories should be
especially alert to the possibility of C. auris when an isolate
is identified by biochemical methods as C. haemulonii. Table
1 summarizes possible C. auris misidentifications grouped by
identification method.

 MALDI-TOF MS

MALDI-TOF MS is a potentially accurate and rapid method for the
identification C. auris from pure culture. However, current FDA-
cleared libraries for use with the MALDI Biotyper (Bruker,
Billerica, MA) and Vitek MS (bioMérieux, Marcy l’Etoile, France)
platforms do not include C. auris reference spectra. Identification
requires the research use only (RUO) databases for these
instruments or, alternatively, the creation of custom libraries.
C. auris was added to the MALDI Biotyper RUO library in 2013
(database version 5627 and later). The Saramis version 4.14 RUO
database with the Saccharomycetaceae patch is required for a
higher confidence that C. auris will not be missed when using the
Vitek MS
 
A recent mlticenter study evaluated the accuracy of current RUO
databases for the identification of C. auris versus closely related
species (34). Both platforms correctly identified 100% of the test
isolates; the Vitek MS accomplished this using the direct on-slide
extraction method, whereas the MALDI Biotyper required a separate
tube extraction to obtain high-confidence scores. In contrast, another
report that included only 2 C. auris strains observed that the Bruker
RUO system correctly identified both isolates, while the Vitek MS
RUO reported “no species ID” calls (35). Supplementation of the Vitek
MS RUO database with in-house generated spectra subsequently
resulted in both C. auris isolates being correctly identified to the
species level. The variable Vitek MS RUO results may be related to the
RUO database employed. Mizusawa et al. did not specify which Vitek
MS RUO database version was used in their study (34), while Grenfell
et al. reported running version 4.12, which may be why their two C.
auris isolates were missed (35).
 MOLECULAR METHODS

rDNA sequencing of the 28s D1/D2 region or ITS 1/2 will
accurately identify C. auris to the species level. Additionally,
PCR-based methods have also been developed. Kordalewska
et al. designed a real-time PCR assay to detect C. auris and to
differentiate it from C. haemulonii, C. duobushaemulonii,
orC. lusitaniae via melt curve analysis (36). The C. auris
primers showed excellent selectivity versus common fungal
pathogens as well as human DNA, but relatively few
members of the Clavispora clade known to share similar ITS
sequences were evaluated. The development of a PCR-based
test is of particular interest, especially because this approach
may be useful for patient and environmental screening from
swabs or for direct detection from other clinical specimens.
 ANTIFUNGAL
DRUG RESISTANCE

One of the reasons the emergence of C. auris has been
so alarming is the potential for these organisms to
harbor or develop multidrug resistance. In fact, some
isolates have demonstrated elevated MICs to all
available drug classes, indicating that treatment options
for panresistant isolates would be extremely
challenging if not impossible.
 PHENOTYPIC
SUSCEPTIBILITY

 Currently, there are no species-specific antifungal susceptibility
breakpoints established for C. auris. The isolates tested to date
have uniformly displayed elevated fluconazole MICs (i.e., 16
g/ml), along with varied susceptibilities to other azoles,
amphotericin, and the echinocandins (9, 12, 24, 30, 32, 37). Table
2 summarizes several of the larger drug susceptibility surveys.
Posaconazole followed by isavuconazole have generally been
the most potent azoles in vitro, and fewer isolates have had
elevated amphotericin or echinocandin MICs. Of note,
overrepresentation of clonal strains in any one study has the
potential to skew susceptibility patterns, and several of the
larger reports have included a significant proportion of isolates
from India. It should also be recognized that falsely elevated
amphotericin and caspofungin MICs have been reported using
the Vitek 2 susceptibility test method (13, 32).
 MOLECULAR RESISTANCE
DETERMINANTS

 Molecular mechanisms for azole resistance in C. albicans have
been well defined and include: overexpression of multidrug
transporters, mutations in lanosterol demethylase (encoded by
ERG11), increased expression of ERG11, and an alteration in the
sterol biosynthesis pathway which results in the replacement of
ergosterol by other sterols in the cytoplasmic membrane
(encoded by ERG3). Additionally, mutations in Candida FKS
genes result in elevated echinocandin MICs and have been
linked to treatment failures. WGS analyses have shown that
ERG3, ERG11, FKS1, FKS2, and FKS3 homologs were present as
a single copy in the C. auris genome and that these loci share
78% to 85% similarity with C. albicans and C. glabrata genes
(26, 38). Additionally, a significant proportion of the C. auris
genome is predicted to encode ATP-binding cassette (ABC) and
major facilitator superfamily (MFS) efflux pumps (26, 38).
 
Molecular characterization of drug resistance mechanisms in
C. auris has mostly focused on alterations in the lanosterol
demethylase enzyme. Lockhart et al. evaluated ERG11
sequences in a global collection of 54 C. auris isolates and
determined that substitutions linked to fluconazole
resistance in C. albicans were also present in C. auris, and
these mutations were strongly associated with geographic
clades (i.e., F126T in South Africa, Y132F in Venezuela, and
Y132F or K143R in India/Pakistan) (12). Ben-Ami et al. also
observed increased ABC-type transporter activity in C. auris
compared to that in C. glabrata and C. haemulonii, which
suggests that efflux pumps may additionally be involved in
antifungal drug resistance (6).
 TREATMENT

The optimal treatment regimen for C. auris has not been defined.
Because the majority of C. auris isolates identified in the United States
have been susceptible to echinocandins, treatment with a drug from
this class, along with infectious diseases consultation, is suggested for
initial therapy. Alternatively, the treatment of colonization without
evidence of active infection is strongly discouraged
(https://www.cdc.gov/ fungal/diseases/candidiasis/c-auris-
treatment.html). Close monitoring for treatment failure and the
emergence of resistance upon treatment is required. Preventing C.
auris infection altogether is ideal. Many patients with reported C.
auris infection or colonization received antecedent broad-spectrum
antibiotics and/or antifungals. The implementation of antimicrobial
stewardship programs is warranted to minimize unnecessary
antibiotic use. Stewardship teams can also assist with rapid case
identification, appropriate management, and coordinate with infection
prevention to minimize transmission.
 INFECTION PREVENTION AND CONTROL


The transmissibility of C. auris within hospitals, especially
critical-care settings, has been established(17). Although the
precise mode of transmission has yet to be defined, spread
from the patient or their environment to the hands of health
care workers seems highly plausible. Skin or mucosal
colonization of affected patients appears to be common, and
the organism has been recovered from a variety of patient
contact points, such as mattresses, furniture, sinks, and
medical equipment (17, 18). Candida spp. can be transferred
from environmental surfaces to hands (39, 40), and C. auris
has been shown to persist on plastics ex vivo for at least 14
days, with viability testing indicating that cells are also
capable of entering a metabolically active, but nonculturable,
state that persisted for 4 weeks (41).
 
Given the propensity for C. auris to cause outbreaks, the CDC has emphasized
adherence to good hand hygiene combined with standard and contact
precautions, housing of infected patients in private rooms, performance of
thorough daily cleaning, and terminal room disinfection with an agent that is
effective against Clostridium difficile
(https://www.cdc.gov/fungal/diseases/candidiasis/c-auris-infection-
control.html #disinfection). Recent evaluations suggest that nonsporocidal
hydrogen peroxide and chlorine-based disinfectants are also effective against
C. auris (42–44), but the widely used quaternary ammonium products have
relatively poor activity (43). Iodine-based skin cleansers and chlorhexidine
(depending on the formulation) also have demonstrated effective C. auris
killing (42, 44). However, patients continued to be colonized with C. auris
despite daily chlorhexidine washes in a prolonged outbreak setting, potentially
as a result of reinfection from the environment or due to reduced chlorhexidine
susceptibility (17). Additional work is required to determine the optimal
approach to reducing skin colonization.
 SUMMARY (RINGKASAN)

Infeksi C. auris terus dilaporkan di seluruh dunia, seringkali dengan
morbiditas dan mortalitas yang tinggi. Identifikasi tingkat spesies yang akurat
sangat penting untuk deteksi kasus dan penerapan tindakan pencegahan
infeksi yang tepat. Laboratorium klinis harus memiliki kecurigaan tinggi
untuk C. auris ketika ragi tertentu (mis., C. haemulonii atau Candida spp.)
Diidentifikasi dengan metode biokimia atau MALDI-TOF MS yang
dibersihkan FDA. Sekuensing rDNA tetap menjadi metode referensi untuk
identifikasi tingkat spesies C. auris, tetapi database RUO MALDI-TOF MS dan
/ atau tes PCR yang dirancang dengan baik adalah alternatif yang berpotensi
lebih cepat. Kasus yang dicurigai dan dikonfirmasi harus dilaporkan kepada
otoritas kesehatan masyarakat, dengan pengujian kerentanan antijamur
dilakukan untuk infeksi invasif meskipun tidak ada breakpoint spesifik
spesies yang ditetapkan. Berdasarkan data MIC yang tersedia, echinocandins
tampaknya menjadi pilihan terbaik untuk perawatan awal. Kemitraan antara
laboratorium klinis, penatalayanan antimikroba, dan pencegahan dan
pengendalian infeksi rumah sakit sangat penting untuk mengoptimalkan
diagnosis dan manajemen dan mengurangi penyebaran nosokomial.