Results

A total of 182 episodes of bloodstream infection caused by _Candida _were identified during the study period from January 2018 to December 2022. Twenty-two patients were excluded from the study, as described in the Materials and Methods section. Therefore, 160 patients were analyzed. The patients were divided into two groups: 58 patients with _C. auris _bloodstream infection, who comprised the _C. auris _group, and 102 patients with bloodstream infection caused by species other than C. auris, who comprised the non-_C. auris _group. Among the 102 patients in the non-_C. auris _group, 35 (34.3%) had C. albicans, 27 (26.4%) had C. glabrata, 15 (14.7%) had C. parapsilosis, and 13 (12.7%) had C. tropicalis, followed by four cases each of _Candida orthopsilosis _and Candida dublinensis, three cases of C. krusei, and one case of Candida lusitaniae.

The median age in both groups was 61 years. In the _C. auris _group, 35 of 58 patients (60.3%) were admitted to a critical care area, compared with 67 of 102 patients (65.7%) in the non-C. auris group. Time to positivity, defined as the time from hospitalization to the first positive blood culture for Candida, had a median of 45 days (range, 1-200 days) with an IQR of 74.5 days in the _C. auris _group, compared with a median of 19 days (range, 0-88 days) and an IQR of 9.5 days in the non-C. auris group.

The comorbidities observed in both groups are presented in Table 1.

Comorbidity | Candida auris (n = 58) | Non-C. auris (n = 102) | p-value | OR (95% CI)
Diabetes mellitus | 27/58 (46.6%) | 47/102 (46%) | 0.91 | 1.02 (0.53-1.95)
Hypertension | 31/58 (53.4%) | 44/102 (43.1%) | 0.27 | 1.51 (0.79-2.89)
Dyslipidemia | 23/58 (39.6%) | 32/102 (31.4%) | 0.37 | 1.43 (0.73-2.82)
Coronary artery disease | 16/58 (27.6%) | 26/102 (25.5%) | 0.92 | 1.11 (0.54-2.31)
Obesity | 11/58 (18.9%) | 11/102 (10.8%) | 0.23 | 1.94 (0.78-4.80)
Chronic kidney disease | 20/58 (34.5%) | 21/102 (20.6%) | 0.08 | 2.03 (0.99-4.19)
Steroid use | 21/58 (36.2%) | 21/102 (20.6%) | 0.04 | 2.19 (1.07-4.49)
Inflammatory bowel disease | 2/58 (3.45%) | 1/102 (0.99%) | 0.62 | 3.55 (0.31-39.9)

The associations studied in the two groups are shown in Table 2. On comparing the two groups, prior colonization with _Candida _species was one of the strongest associations with C. auris bloodstream infection, with an OR of 6.71 (95% CI, 3.26-13.80) and a statistically significant p-value of <0.00001.

Association | Candida auris (n = 58) | Non-C. auris (n = 102) | p-value | OR (95% CI)
Admission to critical area | 35 (60.3%) | 67 (65.7%) | 0.5 | 0.79 (0.41-1.55)
Prior colonization with Candida species | 36 (62.1%) | 20 (19.6%) | <0.00001 | 6.71 (3.26-13.80)
Previous health care contact | 49 (84.5%) | 49 (48%) | <0.00001 | 5.89 (2.61-13.24)
Solid organ malignancy | 13 (22.4%) | 15 (14.7%) | 0.31 | 1.68 (0.73-3.82)
Hematological malignancy | 7 (12.1%) | 6 (5.9%) | 0.28 | 2.20 (0.70-6.88)
Solid organ transplant | 2 (3.45%) | 2 (1.96%) | 0.96 | 1.79 (0.24-13.02)
Hematopoietic stem cell transplant | 4 (6.9%) | 2 (1.96%) | 0.25 | 3.70 (0.66-20.88)
Hemodialysis | 27 (46.6%) | 24 (23.6%) | 0.004 | 2.83 (1.42-5.64)
Presence of CVC | 25 (43.1%) | 85 (83.3%) | <0.00001 | 0.15 (0.07-0.32)
Abdominal surgery | 10 (17.2%) | 22 (21.6%) | 0.65 | 0.76 (0.03-1.74)
TPN use | 15 (25.9%) | 18 (17.6%) | 0.3 | 1.63 (0.75-3.54)
Urinary catheter use | 46 (79.3%) | 71 (69.6%) | 0.25 | 1.67 (0.78-3.56)
Presence of bacteremia | 36 (62.1%) | 50 (49%) | 0.15 | 1.54 (0.79-2.99)

Similarly, previous health care contact, defined as any contact with a health care system within the last 90 days, was significantly associated with _C. auris _bloodstream infection, with an OR of 5.89 (95% CI, 2.61-14.24) and a p-value of <0.00001. Patients on hemodialysis had a significantly higher association with C. auris bloodstream infection, with an OR of 2.83 (95% CI, 1.42-5.64; p = 0.004). The presence of CVCs was significantly higher in the non-_C. auris _group compared with the _C. auris _group (83.3% versus 43.1%). The OR of 0.15 suggests that CVC presence was less common in the _C. auris _group than in the non-_C. auris _group. The other factors listed in the table, including the presence of malignancy, transplant recipients, abdominal surgery, TPN, and urinary catheterization, were not statistically significant when comparing the two groups. On comparing the presence of bacteremia (blood culture positivity for bacteria), it was observed in 62% of patients in the C. auris group compared with 49% in the non-_C. auris _group. However, this difference was not statistically significant.

Susceptibility testing was performed on 126 isolates, of which 51 were from the C. auris group, and 75 were from the non-_C. auris _group. All isolates in the _C. auris _group were resistant to azoles; the drugs tested were fluconazole and voriconazole. Echinocandin susceptibility testing showed that 50 isolates were susceptible to all three echinocandins, namely caspofungin, micafungin, and anidulafungin, whereas one isolate was resistant. For the polyene group, amphotericin B was the tested drug, and 56.9% of isolates were susceptible. Among the non-_C. auris _isolates, 75 of 102 underwent susceptibility testing, and the details are shown in Table 3.

Antifungal class | Candida auris (n = 58) | Non-C. auris(n = 102)
Drug susceptibility available | 51 | 75
Azole susceptibility (includes fluconazole and voriconazole) | 0% | 61/75 (81.3%) susceptible; 6 resistant (2 Candida glabrata, 3 Candida parapsilosis, and 1 Candida krusei); five intermediate (C. glabrata); 3 SDD (C. glabrata)
Echinocandins (caspofungin, micafungin, and anidulafungin) | 50/51 (98.03%) susceptible; 1 resistant | 100%
Polyenes (amphotericin B) | 29/51 (56.9%) susceptible; 22/51 (43.1%) resistant | 100%

Of the total cohort of 182 patients, 78 (42.9%) patients died, and two patients left against medical advice (LAMA). In the _C. auris _group, 30 of 58 patients (51.72%) died, and two patients LAMA. The total number of deaths in the non-C. auris group was 48 of 102 patients (47.05%).