Hostname: page-component-6898cfcb55-w5hgh Total loading time: 0 Render date: 2026-11-11T06:30:36.621Z Has data issue: false hasContentIssue false
  • English
  • Français

Outcomes of patients with Candidozyma auris vs. Candida glabrata and C. krusei: the after-effect of lifetime contact precautions

Published online by Cambridge University Press:  20 July 2026

Anjali KewalramaniOpen the ORCID record for Anjali Kewalramani[Opens in a new window],
Kimberly Mae Soultan,
Durga Prasad Matlapudi,
Tamara Nawar,
Marie AbdallahOpen the ORCID record for Marie Abdallah[Opens in a new window],
Briana Episcopia,
Jennifer Lee and
John QualeOpen the ORCID record for John Quale[Opens in a new window]
Anjali Kewalramani
Affiliation:
Kings County Hospital Center, USA
Kimberly Mae Soultan
Affiliation:
Kings County Hospital Center, USA
Durga Prasad Matlapudi
Affiliation:
Kings County Hospital Center, USA
Tamara Nawar
Affiliation:
Kings County Hospital Center, USA
Marie Abdallah
Affiliation:
Kings County Hospital Center, USA
Briana Episcopia
Affiliation:
Kings County Hospital Center, USA
Jennifer Lee
Affiliation:
Kings County Hospital Center, USA
John Quale*
Affiliation:
Infectious Diseases, Kings County Hospital Center , Brooklyn, USA
*
Corresponding author: John Quale; Email: john.quale@nychhc.org

Abstract

Background:

Candidozyma auris, Candida glabrata, and C. krusei are all fungal pathogens intrinsically resistant to azoles. Patient characteristics and outcomes were compared for patients with cultures positive for these three pathogens.

Methods:

A retrospective cohort study was performed involving patients from an 11 acute care safety net hospital system in New York City. Echinocandin susceptibility rates and patient outcomes, including overall mortality and lengths of hospital stay, were compared for patients with C. auris versus C glabrata/krusei.

Results:

Resistance to caspofungin was low in all three pathogens. Compared to patients with C. glabrata/C. krusei, patients with C. auris had similar mortality rates. However, compared to patients harboring C. glabrata/C krusei, those with C. auris had longer hospital stays when discharged to a skilled nursing facility, including from the time from culture positivity to discharge (78 ± 148 vs 33 ± 44 d, P = .06). Multivariate regression analysis revealed two factors associated with length of stay: presence of C. auris (P < .001) and hemodialysis (P = .051).

Discussion:

Echinocandin resistance was unusual, and overall mortality rates were similar, for patients with C. auris, C. glabrata, and C. krusei. However, for patients discharged to skilled nursing facilities, the length of hospital stay was longer for patients with C. auris. The implementation of lifelong contact precautions for C. auris may be an impediment for discharge planning.

Information

Type
Original Article
Information
Antimicrobial Stewardship & Healthcare Epidemiology , Volume 6 , Issue 1 , 2026, e219
Creative Commons
Creative Common License - CCCreative Common License - BYCreative Common License - NCCreative Common License - ND
This is an Open Access article, distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives licence (https://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided that no alterations are made and the original article is properly cited. The written permission of Cambridge University Press or the rights holder(s) must be obtained prior to any commercial use and/or adaptation of the article.
Copyright
© The Author(s), 2026. Published by Cambridge University Press on behalf of The Society for Healthcare Epidemiology of America

Introduction

Candidozyma auris (C. auris) has rapidly emerged as a serious nosocomial pathogen. Among the six known clades, clades I and III (both common in the United States) are typically resistant to azoles and amphotericin. Reference da Silva, Lucini and Dos Santos1,Reference Lyman, Forsberg and Sexton2 Echinocandin resistance is also an increasing problem in clades I, III, and IV, with rates approaching 3% in some regions. Reference Lyman, Forsberg and Sexton2

C. auris possesses unique adhesins that have allowed it to become a formidable nosocomial pathogen. Reference Santana, Anku and Zhao3 These adhesins, along with biofilm formation, allow prolonged survival of C. auris on cutaneous and abiotic surfaces. Reference Horton, Holt and Nett4–Reference Lionakis and Chowdhary6 Prolonged skin colonization and extensive environmental contamination enhance transmission in healthcare settings; this appears to be especially problematic in long-term acute care and ventilator-capable skilled nursing facilities. Reference Sansom, Gussin and Schoeny7

Because negative surveillance cultures do not reliably predict clearance of cutaneous colonization, Reference Pacilli, Kerins and Clegg8,Reference Arenas, Persad and Patel9 it is recommended patients with C. auris be placed on “lifelong” contact precautions while in healthcare facilities. In this report we compare outcomes of patients with C. auris with patients with two candida species intrinsically resistant to azoles, Candida glabrata and C. krusei, and the impact of lifelong contact precautions on patient care.

Methods

The NYC Health and Hospitals System includes 11 acute care hospitals that serve patients primarily of low socioeconomic status in the boroughs of the Bronx, Brooklyn, Manhattan, and Queens. All have major academic affiliations.

Line listings of patients from the 11 hospitals that had cultures positive for C. auris, C. glabrata, and C. krusei were obtained from January 1, 2021 through December 31, 2025. Additional chart review was conducted on select patients to determine discharge destination, and the presence of mechanical ventilation and/or hemodialysis upon discharge. Patients discharged to long-term care facilities or acute/subacute rehabilitation centers were considered to be discharged to a skilled nursing facility.

Student’s-test was used to compare continuous variables, and Fisher’s exact test and χ2 analysis were used to compare categorical values. Propensity score matching was used to establish a control group of patients with C. glabrata/C. krusei to match those with C. auris. Multivariate regression analysis was used to determine factors correlating with the length of stay. Propensity score matching and regression analysis were performed using SPSS®.

This study was approved by the Brany IRB services and the NYC Health+Hospitals Systems to Track and Approve Research program.

Results

From 2021 through 2025 there were 119 unique patients with a clinical culture positive for C. auris. During that same time period there were 871 patients with C. glabrata and 172 patients with C. krusei. Compared to the patients with C. glabrata/C. krusei, those with C. auris had similar age (64.8 ± 15.2 vs 66.4 ± 16.1 yr) and BMI (25.8 ± 8.2 vs 26.8 ± 8.2 kg/M2), but a lower likelihood of a diagnosis of diabetes mellitus (48% vs 51%, P = .03). Among the patients with C. auris, 36% had positive blood cultures, compared to 23% (P = .002) of patients with C. glabrata/C. krusei. The percentage of patients with positive urine cultures was similar, 34% versus 37% (P = .47), for the patients with C. auris and C. glabrata/C. krusei, respectively. However, positive respiratory tract cultures occurred in 7% of C. auris cultures, compared to 18% (P = .003) of C. glabrata/C. krusei cultures. Susceptibility testing for caspofungin was performed for 33 isolates of C. auris, 342 isolates of C. glabrata, and 25 isolates of C. krusei. All of the isolates of C. auris were susceptible; by comparison, nine (3%) the C. glabrata isolates were intermediate and one (0.3%) was resistant. Among the C. krusei isolates, 7 (28%) were intermediate and none were resistant to caspofungin.

Overall, 46% (55 of 119) patients with C. auris cultures did not survive hospitalization, compared to 40% (412 of 1,043, P = .16) of patients with C. glabrata/C. krusei. Looking only at patients with candidemia (Table 1), mortality rates were again similar between those with C. auris (23 of 43, 53%) and C. glabrata/C. krusei (138 pf 242, 57%, P = .67). The time from candidemia to death was also similar between the two groups.

Table 1.

Comparison of patients with candidemia with C. auris and C. glabrata/C. krusei

A table comparing patients with candidemia caused by C. auris and C. glabrata/C. krusei.

a P = .05 compared to patients with C. auris.

Among the patient discharged to a home residence or shelter, the length of hospital stay from time of culture to discharge was not significantly different between those with C. auris versus C. glabrata/C. krusei (41.4 ± 52.6 vs 20.0 ± 29.9 d, P = .11) and C. auris versus C. krusei (41.4 ± 52.6 vs 30.9 ± 44.9 d, P = .49).

A total of 40 patients with C. auris and 257 patients with C. glabrata/C. krusei survived hospitalization and were ultimately discharged to a skilled nursing facility (Table 2). Patients with C. auris had longer hospital stays, including from the time of the positive culture to the time of discharge. The percentage of patients located in an intensive care unit, were on hemodialysis, or had a central venous catheter at the time of the culture was similar for both groups (Table 2). For the patients with C. auris, sites of positive culture included urine (48%), blood (28%), wound (17%), and respiratory tract (5%). Similarly, sites of positive cultures in patients with C. glabrata/C. krusei included urine (46%), blood (21%), wound (12%), and respiratory tract (19%; P = .03 compared to patients with C. auris). Multivariate regression analysis was performed to correlate length of hospital stay from the positive culture with the following variables: culture positive for C. auris, age, presence of diabetes mellitus, BMI, and site of positive culture, location in an intensive care setting, presence of a central venous catheter, and hemodialysis. Two variables correlated with length of hospital stay: presence of C. auris (P < .001) and receipt of hemodialysis (P = .051).

Table 2.

Comparison of patients with C. auris and C. glabrata/C. krusei discharged to skilled nursing facilities

Table comparing patients with C. auris and C. glabrata/C. krusei discharged to skilled nursing facilities.

a P =.02 compared to patients with C. auris.

b P =.06 compared to patients with C. auris.

Patients requiring mechanical ventilation and/or hemodialysis may face challenges for discharge planning to skilled nursing facilities. To assess the potential impact of these conditions, their frequency was determined in closely matched patients with C. auris and C. glabrata/C. krusei. Propensity score matching, controlling for age, presence of diabetes, site of positive culture, and hospital length of stay, was performed to create closely matched cohorts of patients with C. auris and C. glabrata/C. krusei. Overall 30 patients with C. auris were matched with 30 patients with C. glabrata/C. krusei. As expected, compared to the patients with C. glabrata/C. krusei, those with C. auris had similar age (69.4 ± 13.6 vs 70.5 ± 10.7 yr), length of hospital stay (49.6 ± 43.3 vs 42.2 ± 40.5 d), and incidence of diabetes (40% vs 40%). The distribution of patients according to the site of infection was similar between the two groups: urine 50% versus 43%, blood 30% versus 27%, wound 17% versus 23%, and respiratory tract 3% versus 3%. Eight of the patients with C.auris were located in an intensive care unit at the time of the culture, compared to 7 patients with C. glabrata/C. krusei. Central venous catheters were present in 7 of the patients with C. auris and 9 of the patients with C. glabrata/C. krusei. Of the 30 patients with C auris, 15 were discharged on mechanical ventilation, compared to 12 patients (P = .6) with C. glabrata/C. krusei. Similarly, four patients with C. auris required hemodialysis, compared to none with C. glabrata/C. krusei (P = .06).

Discussion

Patients with C. auris versus other Candida species infection share several acquisition risk factors, including advanced age, diabetes, indwelling devices, renal failure, and recent surgery. Reference Wasylyshyn and Stoneman10 However, patients with C. auris are more likely to have had prior surgery, intensive care unit admission, and prior antifungal exposure. Reference Sayeed, Farooqi, Jabeen and Mahmood11–Reference Rudramurthy, Chakrabarti and Paul13 Because of its ability to persist on the skin for prolonged periods, blood stream infections are more common in patients with C. auris when there are intravascular devices present. Reference Horton, Holt and Nett4,Reference Sayeed, Farooqi, Jabeen and Mahmood11 As observed in our report; compared to patients with C. glabrata or C. krusei, patients with C. auris were more likely to have bloodstream infection and central venous catheters.

Mortality rates for bloodstream infections appear to be similar for patients infected with C. auris versus other Candida species. Reference Salmanton-García, Nóbrega de Almeida and Colombo5,Reference Sayeed, Farooqi, Jabeen and Mahmood11,Reference Simon, Li and Silver14 Crude mortality rates of approximately 30%–50% have been noted for bloodstream infections for patients with either C. auris versus other candida species. Reference Salmanton-García, Nóbrega de Almeida and Colombo5,Reference Lionakis and Chowdhary6,Reference Simon, Li and Silver14,Reference Benedict, Forsberg, Gold, Baggs and Lyman15 In our report mortality rates between patients with C. auris versus C. glabrata/C.krusei were similar, including those with bloodstream infections. While the attributable mortality rate from C. auris bloodstream infection is unknown, it appears to be low, given the rather prolonged time between the positive blood culture and death of the patient.

A consistent finding is, when compared to patients with other candida infections, patients with C. auris have longer hospital stays. Reference Fan, Li and Zhao12,Reference Rudramurthy, Chakrabarti and Paul13 This is likely multifactorial, given patients with C. auris typically have multiple co-morbid conditions, intensive care unit stays, and prior surgeries. Reference Sayeed, Farooqi, Jabeen and Mahmood11–Reference Rudramurthy, Chakrabarti and Paul13 However, the length of stay from the time of the positive culture to discharge is also prolonged. Reference Sayeed, Farooqi, Jabeen and Mahmood11 In our report, among patients discharged to a skilled nursing facility, those with C. auris stayed an average of 45 days longer in the hospital compared to patients with C. glabrata/C. krusei. This increased length of stay could not be explained by an increased number of patients requiring mechanical ventilation or hemodialysis, often barriers to discharge.

The unique capability of C. auris to colonize environmental surfaces and skin, increasing the risk for catheter-related bloodstream infection, is well recognized. However, C. auris does not appear to be more virulent than other candida species. Also, although concerns of increasing resistance have been raised, overall echinocandin resistance was low (as noted in our study). Reference Lyman, Forsberg and Sexton2

The implementation of lifelong contact precautions was intended to limit the spread of C. auris in healthcare facilities. However, the requirements of a single room, gown and glove usage, and enhanced environmental cleaning for the lifetime of a patient pose an obstacle for discharge planning, particularly to skilled nursing facilities. If the average cost of a hospital stay in New York is $3700 (https://nchstats.com/average-cost-of-hospital-stays-in-us/), the increased length of stay for the 40 patients with C. auris (compared to patients with C. glabrata/C. krusei) in this study amounted to over $6.5 million dollars of increased hospital expenditure.

Proposals have been made to develop more effective patient antiseptic techniques and environmental cleaning methods, including development of longer acting disinfectants and antimicrobial surfaces. Reference Salmanton-García, Nóbrega de Almeida and Colombo5,Reference Sansom, Gussin and Schoeny7 If alternative strategies are found to be effective in reducing transmission, perhaps the stigma of lifetime contact precautions can be avoided.

Financial support

None to declare.

Competing interests

None to declare.

References

da Silva, KJG, Lucini, F, Dos Santos, RAC, et al. How does antifungal resistance vary in Candida (Candidozyma) auris and its clades? Quantitative and qualitative analyses and their clinical implications. Clin Microbiol Infect 2025;31:1146–1156.10.1016/j.cmi.2025.04.003CrossRefGoogle ScholarPubMed
Lyman, M, Forsberg, K, Sexton, DJ, et al. Worsening spread of Candida auris in the United States, 2019 to 2021. Ann Intern Med 2023;176:489–495.10.7326/M22-3469CrossRefGoogle ScholarPubMed
Santana, DJ, Anku, JAE, Zhao, G, et al. A Candida auris-specific adhesin, Scf1, governs surface association, colonization, and virulence. Science 2023;381:1461–1467.10.1126/science.adf8972CrossRefGoogle ScholarPubMed
Horton, MV, Holt, AM, Nett, JE. Mechanisms of pathogenicity for the emerging fungus Candida auris . PLoS Pathog 2023;19:e1011843.10.1371/journal.ppat.1011843CrossRefGoogle ScholarPubMed
Salmanton-García, J, Nóbrega de Almeida, J Jr, Colombo, AL. Candidozyma auris (formerly Candida auris): resistant, long lasting, and everywhere. Clin Microbiol Infect 2026;32:374–381.10.1016/j.cmi.2025.12.022CrossRefGoogle ScholarPubMed
Lionakis, MS, Chowdhary, A. Candida auris infections. N Engl J Med 2024;391:1924–1935.10.1056/NEJMra2402635CrossRefGoogle ScholarPubMed
Sansom, SE, Gussin, GM, Schoeny, M, et al. Rapid environmental contamination with Candida auris and multidrug-resistant bacterial pathogens near colonized patients. Clin Infect Dis 2024;78:1276–1286.10.1093/cid/ciad752CrossRefGoogle ScholarPubMed
Pacilli, M, Kerins, JL, Clegg, WJ, et al. Regional emergence of Candida auris in Chicago and lessons learned from intensive follow-up at 1 ventilator-capable skilled nursing facility. Clin Infect Dis 2020;71:e718–e725.10.1093/cid/ciaa435CrossRefGoogle ScholarPubMed
Arenas, SP, Persad, PJ, Patel, S., et al. Persistent colonization of Candida auris among inpatients rescreened as part of a weekly surveillance program. Infect Contr Hosp Epidemiol 2024;45:762–765.10.1017/ice.2023.251CrossRefGoogle ScholarPubMed
Wasylyshyn, A, Stoneman, EK. Management of Candida auris . JAMA 2024;331:611–612.10.1001/jama.2023.24921CrossRefGoogle Scholar
Sayeed, MA, Farooqi, J, Jabeen, K, Mahmood, SF. Comparison of risk factors and outcomes of Candida auris candidemia with non-Candida auris candidemia: a retrospective study from Pakistan. Med Mycol 2020;58:721–729.10.1093/mmy/myz112CrossRefGoogle ScholarPubMed
Fan, T, Li, Z, Zhao, Z, et al. Analysis of Candida auris resistance and associated risk factors in hospitalized patients at a tertiary care hospital in China. Sci Rep 2025;15:44769.10.1038/s41598-025-29061-8CrossRefGoogle Scholar
Rudramurthy, SM, Chakrabarti, A, Paul, RA et al. Candida auris candidaemia in Indian ICUs: analysis of risk factors. J Antimicrob Chemother 2017;72:1794–801.10.1093/jac/dkx034CrossRefGoogle ScholarPubMed
Simon, SP, Li, R, Silver, M, et al. Comparative outcomes of Candida auris bloodstream infections: a multicenter retrospective case-control study. Clin Infect Dis 2023;8(76):e1436–e1443.10.1093/cid/ciac735CrossRefGoogle Scholar
Benedict, K, Forsberg, K, Gold, JAW, Baggs, J, Lyman, M. Candida auris‒associated hospitalizations, United States, 2017-2022. Emerg Infect Dis 2023;29:1485–1487.10.3201/eid2907.230540CrossRefGoogle ScholarPubMed
Figure 0

Table 1.Comparison of patients with candidemia with C. auris and C. glabrata/C. krusei

Figure 1

Table 2.Comparison of patients with C. auris and C. glabrata/C. krusei discharged to skilled nursing facilities