To the Editor

Candida auris is an emerging multidrug-resistant yeast notable for healthcare-associated transmission, environmental persistence, and resistance to multiple antifungal classes. ^{Reference Forsberg, Woodworth and Walters1–Reference Ademe and Girma4} Donor-derived invasive candidiasis is recognized in solid organ transplantation, but donor-associated C. auris infection is rare, with only one prior lung transplant case reported. ^{Reference Singh, Huprikar and Burdette5,Reference Azar, Turbett and Fishman6} We describe a cluster of three C. auris infections at a transplant center with no previous cases—two in solid organ recipients from a shared donor and one nosocomial case in a non-transplant patient exposed to a contaminated environment—highlighting dual risks of donor and environmental transmission.

In October 2023, a man in his 40s with dextro-transposition of the great arteries underwent orthotopic heart transplantation (patient 1). His postoperative course was complicated by atrial fibrillation and acute kidney injury. On postoperative day 14, C. auris was isolated from purulent drainage at a prior chest tube site, and fungemia developed by day 22. Imaging revealed a loculated pericardial effusion and a retained epicardial lead. He underwent four mediastinal and pericardial washouts and received micafungin plus posaconazole, surviving on suppressive therapy.

A man in his 50s with advanced liver disease and hepatorenal syndrome underwent simultaneous liver–kidney transplant from the same donor (patient 2). His postoperative course was complicated by a suspected infected biloma not amenable to drainage. On postoperative day 14, he developed fungemia with C. auris and Candida glabrata; an abdominal wall collection grew C. auris on surgical washout on postoperative day 28. He received dual antifungal therapy and treatment for an extended-spectrum beta-lactamase Klebsiella pneumoniae bacteremia but died on day 93 of multifactorial shock without regrowth of C. auris.

A woman in her 40s (patient 3) with chronic lung disease and recent Stenotrophomonas maltophilia pneumonia treated with trimethoprim–sulfamethoxazole was admitted in December 2023 with hypoxemic respiratory failure and a diffuse, desquamating drug-related rash. On hospital day 15, she developed C. auris fungemia with native aortic valve endocarditis. At fungemia onset, she had a tunneled venous catheter and a diffuse rash, suggesting catheter and/or skin entry. Despite therapy with an echinocandin, flucytosine, and posaconazole, she developed septic shock and died. She had occupied the same hospital room approximately 11 days after patient 2’s death, supporting probable healthcare-associated environmental acquisition. ^{Reference Forsberg, Woodworth and Walters1,Reference Cortegiani, Misseri and Fasciana2,Reference Tsay, Kallen and Jackson7,Reference Hata, Humphries and Lockhart8}

The organ donor, an adolescent male hospitalized 56 days after trauma before procurement, had airway cultures positive for a Pseudomonas species and “yeast with multiple morphologies,” and urine cultures showing 40,000 CFU/mL of an unidentified yeast. Species-level identification was not performed, and C. auris was unrecognized. A kidney recipient at our center from the same donor underwent post-transplant C. auris surveillance with negative urine fungal cultures and died from septic shock without growth of C. auris on postoperative day 95. Suspected donor-associated infections were reported to the organ procurement organization and the Organ Procurement and Transplantation Network Disease Transmission Advisory Committee for coordinated evaluation of other recipients. ^{Reference Singh, Huprikar and Burdette5}

At the time of this cluster, our institution used a terminal disinfectant containing peracetic acid and hydrogen peroxide for all patient rooms. ^{Reference Tsay, Kallen and Jackson7,Reference Hata, Humphries and Lockhart8} C. auris infection in patient 2 was not recognized at the time of terminal cleaning; his room did not receive effective C. auris disinfection, and persistent environmental contamination likely contributed to patient 3’s infection. C. auris can survive for weeks on healthcare surfaces and is resistant to many disinfectants, but the protocol gaps most consequential in the transmission to patient 3 were related to implementation of cleaning, not the choice of terminal disinfectant. ^{Reference Forsberg, Woodworth and Walters1,Reference Cortegiani, Misseri and Fasciana2,Reference Tsay, Kallen and Jackson7,Reference Hata, Humphries and Lockhart8}

After recognition of C. auris in these patients, we implemented an institutional outbreak response. Inpatients with epidemiologic links to patients 1 and 2 underwent axilla–groin polymerase chain reaction screening; 35 patients in the unit of patient 1 and 4 patients in the unit of patient 2 were screened, and all results were negative. ^{Reference Cortegiani, Misseri and Fasciana2,Reference Tsay, Kallen and Jackson7} Terminal cleaning protocols were reviewed to ensure use of agents with proven activity against C. auris for rooms of infected or high-risk patients, and infection prevention collaborated with public health authorities for ongoing surveillance. No additional secondary cases have been identified to date.

This cluster highlights critical implications for transplant and infection-prevention programs. Emerging pathogens such as C. auris pose a substantial risk to solid organ recipients. ^{Reference Theodoropoulos, Bolstorff and Bozorgzadeh9,Reference Mishkin10} Donor-associated C. auris infection may occur when yeast detected in donor non-sterile site cultures are not worked up to the species level. ^{Reference Singh, Huprikar and Burdette5,Reference Azar, Turbett and Fishman6,Reference Theodoropoulos, Bolstorff and Bozorgzadeh9,Reference Mishkin10} In donors with prolonged hospitalizations in regions where C. auris is emerging, targeted PCR screening or species-level identification of yeast isolates should be considered, and donor cultures should be interpreted in collaboration with transplant infectious diseases specialists. ^{Reference Forsberg, Woodworth and Walters1,Reference Ademe and Girma4,Reference Singh, Huprikar and Burdette5,Reference Theodoropoulos, Bolstorff and Bozorgzadeh9,Reference Mishkin10} Suspected donor-derived C. auris infections should be promptly reported to the Organ Procurement and Transplantation Network and involved organ procurement organizations to facilitate case finding and coordinated guidance for all centers caring for recipients of organs from the same donor. ^{Reference Singh, Huprikar and Burdette5}

Our experience also underscores the critical importance of terminal cleaning protocol implementation, without which environmental transmission of C. auris can occur to vulnerable hospitalized patients. ^{Reference Forsberg, Woodworth and Walters1,Reference Cortegiani, Misseri and Fasciana2,Reference Tsay, Kallen and Jackson7,Reference Hata, Humphries and Lockhart8} Institutions should consider using C. auris–active disinfectants universally even when C. auris is not yet endemic; environmental cleaning effectiveness monitoring also needs periodic review. ^{Reference Forsberg, Woodworth and Walters1–Reference Ademe and Girma4,Reference Tsay, Kallen and Jackson7,Reference Hata, Humphries and Lockhart8}

In summary, we describe a cluster at a previously C. auris–naïve transplant center involving two solid organ transplant recipients with epidemiologically consistent donor-associated C. auris infection and a subsequent probable healthcare-associated environmental transmission to a non-transplant patient. These cases highlight the need for enhanced donor yeast identification, prompt reporting of suspected donor-derived C. auris, and effective implementation of disinfectants with demonstrated C. auris activity to prevent transmission in transplant settings.