Cited by 289Antifungal resistance and susceptibilityFungal Infections and StudiesYeasts and Rust Fungi Studies

Worsening Spread of Candida auris in the United States, 2019 to 2021

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Lyman, Meghan, Forsberg, Kaitlin, Sexton, D. Joseph, Chow, Nancy A., Lockhart, Shawn R., Jackson, Brendan R., Chiller, Tom·2023·Annals of Internal Medicine

Abstract

Background: Candida auris is an emerging fungal threat that has been spreading in the United States since it was first reported in 2016. Objective: To describe recent changes in the U.S. epidemiology of C auris occurring from 2019 to 2021. Design: Description of national surveillance data. Setting: United States. Patients: Persons with any specimen that was positive for C auris. Measurements: Case counts reported to the Centers for Disease Control and Prevention by health departments, volume of colonization screening, and antifungal susceptibility results were aggregated and compared over time and by geographic region. Results: A total of 3270 clinical cases and 7413 screening cases of C auris were reported in the United States through 31 December 2021. The percentage increase in clinical cases grew each year, from a 44% increase in 2019 to a 95% increase in 2021. Colonization screening volume and screening cases increased in 2021 by more than 80% and more than 200%, respectively. From 2019 to 2021, 17 states identified their first C auris case. The number of C auris cases that were resistant to echinocandins in 2021 was about 3 times that in each of the previous 2 years. Limitation: Identification of screening cases depends on screening that is done on the basis of need and available resources. Screening is not conducted uniformly across the United States, so the true burden of C auris cases may be underestimated. Conclusion: C auris cases and transmission have risen in recent years, with a dramatic increase in 2021. The rise in echinocandin-resistant cases and evidence of transmission is particularly concerning because echinocandins are first-line therapy for invasive Candida infections, including C auris. These findings highlight the need for improved detection and infection control practices to prevent spread of C auris. Primary Funding Source: None.

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  • C. auris is now a global human threat, particularly in healthcare settings, causing large outbreaks in ICUs in India, Southern Europe, the United Kingdom, Brazil, and the United States.

    “C. auris is now a global human threat, particularly in healthcare settings, causing large outbreaks in ICUs in India, Southern Europe, the United Kingdom, Brazil and the United States.70,71,73”

    From Epidemiology of Invasive Candidiasis (2024) · cites this paper as [73]

    The introductory passage (page unavailable) describes C. auris as an urgent threat that spreads in healthcare facilities, and the Discussion reports several large outbreaks in U.S. acute-care hospitals. The paper does not identify those outbreaks as ICU outbreaks or report outbreaks in India, Southern Europe, the United Kingdom, or Brazil; its threat assessment concerns the United States rather than the globe. (LLM, conf=0.88)

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  • Up to 60% of clinical C. auris isolates can acquire high amphotericin B MIC values.

    “One of the open unsolved questions in C. auris pathophysiology is why and how up to 60% of clinical isolates6,7 can acquire high AMBMIC values.”

    From Candida auris skin tropism and antifungal resistance are mediated by carbonic anhydrase Nce103 (2025) · cites this paper as [7]

    The Results > Drug Resistance section reports amphotericin B resistance in clinical C. auris isolates: 26% overall among isolates tested in 2020, with regional rates of 45% in the Northeast and 85% in the Mid-Atlantic. It does not report a 60% figure or show that isolates acquired high amphotericin B MIC values over time. Page numbers were not available in our copy. (LLM, conf=0.87)

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  • Candida auris, a highly transmissible and frequently multidrug-resistant Candida sp., has emerged as a cause of health care-associated outbreaks and candidemia.

    “In addition, Candida auris, a highly transmissible, and frequently multidrug-resistant Candida sp., has emerged as a cause of health care–associated outbreaks and candidemia (15,16).”

    From Population-Based Active Surveillance for Culture-Confirmed Candidemia — 10 Sites, United States, 2017–2021 (2025) · cites this paper as [15]

    The introduction (page not available) describes C. auris as often multidrug-resistant, easily spread in health care facilities, and capable of causing severe invasive infections. The conclusion reports rising cases and transmission, supporting its emergence as a health care-associated threat. Our copy does not specifically identify candidemia as an outcome; a search for that term found no passage addressing it. (LLM, conf=0.82)

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  • Treatment of C. auris is complicated by widespread resistance to approved antifungal drugs.

    “Treatment is further complicated by widespread resistance to approved antifungal drugs [14,15].”

    From Host–Candida auris interactions in the skin (2026) · cites this paper as [14]

    The Results (Drug Resistance; page not provided) report resistance to azoles in 86% of tested isolates and to amphotericin B in 26%, supporting concern about resistance to antifungal drugs. But the same section reports echinocandin resistance below 5%, and the Discussion says it remains uncommon despite echinocandins being first-line treatment. Thus, “widespread resistance” overstates the finding if applied to approved antifungals generally. (LLM, conf=0.85)

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  • The incidence of resistance to azoles and amphotericin B, and the emergence of pan-resistant isolates of C. auris, had increased in the US by 2021.

    “The incidence of resistance to azoles and amphotericin B, and the emergence of pan-resistant isolates of C. auris, had increased in the US by 2021 [14].”

    From Host–Candida auris interactions in the skin (2026) · cites this paper as [14]

    The Results, Drug Resistance section (page not provided) reports that azole resistance rose by about 7% from 2019 to 2020 and that patients with pan-resistant isolates increased in 2021. It reports amphotericin B resistance by region, but does not establish a nationwide increase in that resistance by 2021. (LLM, conf=0.88)

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Authors
Lyman, M., Forsberg, K., Sexton, D. J., Chow, N. A., Lockhart, S. R., Jackson, B. R., & Chiller, T.
Affiliations
Centers for Disease Control and Prevention (US)
Venue
Annals of Internal Medicine
Published
2023-04
Volume
176
Issue
4
Pages
489-495
ISSN
  • 0003-4819 (ISSN-L)
  • 1539-3704
OpenAlex
W4327912896
Cited by
287
References
38
Citations by year
2026: 75 · 2025: 87 · 2024: 84 · 2023: 41
FWCI
59.07
Type
journal article
Language
en
Open access
Locations
  • Annals of Internal Medicine (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
Funders
National Institutes of Health (CC999999)
Topics
  • Health Sciences › Medicine › Infectious Diseases › Antifungal resistance and susceptibility
  • Health Sciences › Medicine › Epidemiology › Fungal Infections and Studies
  • Life Sciences › Biochemistry, Genetics and Molecular Biology › Molecular Biology › Yeasts and Rust Fungi Studies
Keywords
Candida auris, fungal epidemiology, emerging fungal pathogens, colonization screening, echinocandin resistance, antifungal susceptibility, invasive candidiasis, infection control, geographic spread, United States
MeSH terms
Candida auris, Antifungal Agents, Candida, Candidiasis, Humans, Microbial Sensitivity Tests, United States, Echinocandins

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