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The director of the National Reference Center for Invasive Fungal Infections, Oliver Kurzai, holding in his hands a petri dish containing the yeast Candida auris. Nicolas Armer/picture alliance via Getty Images
  • Doctors in Brazil report a rapid rise of drug-resistant Candida auris (C. auris), a potentially fatal fungal infection, in a hospital where patients with COVID-19 are treated.
  • Cases of drug-resistant C. auris have been increasing in the United States during the COVID-19 pandemic.
  • The Centers for Disease Control and Prevention (CDC) report that outbreaks may be related to changes in infection control practices, including limited availability of gloves and gowns, or reuse of these items.

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Brazil has reported its first cases of a potentially fatal fungal infection called Candida auris (C. auris) that is becoming increasingly resistant to antifungal drugs.

The country had been on high alert for the emerging infection since 2016, when the first outbreak in the Americas was reported in Venezuela.

Outbreaks soon followed in Colombia, Panama, Chile, and the U.S., but there were no cases in Brazil until December 2020, shortly after a second wave of COVID-19 began in the country.

Researchers led by Arnaldo Colombo, M.D., Ph.D., head of the Special Mycology Laboratory at the Federal University of São Paulo, analyzed samples from the first two cases. Both occurred in the COVID-19 intensive care unit of a hospital in Salvador, northeast Brazil.

The hospital has reported nine further cases of infection or asymptomatic colonization by the fungus.

In March 2021, Dr. Colombo and his colleagues reported in the Journal of Fungi that the fungus remained highly susceptible to antifungal drugs.

However, since then, they have detected a steep increase in the resistance of C. auris to fluconazole and a class of antifungal drugs called echinocandins in samples from the hospital.

“In the case of C. auris present in samples recently isolated in Salvador, for example, the dose has to be four to five times larger than the dose used to inactivate the isolate cultured in December 2020,” says Dr. Colombo.

No other cases have been reported in Brazil, but Dr. Colombo believes there are grounds for concern.

“The species quickly becomes resistant to multiple drugs and isn’t very sensitive to the disinfectants used by hospitals and clinics,” he says.

“As a result, it’s able to persist in hospitals, where it colonizes health workers and ends up infecting patients with severe COVID-19 and other long-stay critical patients.”

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The CDC reports that C. auris can cause infections of the bloodstream, wounds, and the ear.

It estimates that 30–60% of people with C. auris infections die, though many of these patients also had other life threatening illnesses.

Dr. Colombo’s paper stated that superinfection by C. auris in critically ill patients with COVID-19 is estimated to have a 30-day mortality rate of above 50%.

The CDC says that, in the past, C. auris infections were mostly seen in long-term care facilities for people with severe illnesses.

However, since the start of the pandemic, outbreaks have been occurring in the COVID-19 units of hospitals.

“During the COVID-19 pandemic, there has been an increase in C. auris cases, particularly in some areas of the United States that had not previously had many cases,” said Dr. Meghan Marie Lyman from the CDC’s Mycotic Diseases Branch.

C. auris and COVID-19 often affect a similar patient population, particularly those in long-term care facilities,” she told Medical News Today.

Hot spots of C. auris infections in the U.S. include California, New York state, and Illinois.

The pandemic provided ideal conditions for fungal infections such as C. auris and mucormycosis in India to spread in hospitals.

The steroid dexamethasone that doctors use to treat severely ill patients suppresses immunity to other infections. In addition, broad-spectrum antibiotics kill bacteria that live in the gut and on the skin that usually compete with fungi for living space.

Catheters can allow C. auris to invade the bloodstream and urinary tract. There is also evidence that the virus damages the mucous lining of the intestine, which provides the fungus another entry point to the bloodstream.

Dr. Lyman said outbreaks may be related to changes in infection control practices during the pandemic, including limited availability of gloves and gowns, or reuse of these items, and changes in cleaning and disinfection practices.

A CDC report of an outbreak in Florida in July 2020 implicated the use of multiple layers of personal protective equipment in the spread of the fungus.

“There’s also been new C. auris cases without links to known cases or healthcare abroad identified recently in multiple states, suggesting an increase in undetected transmission,” said Dr. Lyman.

She added that routine screening for C. auris colonization in patients at healthcare facilities has been limited because resources have been diverted to respond to COVID-19.

Since 2009 when C. auris was first identified in Japan, infections have been reported in more than 30 countries.

However, because specialized laboratory equipment is needed to distinguish the species from other Candida infections, C. auris is likely to be more widespread.

Most infections remain susceptible to echinocandins, but some strains of the fungus have developed resistance to all three main classes of antifungal drug.

“Reports of echinocandin- or pan-resistance C. auris cases in the United States are increasing, which is concerning because antifungal treatment options for these highly resistant infections are extremely limited,” said Dr. Lyman.

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