Increase in Candida auris infections among EU/EEA nations between 2020 and 2021

In a recent study published in Eurosurveillance, researchers evaluated the trends in Candida auris infections among European Union/European Economic Area (EU/EUA) nations between 2020 and 2021.

ECDC (European centre for disease prevention and control) previously surveyed EU/ERA nations twice to obtain data on the epidemiology, laboratory capacities, and level of preparedness against Candida auris among EU/EEA nations between 2013 and 2017 and between January 2018 and May 2019. However, the data needed to be updated post-commencement of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic.

The massive fungal outbreak in health centers in two Italian regions resulted in another Candida auris survey conducted on 4 April 2022 to update data on Candida auris epidemiology and mitigation efforts among EU/EEA nations.

About the study

In the present study, researchers assessed changing patterns in Candida auris infections among EU/EUA nations and presented the combined results of the three ECDC Candida auris surveys.

The national-level healthcare facility-related infection focal points and their substitutes were invited to complete the third survey. The survey comprised 14 questions about the total case counts of Candida auris infections or carriage and the fungal outbreaks documented each year between June 2019 and December 2021. The survey included an option to add Candida auris infection cases identified retrospectively between January 2013 and May 2019, national-level laboratory capacity detection, and preparedness against Candida auris.

Questions similar to those of previous C. auris surveys were added to the third survey, with an extra question on C. auris epidemiology stages. Data on Candida auris cases were obtained between 2013 and 2021 in a standardized format; however, cases detected beyond the period but of potential clinical relevance were also documented, including those with an earlier identification date than previously known or new nations affected. Epidemiological staging of Candida auris dissemination based on assessments similar to those reported previously for multidrug-resistant bacteria such as Enterobacterales (producing carbapenemase) and Acinetobacter baumannii resistant to carbapenem.

Results

All the 30 EU/EEA nations invited responded to the third survey. Agglomerating data of the three Candida auris surveys showed that 1,812 cases of Candida auris infections were documented by 15 nations between 2013 and 2021. Within a year, C. auris infection case counts almost doubled (335 Candida auris infections documented by eight nations in 2020, increasing to 655 cases documented by 13 nations), and the counts were considerably greater than those reported previously.

Most cases (1,146 cases; 63%) spread by carriage, whereas 15% (n=277) and 10% (n=186) of infections occurred through blood or by other routes, respectively. Data on carriage or infection was unavailable for 11% (n=203) of cases. No Candida auris cases were detected among 11 EU/EEA nations before 2021, and national-level data on Candida auris infections was unavailable for four nations. The case counts and nations documenting Candida auris infections increased, with 13 nations documenting C. auris infections in 2021. 

Data on categorizing Candida auris infections as carriage locally acquired or imported was unavailable for 97% (n=1,758) of cases. Available data indicated that one percent (n=10) and two percent (n=44) of cases were documented as acquired locally and imported, respectively; however, the source of imported C. auris infection cases could not be determined due to scarcity of data.

Available data mentioned that documented cases originated from African nations (Ethiopia, Egypt, South Africa and Kenya), Middle East nations [United Arab Emirates (UAE), Kuwait, and Iraq] and Asian nations (Pakistan and India).

Notably, one case of infection transfer across borders was documented as a Candida auris infection originating in Spain. Between 2019 and 2021, five nations (France, Denmark, Greece, Italy and Germany) documented 14 outbreaks of Candida auris described as ≥2 cases with epidemiological links, with a total of 327 individuals affected. The count of affected individuals per Candida auris outbreak ranged between two and 214 individuals. The organism was transmitted between facilities during eight outbreaks of C. auris, and three C. auris outbreaks were ongoing during the third survey.  

Six nations documented only imported Candida auris cases (first stage), four nations had sporadic cases acquired locally or their origin was unknown (second stage), three nations had sporadic outbreaks with or without limited spread between facilities (third stage), two nations had outbreaks of Candida auris with plausible or confirmed spread between facilities (fourth stage), and one nation had C. auris endemic to certain regions (fifth stage). During the third survey period, C. auris carriage or infection was notifiable among six nations, 12 nations established surveillance, and 23 nations had an adequate laboratory capacity for Candida auris detection and testing. 

Twelve laboratories used MALDI-TOF MS (matrix-assisted laser desorption/ionization time-of-flight mass spectrometry) for Candida auris identification, 10 detected the organism by a combination of MALDI-TOF MS and other techniques such as ITS (internal transcribed spacer) sequencing whereas one laboratory used only ITS sequencing for C. auris detection.

Guidance for infection control and prevention and laboratory-based testing was documented as available among 15 and 17 nations, respectively, representing a minor improvement in response and preparedness from 2019.

Overall, the study findings showed that prompt local-level control of Candida auris before the organism establishment in health facilities could benefit at a national level by decreasing healthcare-related Candida auris infections in the future.

Therefore, EU/EEA nations’ laboratories need sufficient capacity, and continued national-level surveillance efforts are required for early Candida auris identification and rapid implementation of control and prevention measures.

Written by

Pooja Toshniwal Paharia

Dr. based clinical-radiological diagnosis and management of oral lesions and conditions and associated maxillofacial disorders.