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. 2020 Nov 21;6(4):307.
doi: 10.3390/jof6040307.

Molecular Epidemiology of Candida Auris Outbreak in a Major Secondary-Care Hospital in Kuwait

Affiliations

Molecular Epidemiology of Candida Auris Outbreak in a Major Secondary-Care Hospital in Kuwait

Wadha Alfouzan et al. J Fungi (Basel). .

Abstract

The emerging, often multidrug-resistant Candida auris is increasingly being associated with outbreaks in healthcare facilities. Here we describe the molecular epidemiology of a C. auris outbreak during 18 months, which started in 2018 in the high dependency unit (HDU) of a secondary-care hospital in Kuwait. Demographic and clinical data for candidemia and colonized patients were prospectively recorded. Clinical and environmental isolates were subjected to phenotypic and molecular identification; antifungal susceptibility testing by broth microdilution method; PCR-sequencing of ERG11 and FKS1 for resistance mechanisms to triazoles and echinocandins, respectively; and molecular fingerprinting by short tandem repeat (STR) analyses. Seventy-one (17 candidemic and 54 colonized) patients including 26 with candiduria and seven environmental samples yielded C. auris. All isolates were identified as C. auris by Vitek2, MALDI-TOF MS, PCR amplification and/or PCR-sequencing of rDNA. Twelve candidemia and 26 colonized patients were admitted or exposed to HDU. Following outbreak recognition, an intensive screening program was instituted for new patients. Despite treatment of all candidemia and 36 colonized patients, 9 of 17 candidemia and 27 of 54 colonized patients died with an overall crude mortality rate of ~50%. Nearly all isolates were resistant to fluconazole and contained the Y132F mutation in ERG11 except one patient's isolates, which were also distinct by STR typing. Only urine isolates from two patients developed echinocandin resistance with concomitant FKS1 mutations. The transmission of C. auris in this outbreak was linked to infected/colonized patients and the hospital environment. However, despite continuous surveillance and enforcement of infection control measures, sporadic new cases continued to occur, challenging the containment efforts.

Keywords: C. auris; Farwaniya Hospital; Kuwait; candidemia; colonization; outbreak.

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Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
Timeline for the detection of patients with candidemia and colonization due to C. auris in Farwaniya Hospital during the course of outbreak from January 2018 to June 2019. Number of thick and thin lines indicate number of candidemia and colonized patients, respectively, detected in each month and the spacing between the lines within a month or between months is not relevant. Some candidemia patients also yielded C. auris from other anatomic sites, but they are not included among colonized cases. Multiple C. auris isolates were obtained over time from many anatomic sites from most of the colonized patients. None of the colonized patient yielded C. auris from bloodstream.
Figure 2
Figure 2
Short tandem repeat (STR) typing patterns of C. auris outbreak isolates from Farwaniya Hospital in Kuwait. Only one isolate from each patient is shown. Multiple isolates from each patient from same or different sites exhibited identical patterns. The first C. auris isolate (Kw2027/17) obtained from this hospital in 2017 as well as isolates from other hospitals in Kuwait are also included for comparison purpose. Representative South Asian clade 1 isolates from India and Oman and clade 2 to 5 isolates from Korea, South Africa, Venezuela and Iran, respectively, are also shown. The source of outbreak isolates and patient no. are also shown. (B1) = bloodstream isolate from candidemia patient 1; (C1) = colonizing strain from colonized patient 1; (E1) = environmental isolate 1. The scale in the upper left corner represents similarity (%).

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