RETRACTED: A Life-threatening Case Report of Candidemia in an Infant Hidden behind Multiple Co-morbidities Detected by MALDI-TOF

Background and purpose: Candida auris is an emerging species of the Candida genus causing outbreaks of nosocomial infections worldwide. It is a multidrug-resistant fungal pathogen causing disruption in healthcare settings as it quickly colonizes the surfaces in hospitals and ICUs and causes repeated infections. This report describes a case of C. auris fungemia from a tertiary care hospital in Central Delhi, India.

Case report: Our patient is a 5-month-old male infant from the town of Allahabad, Northern India. Septic arthritis is treated by arthrotomy. Urinary Tract Infection (UTI) developed as a secondary complication due to suspected pyonephrosis or vesicoureteral reflux. The patient was treated with Caspofungin. In this report, Candida auris was identified using matrix-assisted laser desorption/ionization-time of flight mass spectrometry (MALDI-TOF MS) and VITEK 2 (bioMérieux), from bloodstream infection in a patient with multiple underlying risk factors and COVID-19 positive. Candidemia was diagnosed with sepsis following prolonged hospitalization in spite of aggressive medical management.

Conclusion: In conclusion, C. auris is a new multidrug-resistant pathogenic Candida species, increasingly associated with nosocomial outbreaks and sporadic infections. This species is a concern for clinicians and microbiologists as they pose a major challenge during the management of the infection. The nosocomial spread can be controlled through proper disinfection, increasing awareness, early detection and appropriate anti-fungal susceptibility-guided treatment.

Introduction

Candida auris is a type of opportunistic, nosocomial yeast pathogen that was first reported in a patient’s ear discharge in 2009 in Japan [1]. There has been an increase in incidence during the COVID-19 pandemic [2]. As of February 2021, according to data published by the CDC, C. auris had been identified in 47 countries across six continents [3] It has been reported in hospitals in India, South Korea, the Middle East, South Africa, and South America. The recent inaugural World Health Organisation 10 Fungal Priority Pathogen list considers C.auris a critical priority pathogen, highlighting its threat to global public health [4]. This species is an emerging Multidrug-Resistant (MDR) nosocomial pathogen which is difficult to manage in critical care units as it can cause outbreaks [5]. The most common infected site is the bloodstream, followed by isolation from the urinary or respiratory tract, wound, osteomyelitis, malignant otitis media, ventriculitis, intra-abdominal infections, pleural effusions, pericarditis, and vulvovaginitis [6]. Due to its multidrug-resistant nature, the species exhibits resistance to multiple antifungal agents, including azoles, echinocandins, and amphotericin B [6]. Risk factors implicated for C.auris infections include central venous catheter use, a recent history of surgery, diabetes, and prolonged use of broad-spectrum antibiotic or antifungal use [7]. Candida species are identified in approximately 25% of ICU patients with central line associated blood stream infections and the prevalence of C. auris was estimated to be ranging from 5 to 30% among Candidemia patients [8,9]. Recently, North Indian public-sector hospitals have reported the prevalence of Candida auris in immunocompromised patients with prolonged ICU stays in ICUs with prolonged antibiotic therapy given [10].

Specialized laboratory methods are required to identify C. auris. This can cause challenges with identification, outbreak detection, and control. As with other nosocomial infections, but unlike other Candida species, C. auris appears to be highly transmissible between patients and in healthcare settings from contaminated environments or equipment and is also associated with prolonged persistence in the environment [11,12].

Case presentation

Our patient was a 5-month-old male infant born in Allahabad, Northern India (Figure 1). The patient presented to the Nephrology Out-patient department of Kalawati Saran Children’s Hospital (KSCH), Delhi on 22/1/2024. The parents provided us with history and clinical details from the attending pediatrician. He presented with complaints of excruciating pain during micturition for the past two months, along with a high-grade fever and swelling of the left knee joint, both persisting for 10 days. The mother observed that the child was crying during micturition, associated with decreased urine output, difficulty in passing urine and intermittent urinary stream. There were 2-3 episodes of fever spikes up to 103 °F as per the guardian. There was no history of febrile seizures, rashes or any allergic reactions reported. On examination, left knee swelling was observed. 4-5 episodes of loose stools, semi-solid, intermittently were reported. The patient was hospitalized for one month in Allahabad Private Hospital and treated and subsequently referred to KSCH, Delhi.

Figure 1: 5-month-old male infant.

While eliciting the past medical history, it was found out that he was admitted to a private hospital for one week with left knee swelling which was diagnosed as septic arthritis for which he underwent arthrotomy. Urinary Tract Infection (UTI) developed as a secondary complication due to suspected pyonephrosis or vesicoureteral reflux. Therefore the patient was referred to KSCH, a tertiary care hospital for better management. At birth, the infant was born late preterm, was small for gestational age with a birth weight of 2 kg, and delivered via Lower Segment Cesarean Section (LSCS) due to breech presentation. NICU care was required for 6 days in view of prematurity and received supportive care including oxygen via nasal prongs, and or gastric feeds. The infant was immunized till age. His family history was unremarkable.

On presentation, the patient was stable, conscious and alert and significant pallor was seen. There were no signs of respiratory distress or sunken eyes. His temperature was 98°F, heart rate was 126 beats per minute, respiratory rate was 42 breaths per minute, CFT<35, and had a surgical dressing on his left knee with 99% oxygen saturation on room air. Anterior fontanelle was open and at level .The patient’s weight on admission was 4.5 kg. On systemic examination, the central nervous system showed normal tone and reflexes of all limbs with a paucity of left limb movement present. The respiratory examination showed no signs of respiratory distress. On auscultation of the lungs, bilateral vesicular breath sounds were heard. Air entry and chest expansion were normal. The abdominal exam showed a soft, lax abdomen with normal bowel sounds. There was no distention or organomegaly noted. His motor and social skills were normally present and appropriate for his age suggesting normal growth to date.

The patient had been earlier admitted to a private hospital in Allahabad from 28th December 2023 to 10th January 2024 and had undergone an arthrotomy due to septic arthritis. A urinary tract infection with nephropathy developed during the hospital stay. All basic investigations were done including CBC, pus culture and sensitivity(c/s), urine culture and sensitivity(c/s), and routine microscopy of urine. The blood workup of the child showed low Hb -7.8 gm% for which one unit PRBC blood transfusion was given. The reports of pus aspirated from the left knee joint during arthrotomy showed micrococci grown while urine c/s grew Citrobacter species. The Ultrasound KUB was suggestive of pyonephrosis in the left kidney. He had received a course of antibiotics consisting of metronidazole, levofloxacin, vancomycin, and piperacillin-Tazobactam for 5 days. As no improvement was observed in the patient’s condition, he was referred to KSCH, Delhi, and Pediatric Nephrology OPD and admitted to the pediatric ward.

On the first day of his admission to KSCH, all routine workup was done, and orthopedics and pediatric surgery expert opinion was taken. Temperature charting was performed, urine output monitored, and urinary catheterization was performed. Investigations revealed hemoglobin of 9.3 g/dl, total leukocyte count of 64,200/µl (polymorphs 86%, lymphocytes 7%, with normal platelet, and red blood cell counts and a elevated C-reactive protein levels. Renal function tests were deranged with blood urea (76 mg/dL) and serum creatinine (1.46 mg/dL).

On the second day, a fever spike was observed two times and COVID RT-PCR test done was positive. The patient was immediately shifted to COVID ward for better isolation. The patient had an abnormal urea/creatine ratio suggesting acute kidney injury therefore intravenous ceftriaxone 225 mg and Vancomycin 45 mg were given on adjusted renal doses. Lumbar puncture showed increased protein (47.4mg %) and glucose decreased to 55 mg% (n = 120 mg%) in CSF and no growth on culture. From the Chest X-ray, she was diagnosed with a COVID-19 infection, complicated by pneumonia (Figure 2). The patient was started on Linezolid 45 mg IV twice daily and IV Meropenem were hence, started. After 10 days of hospital stay, the patient developed increased tenderness and swelling at the operation site. USG whole abdomen and X-ray hip (Figure 3) were done, and fluid collection in the left knee joint extending to the calf region was reported. Knee traction was applied following an orthopedic consultation. Aspiration was performed on 2/2/2024, but no fluid was obtained. To rule out immunodeficiency, Serum immunoglobulin profile revealed low IgA suggestive of transient hypogammaglobinemia and IgA deficiency. However, after doing a full genetic profile any type of immunodeficiencies were ruled out. COVID-19 RT-PCR repeat test was positive on 2/2/2024. He had leukocytosis, elevated CRP, and anemia confirming sepsis and anemia even though afebrile.

Figure 2: Chest X-ray showing signs of pneumonia due to COVID-19.

Figure 3: X ray of Left hip showing swollen limb.

For the persisting pyonephrosis and sepsis, the patient was started on IV Clindamycin and Piperacillin-Tazobactam on 25/2/2024. Other supportive treatments given were oral paracetamol, nasal drops, nebulization with adrenaline (i/v/o hyperkalemia), oral calcium, vitamin D, and multivitamins. The repeated COVID-19 RT PCR test on 4/2/2024 was negative. The patient showed symptomatic improvement with normalization of blood parameters. The USG KUB (3/3/2024) reported (Figure 4) left pyonephrosis with persistent size without evidence of further progression. The urea/creatinine ratio was normalized further supporting the improvement of AKI.

Figure 4: Whole abdomen USG showing pyonephrosis.

Material and methods

Blood, urine, CSF, and aspirated fluid samples were processed in the Microbiology laboratory of Lady Hardinge Medical College and Associated Hospitals. CSF for culture and sensitivity sent on 24/1/2024 had no pathogenic organisms. Identification of Candida auris has been challenging using conventional laboratory diagnostic techniques [2]. Blood sample for culture and sensitivity was performed by the automated BACT/ALERT 3D Microbial Identification system (Biomerieux, France) which signaled positive growth after 3 days of incubation. It was cultured on 5% Sheep Blood Agar as shown in Figure 5. Direct Gram-staining revealed ovoid to elongated, single, paired and/or grouped, budding yeast-like cells (Figure 6). Additionally, a negative germ tube test ruled out Candida albicans and Candida dubliniensis. C.auris does not form germ tubes in serum or chlamydospores on corn meal agar (CMA) and rarely forms pseudohyphe, which appears to be dependent on specific conditions such as the presence of NaCl (Figure 7). On subculture, tiny white opaque, non-hemolytic colonies were obtained on 5% sheep blood agar. The subculture done on Sabouraud dextrose agar containing chloramphenicol (0.5 g/100 mL) and gentamicin (0.3 g/100 mL) (HiMedia, Mumbai, India) showed cream-colored colonies. SDA plate incubated at 42 °C also grew yeast-like pasty colonies (Figure 8). The tests were done to confirm Candida auris growth at 42 °C, sugar fermentation, and no growth at 37°C in the presence of 0.1% cycloheximide. The yeast grows well at 42 °C, but not at 45 °C; and fails to grow in the presence of 0.01% or 0.1% cycloheximide [6,8].

Figure 5: Blood Agar showing growth of non-hemolytic, pale-coloured opaque colonies of Candida auris.

Figure 6: Gram staining demonstrates oval budding yeast cells.

Figure 7: Slide culture on Corn meal agar showing Yeast alone and some with blastoconidia, the size and spherical shape are constant.

Figure 8: SDA showing white creamy pasty colonies.

Results

CHROMagar Candida (HiCrome™ Candida Differential Agar from HiMedia) showed cream colonies with a purple tinge after 48 h of incubation (Figure 9). Hence, species identification was based on pigmentation differences, visually interpreted [13]. The fermented sugars were glucose, sucrose and trehalose, and the non-fermented sugars were galactose, maltose and lactose leading to the conclusion of same diagnosis (Figure 10). “The repeated blood culture sensitivity samples sent were found to be sterile. Two urine samples were sent for culture and sensitivity on 4/3/2024 and 8/3/2024, both had grown white yeast-like colonies, and phenotypic and biochemical identification was performed. Species identification was subsequently performed by the VITEK-2 automated identification system (BioMerieux, France), confirmed as Candida auris. MALDI-TOF, bioMérieux, Inc. (Durham, NC, USA) VITEK MS was used to confirm the diagnosis of Candidemia caused by Candida auris from all samples that isolated the same pathogen. MALDI-TOF MS identifies microorganisms by comparing the unique protein profile created by the system upon receiving the input to reference databases [14-16].

Figure 9: CHROMagarTM Candida Medium showing pale pink colonies of Candida auris.

Figure 10: Sugar fermentation tests (2% Glucose, lactose, galactose, trehalose, maltose, sucrose).

Regarding the nonspecific phenotypic features of C. auris, differentiating this pathogen from other Candida species remains challenging [17]. CHROMagar Candida medium is incubated at 37 °C, C.auris forms creamy white colonies, while yeasts of the C. hemulonii complex appear as light pink colonies [18]. Furthermore, at 42 °C, members of the C. hemulonii complex do not grow on this medium, whereas C.auris exhibits confluent growth. However, as these findings are not based on a global representation of C.auris isolates, variations between different clades of C. auris may limit the application of this method. A major drawback of these systems is the similarity of assimilation patterns between C.auris and other Candida or even non-Candida species, resulting in misidentification [19-21].

Antifungal susceptibility testing (AFST) was determined using the Broth Microdilution method (BMD) and Vitek 2 with the YST ID card (bioMérieux) [20]. Vitek-2 Compact system using a YST-ID and AST-YS08 card, which tests the MIC of the six antifungals (Amphotericin B, 5-Fluocytosine, Voriconazole, Fluconazole, Caspofungin, and Micafungin. All drugs were resistant to the pathogen identified as Candida auris by VITEK.

According to the Clinical and Laboratory Standards Institute broth microdilution method (CLSI-BMD), following the M27-A3 guidelines; the antifungals tested were Amphotericin B, Fluconazole, Voriconazole, Caspofungin, Micafungin, and Anidulafungin. Antifungal susceptibility testing of C.auris isolates was performed by broth microdilution using the CLSI M27-A3 guidelines [22]. Since, no antifungal susceptibility breakpoints for C.auris are currently standardized for the Clinical and Laboratory Standards Institute (CLSI) and European Committee on Antimicrobial Susceptibility Testing (EUCAST). Therefore, the Centers for Disease Control and Prevention (CDC) defined a C.auris-specific antifungal susceptibility interpretation based on a close phylogenetic relationship to other Candida spp [23]. The correlation between the microbiologic breakpoints and clinical outcomes is not known. The current breakpoints are summarized in Table 1 [24,25].

Discussion

Candida auris is an emerging multi-drug resistant yeast pathogen that causes fatal invasive infections. Due to lacking lab facilities, research studies and difficulty in timely identification of the organism, leads to inadequate management of life-threatening infections. C. auris was found mainly in immunocompromised ICU patients as skin or urinary tract colonization as seen in Rudramurthy, et al. [5] studies and Chowdhary, et al. [18,19]. As per other literature, ICU-acquired candidemia in India found an overall incidence of 6.51 cases per 1,000 ICU admissions [9]. “In this study, we present a case of Candida auris fungemia in a patient with multiple underlying risk factors, including pyonephrosis, with secondary complications such as urinary tract infection, knee joint swelling, and an immunodeficiency disorder. The patient suffered from acute kidney injury leading to a prolonged hospital stay and long-term central venous catheters and sepsis. Most recent cases report similar multiple comorbidities precipitating C. auris infection in patients with a prolonged hospital stay [5,10]. According to Rajni E, et al. [26], there was a twofold increase in candidemia cases among individuals with COVID-19 compared to those without COVID-19, with Candida auris as the predominant species, accounting for 42% of these cases which was similar to our case study.

C. auris is commonly misidentified as C. hemulonii, Candida famata, Candida sake, Rhodotorula glutinis, and Saccharomyces cerevisie by culture and automated identification systems such as Vitek- 2. Thus, to avoid reporting contaminants and misinterpretation samples of our case were confirmed by MALDI-TOF similar to findings by Kathuria, et al. [20].

C. auris is a human threat due to its intrinsic resistance to one or more classes of antifungal agents due to biofilm formation, drug resistance genes and multidrug efflux [18,19,24].

We routinely screened for all clinically significant fungal pathogens from the same cubicle/ward. No other patient besides our case in the mentioned ICU as the baby was located in the corner of the ward. Bloodstream infection in this particular patient appeared to be healthcare-associated. It could have been facilitated by such risk factors as a central venous catheter, broad-spectrum antibiotics, and prolonged hospital stay [21,25].

In our case study, BMD results were similar to Koleri, et al. Which remained broadly susceptible to echinocandins, supporting their empirical use. Our isolate exhibited higher MIC for Fluconazole and Amphotericin B which is in concordance with studies of Chowdhary A, et al. [27] and Sharma, et al. [28]. In our study, Voriconazole and other second-generation azoles were also resistant including Fluconazole showing high MIC which corresponds with results of Chowdhary, et al. [19], Kathuria, et al. [20], Morales Lopez, et al. [29]. Invasive C. auris infection may range from candidemia (mainly associated with central venous catheter use) to pericarditis, respiratory tract, and urinary tract infections, especially occurs in critically ill patients, as we have found in this case similar to Chowdhary A, et al. [2]. Health‑care workers can also be possible agents of transmission; hence, isolation of the patient as well as contact precautions is necessary. The decontamination of instruments and strict adherence to hand hygiene may play an important role in preventing transmission of this hardy fungus. According to CDC guidelines, we observed drugs like Micafungin, Anidulafungin, Posaconazole and Caspofungin were sensitive. Our case was successfully managed with Caspofungin as available drug in our hospital, also correctly identified by the MALDI-TOF MS. This sensitivity pattern was similar to study of Meena, et al. [30]. In conclusion, C. auris as a potentially multidrug-resistant agent associated with nosocomial outbreaks and sporadic infections can be potentially prevented when identified early by implementing contact precautions.

Conclusion

This yeast-like pathogen has become a recent global concern causing nosocomial outbreaks due to limited treatment options available. Recently, several reports made were COVID-19-associated cases but few were missed due to resistance to multiple antifungal drugs which remains a challenge. The challenges in laboratory identification and management highlight the need to strengthen clinician and microbiologist awareness. For effective management and treatment of a Candida auris infection, a high level of suspicion in patients, and robust laboratory markup are required. Implementation of detailed laboratory diagnosis and start therapy based on anti-fungal susceptibility patterns for chronic ICU patients with persistent candidemia should improve prognosis. Since it is an emerging superbug with resistance to azoles, Amphotericin B, 5-flucytosine and and recently to echinocandins as well [2-6]. So in order to control such MDR strains, new data or more studies are required to prove the efficacy of combination therapy like voriconazole and anidulafungin. Amphotericin B is a potent and is therefore preferred by clinicians in invasive candidemia that leads to unfavorable outcomes as it’s resistant in most cases [31]. Echinocandins are the treatment of choice for empiric therapy in most cases; laboratories that test only caspofungin should carry out confirmatory testing using either micafungin or anidulafungin for intermediate or resistant isolates. The drug has limited penetration in the central nervous system, ophthalmic, and urinary infections. Further research is needed to develop novel therapeutic agents or management protocols to prevent recurrences and hospital outbreaks [30]. The data presented will contribute toward establishing the best disinfection and safety protocols to prevent the colonization of this opportunistic pathogen in ICU units and hospital wards. Due to its ease of colonization and rapid spread, C. auris has been associated with a variety of invasive fungal infections. Microbiologists and clinicians should focus on infection control practices, early outbreak management and source control/elimination. In developing countries due to limited availability of molecular and automated diagnostic techniques this species can be misdiagnosed as other Candida species resulting in continuation of an ineffective treatment regimen.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the guardians have given her consent for her images and other clinical information to be reported in the journal. The patient guardian understands that the name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Ethical statement

Ethical clearance and publication consent have been obtained.

1. Satoh K, Makimura K, Hasumi Y, Nishiyama Y, Uchida K, Yamaguchi H. Candida auris sp. nov., a novel ascomycetous yeast isolated from the external ear canal of an inpatient in a Japanese hospital. Microbiol Immunol. 2009;53(1):41-4. Available from: https://doi.org/10.1111/j.1348-0421.2008.00083.x
2. Chowdhary A, Tarai B, Singh A, Sharma A. Multidrug-resistant Candida auris infections in critically ill coronavirus disease patients, India, April–July 2020. Emerg Infect Dis. 2020;26(11):2694. Available from: https://doi.org/10.3201/eid2611.203504
3. Keighley C, Harch SAJ, Robertson M, Chaw K, Teng JC, Chen SC. Candida auris: Diagnostic Challenges and Emerging Opportunities for the Clinical Microbiology Laboratory. Curr Fungal Infect Rep. 2021;23:1-11. Available from: https://doi.org/10.1007/s12281-021-00420-y
4. Fisher MC, Denning DW. The WHO fungal priority pathogens list as a game-changer. Nat Rev Microbiol. 2023;21(4):211-2. Available from: https://doi.org/10.1038/s41579-023-00861-x
5. Rudramurthy SM, Chakrabarti A, Paul RA, Sood P, Kaur H, Capoor MR, et al. Candida auris candidemia in Indian ICUs: analysis of risk factors. J Antimicrob Chemother. 2017;72(6):1794-801. Available from: https://doi.org/10.1093/jac/dkx034
6. Ahmad S, Alfouzan W. Candida auris: Epidemiology, diagnosis, pathogenesis, antifungal susceptibility, and infection control measures to combat the spread of infections in healthcare facilities. Microorganisms. 2021;9(4):807. Available from: https://doi.org/10.3390/microorganisms9040807
7. Du H, Bing J, Hu T, Ennis CL, Nobile CJ, Huang G. Candida auris: Epidemiology, biology, antifungal resistance, and virulence. PLoS Pathog. 2020;16(10):e1008921. Available from: https://doi.org/10.1371/journal.ppat.1008921
8. Cortegiani A, Misseri G, Fasciana T, Giammanco A, Giarratano A, Chowdhary A. Epidemiology, clinical characteristics, resistance, and treatment of infections by Candida auris. J Intensive Care. 2018;6:1-3. Available from: https://doi.org/10.1186/s40560-018-0342-4
9. Sathyapalan DT, Antony R, Nampoothiri V, Kumar A, Shashindran N, James J, et al. Evaluating the measures taken to contain a Candida auris outbreak in a tertiary care hospital in South India: an outbreak investigational study. BMC Infect Dis. 2021;21(1):1-0. Available from: https://doi.org/10.1186/s12879-021-06131-6
10. Shastri PS, Shankarnarayan SA, Oberoi J, Rudramurthy SM, Wattal C, Chakrabarti A. Candida auris candidemia in an intensive care unit–prospective observational study to evaluate epidemiology, risk factors, and outcome. J Crit Care. 2020;57:42-8. Available from: https://doi.org/10.1016/j.jcrc.2020.01.004
11. Centers for Disease Control and Prevention (CDC). Global emergence of invasive infections caused by the multidrug-resistant yeast Candida auris. 2019. Available from: https://www.cdc.gov/fungal/Candida-auris/Candida-auris-infection.html
12. Yadav A, Singh A, Wang Y, Haren MH, Singh A, de Groot T, et al. Colonisation and transmission dynamics of Candida auris among chronic respiratory diseases patients hospitalised in a chest hospital, Delhi, India: a comparative analysis of whole genome sequencing and microsatellite typing. J Fungi. 2021;7(2):81. Available from: https://doi.org/10.3390/jof7020081
13. Borman AM, Fraser M, Johnson EM. CHROMagarTM Candida Plus: A novel chromogenic agar that permits the rapid identification of Candida auris. Med Mycol. 2021;59(3):253-8. Available from: https://doi.org/10.1093/mmy/myaa049
14. Lockhart SR, Lyman MM, Sexton DJ. Tools for detecting a “superbug”: updates on Candida auris testing. J Clin Microbiol. 2022;60(5):e00808-21. Available from: https://doi.org/10.1128/jcm.00808-21
15. Das S, Singh S, Tawde Y, Chakrabarti A, Rudramurthy SM, Kaur H, et al. A selective medium for isolation and detection of Candida auris, an emerging pathogen. J Clin Microbiol. 2021;59(2):10-128. Available from: https://doi.org/10.1128/jcm.00326-20
16. Ghosh AK, Paul S, Sood P, Rudramurthy SM, Rajbanshi A, Jillwin TJ, et al. Matrix-assisted laser desorption ionization time-of-flight mass spectrometry for the rapid identification of yeasts causing bloodstream infections. Clin Microbiol Infect. 2015;21(4):372-8. Available from: https://doi.org/10.1016/j.cmi.2014.11.009
17. Mahmoudi S, Afshari SA, Gharehbolagh SA, Mirhendi H, Makimura K. Methods for identification of Candida auris, the yeast of global public health concern: A review. J Mycol Med. 2019;29(2):174-9. Available from: https://doi.org/10.1016/j.mycmed.2019.04.004
18. Chowdhary A, Sharma C, Duggal S, Agarwal K, Prakash A, Singh PK, et al. New clonal strain of Candida auris, Delhi, India. Emerg Infect Dis. 2013;19(10):1670. Available from: https://doi.org/10.3201/eid1910.130393
19. Chowdhary A, Anil Kumar V, Sharma C, Prakash A, Agarwal K, Babu R, et al. Multidrug-resistant endemic clonal strain of Candida auris in India. Eur J Clin Microbiol Infect Dis. 2014;33:919-26. Available from: https://doi.org/10.1007/s10096-013-2027-1
20. Kathuria S, Singh PK, Sharma C, Prakash A, Masih A, Kumar A, et al. Multidrug-resistant Candida auris misidentified as Candida hemulonii: characterization by matrix-assisted laser desorption ionization–time of flight mass spectrometry and DNA sequencing and its antifungal susceptibility profile variability by Vitek 2, CLSI broth microdilution, and Etest method. J Clin Microbiol. 2015;53(6):1823-30. Available from: https://doi.org/10.1128/jcm.00367-15
21. Centers for Disease Control and Prevention. Tracking Candida auris. 2019. Available from: https://www.cdc.gov/fungal/Candida-auris/tracking-c-auris.html
22. Clinical and Laboratory Standards Institute. M27M44SEd3 | Performance standards for antifungal susceptibility testing of yeasts. 3rd ed. [Internet]. [cited 2022 Sep 16]. Available from: https://clsi.org/standards/products/microbiology/documents/m27/
23. Deshkar S, Patil N, Amberkar S, Lad A, Siddiqui F, Sharan S. Identification and antifungal drug susceptibility pattern of Candida auris in India. J Glob Infect Dis. 2022;14(4):131. Available from: https://doi.org/10.4103/jgid.jgid_44_22
24. Centers for Disease Control and Prevention. Antifungal susceptibility testing and interpretation | Candida auris | Fungal diseases [Internet]. 2023 [cited 2023 Jun 17]. Available from: https://www.cdc.gov/fungal/Candida-auris/c-auris-antifungal.html
25. Centers for Disease Control and Prevention (CDC). Candida auris identification. Atlanta, GA: CDC; 2018.
26. Rajni E, Singh A, Tarai B, Jain K, Shankar R, Pawar K, et al. A high frequency of Candida auris bloodstream infections in coronavirus disease 2019 patients admitted to intensive care units, northwestern India: a case-control study. Open Forum Infect Dis. 2021;8(12):ofab452. Available from: https://doi.org/10.1093/ofid/ofab452
27. Chowdhary A, Prakash A, Sharma C, Kordalewska M, Kumar A, Sarma S, et al. A multicentre study of antifungal susceptibility patterns among 350 Candida auris isolates (2009–17) in India: role of the ERG11 and FKS1 genes in azole and echinocandin resistance. J Antimicrob Chemother. 2018;73(4):891-9. Available from: https://doi.org/10.1093/jac/dkx480
28. Sharma C, Kumar N, Meis JF, Pandey R, Chowdhary A. Draft genome sequence of a fluconazole-resistant Candida auris strain from a candidemia patient in India. Genome Announc. 2015;3(4):10-128. Available from: https://doi.org/10.1128/genomea.00722-15
29. Morales-López SE, Parra-Giraldo CM, Ceballos-Garzón A, Martínez HP, Rodríguez GJ, Álvarez-Moreno CA, et al. Invasive infections with multidrug-resistant yeast Candida auris, Colombia. Emerg Infect Dis. 2017;23(1):162. Available from: https://doi.org/10.3201/eid2301.161497
30. Meena S, Rohilla R, Kaistha N, Singh A, Gupta P. Candida auris emergence in the Himalayan foothills: first case report from Uttarakhand, India. Curr Med Mycol. 2020;6(1):47.
31. Koleri J, Petkar HM, Al Soub RS, Abdel H, AlMaslamani RS, Muna A. Candida auris bloodstream infection—a descriptive study from Qatar. BMC Infect Dis. 2023;23(1):1-7. Available from: https://doi.org/10.1186/s12879-023-08477-5