Candida Auris – the new killer superbug media star.
Should YOU be worried of catching a C. Auris infection?
How can you tell if you have Candida Auris?
What are the symptoms of Candida Auris?
Where can I find some Candida Auris skin pictures?
These are questions that have been troubling public opinion since April
2019, when Candida Auris made the headlines in the New York Times. Pulitzer winner Matt Richtel found out that hospitals had been keeping quiet on the spread of the killer fungus.
When this happened, Candida Auris seemed to have popped up from out of nowhere.
And yet it had been around for at least a decade, causing outbreaks in hospitals all over the world, infecting hundreds of people and killing a good many of them. 30 to 60 percent of those infected died in 30 to 90 days.
Since then, media attention on C. Auris has kept on rising, in waves. Another wave of attention peaked at the end of July 2019, when a new study put forward the hypothesis that the deadly fungus might be a result of climate change.
That’s fascinating, but I hear you asking again: “Should I be worried of catching a Candida Auris infection?”
If you ever need to go to hospital – YES, do worry about Candida Auris.
Even more so if you are already being treated in a hospital, long-term care facility or nursing home. Or if you have a loved one there.
So far the victims of C. Auris have all been patients of such facilities and were being treated for rather serious health problems. Until the summer of 2019, there were no official reports of Community Acquired cases of Candida Auris.
This could change. There are research groups investigating this possibility.
You could also get colonized by C. Auris when visiting someone in a health care facility. Being colonized means that you will not get sick (yet), but the superbug will establish itself on your skin.
And come home with you.
How do I know if I have Candida Auris?
This question obviously has been worrying an increasing number of people.
Alas, the answers you seek are not so easy to find. But we are here to help.
Let’s go on a Candida Auris tour for beginners.
Our starting point is the trivial question: what are the symptoms of Candida Auris?
But we have gathered much more useful information for you. Since it is a long read, here is what you will find in this article:
- Chills, Fever and Fatigue are symptoms of Candida Auris.
- Candida Auris does not respond to antibiotics.
- Candida Auris is resistant to antifungal drugs too.
- Quick diagnosis of Candida Auris is essential, but very difficult.
- Candida Auris sticks everywhere and resists disinfectants.
- Be careful where you travel! Candida Auris is conquering the planet at a very fast pace.
- Candida Auris spread from 14 to 30 countries in two years, 2017-2019.
- Candida Auris may be a result of climate change.
- Risk factors for Candida Auris
- How can we cure Candida Auris?
- Chills, Fever and Fatigue are symptoms of Candida Auris.
All the media hype about the most scary superbug so far and all it does to
you is the same as a banal flu?
Hold on tiger …. this is exactly the reason N. 1 that made it so dangerous!
Keep reading and you will find out. And keep in mind: it does NOT stop at
Candida Auris can kill you if it gets into your bloodstream and internal
organs. There, if not stopped, it becomes deadly.
But let’s take this tour step by step. It is a complicated story and many
pieces are still missing.
Candida Auris starts by colonizing the skin. But you will not see it.
Her is a picture of what Candida Auris looks like in the lab:
To the naked eye, C. Auris is not visible. The skin is the party of the human body where it starts its march of conquest.
“Colonization” is, not by chance, the name of this first phase. But it is invisible. And asymptomatic.
No symptoms. Candida Auris can already be abundantly on you but nothing
will happen (yet).
You will not find Candida Auris skin pictures around, no matter how much you
No telltale rash, red spots, white stains in the mouth or throat, itchings…. Unlike other skin or mucous infections caused by similar pathogens, for example Candida Albicans.
Candida Auris is NOT the same as Candida Albicans.
It is a different fungus (yeast).
There could be a ear infection (rare).
The only possible exception: discharge (pus) from a ear infection. Actually, this is how the superbug got its name, because the first reported case was a woman in Japan who was being treated for that. “Auris” means “ear” in Latin.
There were some more cases of ear infection in South Korea and also one initial
case in both the United States and Canada. But these are more the exception than the rule.
In most cases, Candida Auris will lurk invisible on the skin and give some
sign of presence – those chills, fever and fatigue – only when things have gone serious, i.e. when it has already invaded the patient’s organism.
There could be one more sign then, in some cases: pus in a wound. A surgical wound or the entrance point of a catheter or intravenous line.
We will come back to this when we get to the list of risk factors for C. Auris.
2. Candida Auris does not respond to antibiotics.
The reason for that is simple. C. Auris is not a bacterium, it is a fungus. More precisely, a yeast. Antibiotics do not work on it.
And this is a telltale sign that can reveal a Candida Auris infection. A patient in a hospital or nursing home who does not get better when given antibiotics. Those chills and fever will not go away.
Antibiotics function against bacteria. They do not kill viruses. They do not kill fungi either.
Antibiotics make it worse.
Antibiotics not only cannot cure a fungal infection. They usually contribute to causing it!
How is it possible?
Our immune system is a beautiful and complicated orchestra. Bacteria are part of
Microbiome is the scientific name of a community of trillions of microorganisms living in our body. Mostly bacteria but also viruses and fungi.
Most of them are “good bugs”, with some useful role in our vital functions. Digestion is number one. The bulk of the microbiome lives in our upper and lower intestines. Then there are minor quantities scattered everywhere within us and upon us.
Some guys in the microbiome are, potentially, “bad bugs”. They are kept under control by our good health and by the good bugs.
There are several ways in which “good” bacteria and other microorganisms protect us. They may compete with the “bad bugs” for vital space and food. Or even attack them.
A nuclear bomb to kill a mosquito.
When your doctor gives you a broad spectrum antibiotic it is like using a nuclear bomb to kill a mosquito. Razed ground strategy. If you have some infection and it is uncertain which microorganism is causing it, very likely you will get a broad spectrum antibiotic.
Broad spectrum means that it can kill several species of bacteria. Guess what? Also the good ones.
A broad spectrum antibiotic therapy can throw your microbiome’s balance out of whack.
Some killer superbugs will throw up a party when this happens.
Fungi in particular. When beneficial bacteria, that kept them in check, are
out of the way, fungi flourish.
Overgrowth is the first step towards a fungal infection.
3. Candida Auris is resistant to antifungal drugs too.
Well, not completely. But quite too much. And it is getting worse very quickly.
Resistance to medications is one of the things about Candida Auris that
frightens the medical community the most.
There are not so many antifungal products around. Much less than antibiotics.
Once they become all useless (and we are on the way!), we will really, really
be in trouble.
Only three categories of antifungals are available.
Three categories of antifungals are all that is available at the moment:
- amphotericin B;
They were already in use more than a decade ago, to fight other Candida species, as you can see from this infographic from a scientific article ( “Management of candidiasis in the intensive care unit” ) from 2008:
Today, fluconazole, the most commonly used antifungal medication, is
Candida Auris has shown a resistance to fluconazole close to 100%.
Amphotericin B was more in use some years ago, to treat fungal infections. But is
is heavy on the human organism.
This led to the age of success and ample use of fluconazole. The result: fungi
outsmarted it, by mutating.
Now amphotericin B is back, more effective against C. Auris than azoles, but still failing in about 25% of cases. And resistance to it is growing.
Resistance to antifungals is developing fast.
Echinocandins are a family of more recent products and they usually work.
Candida Auris is becoming resistant to them too!
“No initial isolates were resistant to echinocandins, although subsequent isolates obtained from 3 persons who had received an echinocandin acquired resistance to it”. This is one of the findings from a team of the New York State Department of Health and the Candida Auris Investigation Workgroup.
They investigated the spreading of C. Auris in New York in the years 2013-2017. (Candida auris in Healthcare Facilities, New York, USA, 2013–2017)
Resistance to medications is not the same everywhere.
There are different strains of Candida Auris around. And different situations
of resistance to individual classes of antibiotics.
See for example the situation in Intensive Care Units in Asia, where C. Auris is causing hospital outbreaks in several countries:
The numbers differ. What does this mean in practice?
Know thy enemy.
If you have a Candida Auris infection, you want to hit it with an antifungal that can work. Some still do, others are already useless.
Some will work this time, but next time C. Auris will have already mutated. So they won’t kill it any longer.
What can you do, if you have Candida Auris and want to get rid of it?
4. Quick diagnosis of Candida Auris is essential, but very difficult.
Playing hide and seek in the dark with the killer fungus is pretty useless.
What you need is to nail it on a petri plate, have it tested in a very well equipped laboratory, get to know exactly which antifungal is effective against THAT particular strain of C. Auris, and treat it with that drug. While it still works.
It is not.
How can Candida Auris be diagnosed?
The standard commercial diagnostic equipment and tests that most hospitals have available are not enough.
Candida Auris can easily be confused with some other Candida species. It takes something which goes by the acronym MALDI – TOF (Identification by Matrix-Assisted Laser Desorption/Ionization Time-of-Flight).
In short – a sophisticated spectrometry technique, that requires specific equipment. Not something your family doctor is likely to have, but again, not even most hospitals and nursing homes.
They have to rely on the availability of a national health system which can connect them with adequate laboratories.
Some countries are organized, some are not.
The CDC coordinates the monitoring and prevention effort against Candida Auris in the United States. They can support hospitals and other health care facilities in getting help from suitable laboratories.
If you or someone close to you suspect you might have a C. Auris infection, check that the health professionals in charge of your case already have this information and can take action. They should, but better make sure.
What if you are in Europe?
If you are in the United Kingdom (*** check PHE!) , here is where to look for official information: Guidance for the laboratory investigation, management and infection prevention and control for cases of Candida auris. 2017.
For Europe you have the ECDC, the European Centre for Disease Prevention and
Control. In April 2018 the ECDC reported that:
“Twenty-one out of the 29 EU/EEA countries stated that laboratory capability to detect and identify C. Auris was available, either by formally designated mycology reference laboratories in 12 countries or by laboratories with a reference function in nine countries. Public health measures for preparedness or response to C. Auris were taken in 20 countries”.
Again, your hospital in your country should know all this. But if you know that you shall be needing some hospital treatment, especially if it involves surgery, you’d better check beforehand.
Find out if there are screening procedures, like tests upon admission to hospital of
patients who have risk factors. And isolation measures for patients who are found with a Candida Auris infection.
Around the world.
In South Africa there is the CHARM (Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses ).
In India there are the recommendations of the ICMR (Indian Council for Medical Research). “Guidelines for candida auris infection treatment and management”.
Why South Africa and India? They are two of several countries where the presence of Candida Auris is a more serious threat because it is causing hospital outbreaks.
There are more reasons to pay attention to the situation there. People who had received hospital care in South Africa and India then “exported” the fungus to other countries.
If you receive health care in these or other countries where Candida Auris is present, you might be colonized or even infected by it.
How does it happen?
5. Candida Auris sticks everywhere and resists disinfectants.
Candida Auris spreads from person – to – person contacts.
All the experts who have done research on C. Auris swear on that. All public health authorities state it in their official guidelines.
But how does it happen, exactly?
THIS nobody will tell you clearly.
Can I still hug grandpa?
“I found myself not wanting to touch the guy”, the NYT quoted Dr. Matthew McCarthy as saying. Mc Carthy has treated several C. Auris patients at Weill Cornell Medical Center in New York.
“I didn’t want to take it from the guy and bring it to someone else.There was an overwhelming feeling of being terrified of accidentally picking it up on a sock or tie or gown.”
The NYT also describes the case of an elderly patient who had been left to wait in his feaces for more than an hour because no one answered his call for help to go to the toilet. The staff of the (undisclosed) New York hospital where he was waiting for surgery was clearly afraid to handle him, said the man’s daughter.
Protective gowns and gloves.
A third case reported by the NYT is the sad story of a Chicago lady that died in February 2019 after being infected by C. Auris in the Northwestern Memorial Hospital. She was there for something else, a lung transplant.
When it became certain that she would not survive, the family organized the marriage of her younger son in her hospital bedroom. All the family had to wear protective blue hospital gowns over their clothes, and blue protective gloves.
They had noticed that their mother’s bedroom was treated “like a laboratory” since she was diagnosed with C. Auris. Extreme sterile conditions, staff washing their shoes with chlorine upon entering and leaving the room.
The bloody thing sticks everywhere!
Ripping the tiles off the ceiling and floor to clean a fungus? It sounds extreme, but it is what Mount Sinai Hospital had to do when an elderly patient died of a Candida Auris infection in one of its rooms in 2018.
Two years earlier, the Royal Brompton Hospital in London had to shut down the entire Intensive Care Unit for 11 days while trying to clean it from the fungus. Royal Brompton battled a massive outbreak of C. Auris, with some 70 cases, for more than a year.
Both hospitals found out that Candida Auris sticks to all sorts of materials (plastic, metal, textiles, ceramics). And that it can survive there for weeks.
They found it on the walls, the bed, the doors, the curtains, the phones, the sink, the whiteboard, the poles, the pump, the mattress, the bed rails, the canister holes, the
window shades, the ceiling.
The Royal Brompton sprayed aerosolized hydrogen peroxide for a whole week in an infected room. After that, Candida Auris was still there. Mount Sinai spent a million dollar to clean the contaminated space.
Other countries have the same woes.
The journal Clinical Infectious Diseases, in its issue 1 of January 2019, published an article on the coloniziation of 4 hospitals in Colombia by Candida Auris.
Here is a list of all the spots where the fungus was found:
- a bed hand controller;
- a cellular phone;
- bed trays;
- medical equipment;
- closet cabinets;
- door handles;
- alcohol gel dispensers;
- sink basins;
- mop buckets.
The point of the study was that C. Auris was found not only on the bed and closer bed area of colonized patients, but also further. And on objects that were touched mostly or only by health care workers Even on the shoe sole of one of them!
This gives some insights on the way the fungus spreads within health institution.
Colonized patients shed it from their skin.
Alas! Patients can be as careful as they want, they do not need to touch each other to spread the contamination
If they have the deadly fungus on their skin, they are shedding it into the hospital environment. These bad news have been disclosed at the annual conference of the American Society of Microbiology in June 2019.
The research was led by scientists from Centers for Disease Control and
Prevention (CDC) and the City of Chicago Public Health Department,
So “person to person contact” actually includes the passage of C.Auris from one human being to the other by means of contact with some inanimate surface/object that carries the fungus.
Costs can be a problem.
This is why the recommendation for patients who are found to be carrying Candida Auris is to be put in a single hospital room, if possible. Second best is to “cohort”, i.e. group patients colonized by the fungus in a separate area.
Not all hospitals have the number of single rooms sufficient to respond to a massive outbreak with individual isolations. Not all patients can afford it.
Clearly, transmission in multiple bed rooms must have contributed to the rapid spread of Candida Auris during the past decade.
Which disinfectants are effective?
Some common products used to disinfect rooms in hospitals cannot even tickle Candida Auris.
For example, surface cationic-active disinfectants and quaternary ammonium disinfectants are ineffective.
Chlorhexidine gluconate, iodinated povidone, chlorine bleach and vaporized hydrogen peroxide appear to be more effective. On ultraviolet light there are different opinions.
The CDC recommends Environmental Protection Agency-registered disinfectants effective against Clostridium Difficile spores.
All of these are so far just partial solutions. None seems capable of busting Candida Auris once and for all.
6. Be careful where you travel! Candida Auris is conquering the planet at a very fast pace.
Thirty countries in ten years.
They are probably more but we do not know yet.
When the mainstream media started paying attention to C. Auris, in the spring of 2019 following in the steps of the New York Times viral story, the fungus had already appeared in hospitals in six continents.
The creepy “Outbreak” pattern.
Remember Dustin Hoffman fighting a deadly virus in “Outbreak”?
One single infected person that was enough to spread the illness like wildfire
from person to person?
Well, it was quite realistic. And it might be just how it went with Candida Auris.
The first recorded case in the US, in 2013, was that of a woman who had previously been treated in a hospital in the Arab United Emirates for a respiratory illness. She died a week after being admitted to a US hospital.
Six years later there were over 700 cases in 12 states of the US, more than 300 in New York, the second largest concentration in Illinois (Chicago) and then New Jersey.
In Israel too one study found that a young man who was injured in a bad road accident “imported” C. Auris from South Africa to the Sheba Medical Center in Tel Hashomer. Weeks later, C. Auris infected an older patient admitted to the same facility.
Candida Auris was “imported” to the US, Canada and Europe.
Epidemiologic studies have been carried out and found that the clades of Candida Auris in the United States and Great Britain DID come from abroad. Their genetic structure was compared to the isolates from Asia, Africa and South America.
They all came from one of them. There does not seem to be a “native” European clade of Candida Auris, or one originating in the United States.
As it turns out, the deadly fungus was introduced several times to US, Canada and European hospitals. Clearly from different countries of origin by several different colonized patients.
In some cases it was traceable. For example, when it was known that certain patients had been previously hospitalized in some foreign health care institutions.
The first case of Candida Auris was reported in Japan.
In 2009 an elderly lady was being treated in hospital for a ear infection in Tokyo Metropolitan Geriatric Hospital. The fungus that was isolated by analyzing her ear discharged was found to be a new species of Candida, never identified before.
Later on, two older samples of Candida Auris, which had not been identified when collected from patients, were found in archives. One was from a 2008 case of fungal infection in Pakistan, the other one from 1996 in South Korea.
Does this mean that C. Auris had been around all those years but had not been identified? Confused for some other Candida?
Scientists do not have all the answers on where was Candida Auris BEFORE 2009. Knowing more about its origins would be of great help to fight it better.
What happened AFTER that first reported case in Japan is much better known.
Candida Auris started popping up everywhere.
In a matter of a few years, reports of C. Auris cases started to appear in several continents. In some cases, like in Pakistan, India, Venezuela, Great Britain, Spain, the fungus caused hospital outbreaks with hundreds of patients involved.
Between 2012 and 2016 Candida Auris appeared simultaneously in three continents, with more cases reported in India, Venezuela and South Africa. See: “Simultaneous Emergence of Multidrug-Resistant Candida auris on 3 Continents Confirmed by Whole-Genome Sequencing and Epidemiological Analyses”.
Genetic characteristics are different in different continents.
What puzzled the scientists is that the fungus had some different genetic characteristics in different geographic areas. But Candida Auris was being discovered simultaneously in all of them.
Whole-genome sequencing identified 4 major populations in which isolates cluster by geography. These populations are commonly referred to as the South Asian (I), East Asian (II), African (III), and South American (IV) clades.
Worldwide, C. Auris isolates continue to cluster in 1 of the 4 clades.
This information has helped the scientific community to trace how Candida Auris spread, at least in part.
The bad news is that it did not stop at some patients who had evidently picked it up somewhere abroad.
In other words, you do not need to travel to some other continent to be colonized or infected by C. Auris.
Candida Auris has “gone local” also in the US and Europe.
“Based on laboratory testing, the U.S. strains were found to be related to strains from South Asia and South America. However, none of the patients travelled to or had any direct links to those regions. Most patients likely acquired the infections locally”.
The above is a quote from the CDC’s report on the“First cases of Candida auris reported in United States”, published in November 2016. The report concerns 13 cases. Seven of them occurred between May 2013 and August 2016, the other six were just being investigated.
So what happened is that in only three years C. Auris had passed from patients who were contaminated somewhere in the other three continents to new victims in the United States.
7. Candida Auris spread from 14 to 30 countries in two years, 2017-2019.
Have a look at this map, portraying the situation updated till 2017:
Now look at this one, updated till May 31st 2019:
Woah! It’s THIRTY countries now!
The question is still up: it this Candida Auris spreading, or the knowledge about Candida Auris?
Remember what we have seen in the previous sections of this article:
- Candida Auris has generic symptoms that can be mistaken for another
- Candida Auris is difficult to diagnose without sophisticated equipment.
In other words, Candida Auris could already be in many more places that we still do not know about. It could already be in your neighbourhood.
Science Fiction? Alarmism? Nope.
There is one more detail that scares hell out of doctors all over the globe:
Candida Auris is transmitted from person to person very easily. In ways that science is still trying to understand.
8. Candida Auris may be a result of climate change.
This is the hypothesis presented in the study “On the Emergence of Candida auris: Climate Change, Azoles, Swamps, and Birds”, published by prof. Arturo Casadevall and his team in July 2019.
What left the scientists puzzled was the simultaneous emergence of the superbug in three different continents (Asia, Africa, South America), after the first documented case in Japan. In the beginning the idea was that Candida Auris travelled with health tourists, but it turned out that the strains of the fungus where different.
Casadevall is looking into the possibility that the fungus mutated and can now tolerate a higher temperature. The human body has a natural defense in its relatively high basal temperature.
Fungi and yeasts cannot usually survive at that temperature. This is why most of them cannot colonize the human body and cause infections.
One exception is the more widespread and well known Candida Albicans, that can be found in the guts, throat and vagina of human beings. In case of overgrowth, the candidiasis infection occurs.
Candida Auris on the other hand is the mystery superbug. Where the hell did it come from, scientists are still wondering.
So far C. Auris has been found nowhere except in the human body. This is not normal. Fungi and bacteria are usually also present somewhere in the environment.
Prof. Casadevall is making the hypotheses that Candida Auris might have originally developed in swamps. In recent years, climate change would have stimulated the fungus to develop resistance to higher temperatures.
Source: “On the Emergence of Candida auris: Climate Change, Azoles, Swamps, and Birds”, Arturo Casadevall et al. July 2019.
9. Risk factors for Candida Auris
So, the symptoms of Candida Auris are so banal, we cannot give you something
special there. To help you more, we can provide a list of risk factors for C. Auris.
In April 2019 a study by the title “Factors associated with Candida auris colonization among residents of nursing homes with ventilator units — New York, 2016 – 2018” was presented at the Spring Conference of the Society for Healthcare Epidemiology of America (SHEA 2019).
The study contained a result of an investigation carried out on 6 nursing homes to identify 60 cases and 218 controls. There, between 2016 and 2018, the US Centers for Disease Control and Prevention (CDC) and the New York State Department of Health (NYSDOH) analyzed the factors that lead to Candida colonization.
Investigators determined that the following factors are associated with C. auris
- having a urinary catheter;
- having a tracheostomy;
- being on a ventilator;
- receiving meropenem in the prior 90 days;
- having at least 1 hospitalization in the prior 6
Find more information here:
The New York State – Department of Health (NYSDOH) has a dedicated web page: “Get the Facts About Candida Auris”.
The CDC section on C. Auris: “Candida auris: A Drug-resistant Germ That Spreads in Healthcare Facilities”.
In general, watch out for a possible Candida Auris colonization/infection if you, or a loved one:
- are in hospital, long term health care facility, nursing home;
- have already compromised health, a weakened immune system, from previous illnesses;
- have been on antibiotic/antifungal therapy for a while;
- have some tube entering your body (cathether, intravenous etc.).
10. How can we cure Candida Auris?
Ah… for this one – stay tuned!
In the last few months news started popping up on several possible solutions.
Both on the side of new possible drugs and hygiene products and technology. Read – prevention.
Still, the matter is delicate and we are checking the information
The goal is to give you some practical and usable advice on how to reduce the risk of picking up C. Auris to a minimum. And how to behave if you have had the bad luck of picking it up already.
So far, your best bet is to check on the official health institutions we have quoted in the article. Follow their recommendations.
To be true, it is NOT enough.
You can feel the nervousness of official medicine when Candida Auris is in question.
Keep also in mind that superbugs can party together, especially in hospitals. Nobody says you will have to deal ONLY will Candida Auris.
This is bad news.
The good side of it is that there is a whole series of things you can do to improve your general health and boost your immune system. And THESE are useful against the whole lot of them.
Stay with us, practical advice is coming up!