Emergence of highly resistant Candida auris in the United Arab Emirates: a retrospective analysis of evolving national trends

Abstract

IntroductionThe Centers for Disease Prevention and Control lists Candida auris, given its global emergence, multidrug resistance, high mortality, and persistent transmissions in health care settings as one of five urgent threats. As a new threat, the need for surveillance of C. auris is critical. This is particularly important for a cosmopolitan setting and global hub such as the United Arab Emirates (UAE) where continued introduction and emergence of resistant variant strains is a major concern.MethodsThe United Arab Emirates has carried out a 12 years of antimicrobial resistance surveillance (2010–2021) across the country, spanning all seven Emirates. A retrospective analysis of C. auris emergence from 2018–2021 was undertaken, utilising the demographic and microbiological data collected via a unified WHONET platform for AMR surveillance.ResultsNine hundred eight non-duplicate C. auris isolates were reported from 2018–2021. An exponential upward trend of cases was found. Most isolates were isolated from urine, blood, skin and soft tissue, and the respiratory tract. UAE nationals nationals comprised 29% (n = 186 of 632) of all patients; the remainder were from 34 other nations. Almost all isolates were from inpatient settings (89.0%, n = 809). The cases show widespread distribution across all reporting sites in the country. C. auris resistance levels remained consistently high across all classes of antifungals used. C. auris in this population remains highly resistant to azoles (fluconazole, 72.6% in 2021) and amphotericin. Echinocandin resistance has now emerged and is increasing annually. There was no statistically significant difference in mortality between Candida auris and Candida spp. (non-auris) patients (p-value: 0.8179), however Candida auris patients had a higher intensive care unit (ICU) admission rate (p-value <0.0001) and longer hospital stay (p < 0.0001) compared to Candida spp. (non-auris) patients.ConclusionThe increasing trend of C. auris detection and associated multidrug resistant phenotypes in the UAE is alarming. Continued C. auris circulation in hospitals requires enhanced infection control measures to prevent continued dissemination.

Mapping the Burden of Fungal Diseases in the United Arab Emirates

“…[34,35]. The recent study published by Thomsen et al [31] revealed alarming trends in the resistance patterns of C. auris in the UAE, analyzing 908 C. auris isolates from the 2018-2021 observation period and offered some demographic data associated with C. auris infection.…”

“…Differences in median of length of hospitalization between both groups was also statistically significant, with patients associated with C. auris infections accumulating a median length of stay of 33.5 days as opposed to 14 days for patients associated with non-auris Candida infections. Thomsen J et al also calculated a mortality rate of 27.5% from a subset of patients with known admission and discharge dates in the C. auris group (47/171 patients) [31].…”

“…Candida auris was first reported in 2017 in the UAE [64], and included in the 2021 UAE national AMR report, with reported isolates increasing in frequency between 2010 and 2020 (n = 0 to n = 191). Extrapolating from the national AMR surveillance database, Thomsen J et al [31] reported a total of 908 non-duplicate C. auris isolates from 2018-2021 (2018: n = 9; 2019: n = 93; 2020: n = 192; 2021: n = 614). C. auris isolates from urine sources constituted the leading sample size (280/908, 30.8%), followed by blood sources (248/908, 27.3%) skin and soft tissue sources (221/908, 24.3%), the respiratory tract (142/908, 15.6%), the genital tract (3/908, 0.3%), and cerebrospinal fluid (CSF) specimens (2/908, 0.2%).…”

“…Until 2024, no other dedicated epidemiological or clinical studies on fungal diseases had been published in the UAE. The UAE had very little data on the incidence or prevalence of fungal disease until 2024 [31]. Prior to this, there was only a single-center retrospective study on incidence rates of candidaemia that was published almost three decades ago [32].…”

Candida auris Outbreaks: Current Status and Future Perspectives

“…However, outbreaks of C. auris among severely ill COVID-19 patients during the peak of the pandemic were only observed in certain countries, such as Italy and the USA [21]. An epidemiological analysis conducted during the pandemic in the United Arab Emirates found an increase in COVID-19 and C. auris co-infection in hospitals with overwhelmed intensive care units [57]. Patients had significant underlying comorbidities and were treated with broad-spectrum antibiotics and immunosuppressive therapies.…”