==== Front Emerg Infect Dis Emerg Infect Dis EID Emerging Infectious Diseases 1080-6040 1080-6059 Centers for Disease Control and Prevention 37347923 23-0540 10.3201/eid2907.230540 Research Letter Research Letter Candida auris‒Associated Hospitalizations, United States, 2017–2022 Candida auris‒Associated Hospitalizations, United States, 2017–2022 Candida auris‒Associated Hospitalizations, United States, 2017–2022 Benedict Kaitlin Forsberg Kaitlin Gold Jeremy A.W. Baggs James Lyman Meghan Centers for Disease Control and Prevention, Atlanta, Georgia, USA Address for correspondence: Kaitlin Benedict, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, Mailstop H24-9, Atlanta, GA 30329-4027 USA; email: jsy8@cdc.gov 7 2023 29 7 14851487 2023 https://creativecommons.org/licenses/by/4.0/ Emerging Infectious Diseases is a publication of the U.S. Government. This publication is in the public domain and is therefore without copyright. All text from this work may be reprinted freely. Use of these materials should be properly cited. Using a large US hospital database, we describe 192 Candida auris‒associated hospitalizations during 2017–2022, including 38 (20%) C. auris bloodstream infections. Hospitalizations involved extensive concurrent conditions and healthcare use; estimated crude mortality rate was 34%. These findings underscore the continued need for public health surveillance and C. auris containment efforts. Keywords: Candida auris fungi fungal infections hospitalizations epidemiology United States ==== Body pmcCandida auris is a highly transmissible and frequently drug-resistant emerging fungal pathogen capable of causing severe infections. C. auris can colonize skin, leading to infection and transmission in healthcare settings. In the United States, reported clinical cases increased by 95% during 2020–2021 (1). US data on C. auris come primarily from case series and outbreak investigations and are geographically limited, and national surveillance data lack detail on patients’ underlying conditions, healthcare use, and outcomes. Therefore, we used a large healthcare services database to describe features of hospitalized patients with C. auris infection or colonization. The PINC-A1 Healthcare Database (PHD) (https://offers.premierinc.com/rs/381-NBB-525/images/PINC_AI_Healthcare_Data_White_Paper.pdf) is a hospital-based all-payer database that contains healthcare use, financial, and pharmacy data from >1,000 US hospitals. Laboratory data are available from ≈25% of those hospitals. We identified all hospitalizations with a culture positive for C. auris from any specimen type during 2017–2022. We used diagnosis codes from the International Classification of Diseases 10th Revision, Clinical Modification, to identify underling conditions and complications (Appendix Table) and billing data to identify medical devices. We assessed features of C. auris hospitalizations and compared those with versus those without bloodstream infection (BSI) by using χ2, Fisher exact, and Wilcoxon tests (α = 0.05). A total of 192 C. auris hospitalizations (38 [20%] with BSI) occurred in 42 hospitals. C. auris hospitalizations primarily occurred among older adults (median age 68 years [range 21–89 years]), male patients (54%), and non-Hispanic White patients (60%). Non-Hispanic Black patients more frequently had BSI than did other races/ethnicities (39% vs. 29%; p = 0.022) (Table). The first positive C. auris specimen was collected within 2 days of admission for 63% of bloodstream and 48% of nonbloodstream C. auris hospitalizations. Among hospitalizations with bloodstream C. auris, 58% also had another positive specimen type. Among hospitalizations without bloodstream C. auris, the most common positive specimen types were axilla (38%) and urine (34%). Table Characteristics of hospitalizations involving Candida auris, United States, 2017–2022* Characteristics Total, n = 192 Bloodstream infection,† n = 38 Nonbloodstream infection,‡§ n = 154 p value Mean, median age, y (range) 66.0, 68.0 (21–89) 61.8, 66.5 (32–86) 67.0, 68.0 (21–89) 0.042 Age category, y 0.264 <45 22 (11.5) § § 45–64 52 (27.1) 11 (28.9) 41 (26.6) >65 118 (61.5) 20 (52.6) 98 (63.6) Sex 0.193 M 104 (54.2) 17 (44.7) 87 (56.5) F 88 (45.8) 21 (55.3) 67 (43.5) Race/ethnicity, n = 186 0.022 Non-Hispanic Black 45 (24.2) 14 (38.9) 31 (20.7) All other races/ethnicities¶ 141 (75.8) 22 (61.1) 119 (79.3) Payer 0.483 Medicare 128 (66.7) 25 (65.8) 103 (66.9) Medicaid 35 (18.2) § § Private health insurance 20 (10.4) § § Other § § § Clinical features Mean, median time from admission to first positive C. auris specimen collection, d (range) 8.6, 2.0 (1–187) 8.7, 1.0 (1–53) 8.6, 3.0 (1–187) 0.997 Within 2 d 98 (51.0) 24 (63.2) 74 (48.1) >2 d 94 (49.0) 14 (36.8) 80 (51.9) Systemic antifungal use on or after first positive C. auris culture Echinocandin 68 (35.4) 29 (76.3) 39 (25.3) <0.001 Fluconazole 20 (10.4) § § 0.081 Amphotericin B § § § 0.016 Underlying conditions and complications Sepsis 123 (64.1) 25 (65.8) 98 (63.6) 0.804 Diabetes 106 (55.2) 20 (52.6) 86 (55.8) 0.721 Chronic kidney disease 85 (44.3) 17 (44.7) 68 (44.2) 0.949 Pneumonia 83 (43.2) 17 (44.7) 66 (42.9) 0.834 Chronic respiratory failure 61 (31.8) 15 (39.5) 46 (29.9) 0.255 Liver disease 29 (15.1) § § 0.099 COVID-19 24 (12.5) § § 0.891 Solid organ malignancy 21 (10.9) § § 0.502 Hematologic malignancy § § § 1.000 HIV § § § 0.486 Neutropenia § § § 1.000 Transplant and complications § § § 0.585 Medical devices Central venous catheter 111 (57.8) 29 (76.3) 82 (53.2) 0.010 Mechanical ventilation 83 (43.2) 18 (47.4) 65 (42.2) 0.565 Tracheostomy 29 (15.1) 11 (28.9) 18 (11.7) 0.008 Feeding tube 16 (8.3) § § 0.913 Urinary catheter 17 (8.9) § § 0.297 Total parenteral nutrition 17 (8.9) § 10 (6.5) 0.021 Outcomes Mean, median length of hospitalization, d (range) 18.6, 13 (1–209) 22.5, 16.5 (1–65) 17.6, 12.0 (1–209) 0.212 Intensive care unit stay 145 (75.5) 30 (78.9) 115 (74.7) 0.583 Discharge status 0.046 In-hospital death or discharged to hospice# 65 (33.9) 18 (47.4) 47 (30.5) 0.123 Discharged to skilled nursing facility 53 (27.6) § § Discharged to long-term care acute hospital 28 (14.6) § § Other 46 (24.0) § § *Values are no. (%) patients except as indicated. Data were from the PINC-A1 Healthcare Database (PHD) (https://offers.premierinc.com/rs/381-NBB-525/images/PINC_AI_Healthcare_Data_White_Paper.pdf). Most C. auris hospitalizations were in the South (76.6%) or the Midwest (21.4%) regions; <10 C. auris hospitalizations were in the Northeast or the West regions; >95% of hospitals were in urban locations. A total of 35.4% of C. auris hospitalizations were from 2022, 51.0% were from 2021, and 13.5% were from 2017–2020. We found 0 C. auris hospitalizations for 2012–2016. †A total of 22 (57.9%) patients also had C. auris isolated from another specimen type; among those, 81.8% had both specimens collected on the same day, and the remainder had the bloodstream specimen collected first. ‡Specimen types: 59 axilla, 53 urine, 18 wound, 13 respiratory, 21 other or unspecified. §Nonzero number <10 or cell that would enable calculation of another cell <10. ¶Includes 112 (60.2%) non-Hispanic White and 21 (11.3%) Hispanic. #Forty (20.8%) in-hospital deaths and 25 (13.0%) discharged to hospice. Underlying conditions and complications were similar for patients with bloodstream and nonbloodstream C. auris and most commonly were sepsis (64%), diabetes (55%), chronic kidney disease (44%), and pneumonia (43%). Compared with nonbloodstream C. auris, bloodstream C. auris hospitalizations more frequently involved central venous catheters (CVC) (76% vs. 53%; p = 0.010) and tracheostomies (29% vs. 12%; p = 0.008). Echinocandin use was more frequent for bloodstream (76%) versus nonbloodstream (25%) hospitalizations; median time from first positive culture to echinocandin use was 2 days (interquartile range 1–3 days). Most (75.5%) hospitalizations involved an intensive care unit stay; mechanical ventilation was used in 43% of hospitalizations. Median hospitalization length was 13 days (range, 1–209 days). In-hospital mortality rate was 21%; discharge locations included hospice (13%), skilled nursing facility (28%), and long-term acute care (15%). Estimated crude mortality rates were 47% for bloodstream C. auris vs. 31% for nonbloodstream. This analysis of a large convenience sample of C. auris‒associated hospitalizations provides information about clinical features that are currently unavailable through national public health surveillance. Our results support smaller previous investigations showing that infection and colonization with C. auris occurs most commonly in patients with complex medical conditions (2–5). The proportion of C. auris cases involving BSI (20%) was comparable to the 9%–28% BSI rate among clinical and screening cases found in previous state-specific studies (2,6). Including in-hospital deaths and discharges to hospice, the overall estimated crude mortality rate of 34% (47% for BSI) was similar to the 30-day mortality rate from a previous study in New York (27% overall and 39% for BSI) (2). Consistent with candidemia treatment guidelines, most BSI hospitalizations involved echinocandin use, and treatment lag was typical (7). Hospitalizations involving C. auris BSI were associated with non-Hispanic Black race, similar to those for non–C. auris candidemia (8). The association between CVC use and C. auris BSI is not surprising, given that CVC use is a well-documented risk factor for candidemia and is common among patients with C. auris, because extensive healthcare exposure, intensive care unit stays, and use of medical devices are key factors in C. auris acquisition (2,9). Many BSI patients were probably admitted with C. auris, based on first positive blood specimens occurring soon after admission, similar to finding from a New York case series (3). However, we could not assess previous healthcare exposures and prehospitalization laboratory data, which are major considerations because patients with C. auris usually acquire it in healthcare settings and can remain colonized for months (9). Other limitations of our study include lack of antifungal susceptibility testing data, possible underdetection of cases caused by potential incompleteness of 2022 data, and underrepresentation of the West and the Northeast regions in PHD laboratory data (10), which is particularly relevant because those regions report high case counts (https://www.cdc.gov/fungal/candida-auris/tracking-c-auris.html). PHD laboratory data also underrepresent rural, smaller hospitals (10), potentially further biasing this convenience sample of C. auris cases. In conclusion, this analysis of hospitalization data supports previous targeted reports and demonstrates a need for strengthened national surveillance and further studies to identify risk factors for C. auris infection and colonization. Appendix Additional information on Candida auris‒associated hospitalizations, United States, 2017–2022. This activity was reviewed by the Centers for Disease Control and Prevention (CDC) and was conducted consistent with applicable federal law and CDC policy (e.g., 45 C.F.R. part 46.102(l)(2), 21 C.F.R. part 56; 42 U.S.C. §241(d); 5 U.S.C. §552a; 44 U.S.C. §3501 et seq.). PHD data are fully deidentified; thus, this analysis was not subject to review by the CDC institutional review board. No specific funding was received for this work. Ms. Benedict is an epidemiologist in the Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA. Her research interests include the epidemiology and prevention of fungal infections. Suggested citation for this article: Benedict K, Forsberg K, Gold JAW, Baggs J, Lyman M. Candida auris‒associated hospitalizations, United States, 2017–2022. 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