key: cord-0982635-ct867oqc authors: Villanueva-Lozano, Hiram; Treviño-Rangel, Rogelio de J.; González, Gloria M.; Ramírez-Elizondo, María Teresa; Lara-Medrano, Reynaldo; Aleman-Bocanegra, Mary Cruz; Guajardo-Lara, Claudia E.; Gaona-Chávez, Natalia; Castilleja-Leal, Fernando; Torre-Amione, Guillermo; Martínez-Reséndez, Michel F. title: Outbreak of Candida auris infection in a COVID-19 hospital in Mexico date: 2021-01-08 journal: Clin Microbiol Infect DOI: 10.1016/j.cmi.2020.12.030 sha: 5572bda26771745a41fbef3780f29cb69f33bde7 doc_id: 982635 cord_uid: ct867oqc The aim of this study was to describe the clinical and microbiological characteristics of twelve patients with severe COVID-19 and Candida auris co-infection. Microbiological characterization of the isolates consisting on molecular identification, genotypification through multilocus sequence typing and antifungal susceptibility to eight antifungals was performed. Mortality among patients with COVID-19 and C. auris candidaemia was of 83.3% even with the use of appropriate antifungal therapy. All the isolates studied were resistant to amphotericin B. Causes related to the incidence of COVID-19 and candidaemia are not well understood but seems to be related to common contributing factor seen in critically-ill patients; nonetheless, the high mortality reported demands close attention to patients who present this co-infection. To the Editor, Since its emergence in December 2019, the rapid spread of coronavirus disease 2019 (COVID-19) has necessitated the expansion and transformation of healthcare facilities worldwide to accommodate the constantly increasing numbers of patients. This situation has provided a potential ground for the transmission of nosocomial infections [1] . Candida auris is a multidrug-resistant fungal pathogen with the capability for nosocomial transmission. Some studies have suggested an increased risk for Candida sp. in COVID-19 patients, resulting in poor outcomes [2, 3] . Here we describe an outbreak of C. auris which started in a non-COVID-19 patient at the end of May 2020 (reported previously [4] ). This occurred during the transition of the hospital to an exclusive COVID-19 facility; the infection later spread to 12 patients in the intensive care unit (ICU). We collected the clinical data of all the patients admitted to the hospital from April 2020 to the present date. Characteristics of the patients with a diagnosis of C. auris infection were analysed. This study was approved by the Research Ethics Committee of the Hospital San Jos e Tec-Salud (registration number: P000353-COVID-19-TecSalud-CS001). C. auris strains from 12 patients and three environmental isolates from their bedrooms were identified by matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) mass spectrometry (Bruker Daltonics, MALDI Biotyper) and confirmed by multilocus sequence typing of the ITS1-5.8S-ITS2, D1/D2, RPB1 and RPB2 regions. Sequences were aligned and analysed by MEGA v.7.0.26 and a dendrogram was delineated. Antifungal susceptibility testing for amphotericin B (AMB), fluconazole (FLU), voriconazole (VRC), posaconazole (POS), itraconazole (ITC), isavuconazole (ISA), anidulafungin (ANF) and caspofungin (CAS) was performed using the Clinical and Laboratory Standards Institute (CLSI) broth microdilution method M27-A3/S4. Our team reported the first case of C. auris infection in May 2020. At that time the hospital was transitioning from a general hospital to an exclusive COVID-19 facility which included expansion of the ICU to four areas with 60 beds; this was completed as the last non-COVID-19 patient was discharged. Three months later an outbreak of COVID-19-associated Candida auris infections started in three of the ICUs, affecting 12 patients. All the affected patients were under mechanical ventilation, had peripherally inserted central lines (PICCs), urinary catheters and prolonged hospital stay (20e70 days). C. auris was isolated from blood in six patients (6/12; 50%), from urine in eight (8/12; 66.6%), and from both sites in two (2/12; 16.6%). Mortality was 83.3% (5/6) among the patients with candidaemia (Table 1A) . Sequences of the genes used for the 15 C. auris isolates clustered together in the dendrogram performed with the sequence previously reported from a non-COVID-19 patient, which belonged to the Clade IV (South American) [4] , suggesting a very close relationship. Antifungal susceptibility testing showed that all the isolates (15/15) were resistant to AMB (MIC 2 mg/mL), just one isolate was resistant to ANF (MIC 4 mg/mL), one to CAS (MIC 2 mg/mL) and eight isolates (8/15; 53.3%) were resistant to FLU (MIC 32 mg/ mL). Eight isolates were multidrug-resistant (resistance to two major classes of antifungals) (Table 1B) . Numerous reports have described COVID-19 co-infections by fungal pathogens, especially in critically ill patients. As stated in the work of Arasthefar et al. [5] , classic risk factors commonly found in these patients include diabetes mellitus, use of multiple antibiotics, renal failure, and use of central venous catheters, but other factors specifically associated with COVID-19dsuch as excessive corticosteroid use, which has an immunosuppressive effect on neutrophils and macrophagesdmight also contribute to this problem. Nonetheless, a lot of interest still exists in elucidating a relationship between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) immune response and predisposition to Candida infection [2] . In our report 12 patients have presented COVID-19-associated C. auris infection, and so far only three environmental samples have yielded this pathogen. The prolonged lag between the first case 3 months ago and current cases is thought to be due to measures taken during the transformation process from a general hospital to a COVID-19-exclusive facility, such as reinforcement of hand washing compliance and use of personal protective equipment (PPE). Chowdhary et al. [6] theorized that transmission of COVID-19-associated C. auris by health personnel is unlikely because of the use of PPE. The 15 isolates of C. auris were nonsusceptible to AMB and FLU, which are the main antifungal drugs used in most of the hospitals in Mexico. This study has some limitations as it was conceived as a description of an outbreak; as such, there is no control group, and findings may not be generalizable to other populations. Nonetheless mortality in patients with COVID-19-associated C. auris bloodstream infection was exceedingly high, five of six patients died even with antifungal treatment; strict control of risk factors, such as central line care bundles, corticosteroids and antibiotic stewardship, must therefore be implemented to avoid the lethal combination of these two emergent infectious threats. HV-L, RJT-R and GMG contributed to drafting and revising the article, as well as in the conception and design of the study. RL-M, MTR-E and NG-Ch contributed to the acquisition and interpretation of data. FC-L, MCA-B, CEG-L and GT-A contributed to revision and final approval of the report. MFM-R participated in the analysis and interpretation of data, drafting and final approval of the version to be submitted. All authors declare no conflicts of interest. This work was supported by internal resources of the department. Hospital ward adaptation during the covid-19 pandemic: a national survey of academic medical centers Covid-19 associated invasive candidiasis Candida aurisdthe growing menace to global health First case of Candida auris isolated from the bloodstream of a Mexican patient with serious gastrointestinal complications from severe endometriosis Covid-19-associated candidiasis (CAC): an underestimated complication in the absence of immunological predispositions? Multidrug-resistant Candida auris infections in critically ill coronavirus disease patients Letter to the Editor / Clinical Microbiology and Infection xxx (xxxx) xxx We thank all the health personnel involve in the attention and care of these patients, specially to Mauricio S anchez-Rodríguez MD and Alvaro E. Camero-Garza MD. We also thank Gerald Martin Rhoades-Torres MD for his review of the manuscript prior to submission.