Medical illustration of Candida. (CDC) 
 
 U.S. health officials are warning hundreds of thousands of clinicians in hospitals around the country to be on the lookout for an emerging and highly drug-resistant type of yeast that is causing potentially fatal infections in hospitalized patients around the world. 
 
 Most people are familiar with the garden variety kind of yeast infections that people get on the skin or in their genitals. But invasive yeast infections can be fatal, especially for patients in intensive care or having surgery. Others at risk include people with diabetes, patients taking powerful antibiotics and antifungal medications, and those with catheters. 
 
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 This emerging strain of yeast, known as Candida auris, has triggered outbreaks in health-care settings, causing bloodstream, wound and ear infections. Since 2009, the pathogen has been found in nine countries on four continents, including one possible infection in the United States in 2013. 
 
 The Centers for Disease Control and Prevention sent a clinical alert late last week to U.S. health-care facilities and dozens of medical societies to share with their members. 
 
 “CDC is concerned that C. auris will emerge in new locations, including the United States,” the alert said. The infections have most commonly been acquired in hospitals and occurred several weeks into a patient's hospital stay. 
 
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 Officials warn that the yeast doesn’t respond to common antifungal drugs and is difficult to identify with standard laboratory methods. 
 
 “What concerned us is that it is potentially resistant to one or two, if not all three” main classes of antifungal drugs used to treat these infections, said Tom Chiller, the CDC’s top fungus expert, in an interview Tuesday. 
 
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 Invasive infections with any type of Candida can be fatal. Based on information from a limited number of patients, 60 percent of people with this new type of Candida infection have died, but it’s not clear how many of them had other serious illnesses that also increased their risk of death. 
 
 Most hospital labs in the United States also don’t have the capacity to identify the new strain because it can be confused with other more common types of yeast. As a result, misidentification could lead to inappropriate treatment, he said. 
 
 That’s particularly important with this organism because the limited data so far suggests that the infections have occurred primarily in patients who were already in the hospital for other reasons. Unlike other types of yeast that typically spread from person to person, “this one seems to get into hospital settings and stay there,” Chiller said, and may spread from contact with the environment, such as contaminated surfaces or equipment. 
 
 The organism was first identified in 2009 in Japan from a patient’s external ear discharge. Infections have also occurred in South Korea, India, South Africa, Kuwait, Pakistan, Colombia, Venezuela and the United Kingdom. Because identification requires specialized laboratory methods, the CDC alert said infections likely occurred in other countries but have not been identified or reported. 
 
 Based on a review of specimens collected in the past, CDC officials said they are aware of one possible infection in the United States in 2013 that was collected by a private lab. The CDC has tested a small sample of Candida specimens over the last eight years, and so far the deadly new yeast has not turned up. But the testing is limited, he said — there’s surveillance at only four sites in the country, and only about 7,000 samples have been analyzed. 
 
 The CDC is recommending that hospitals and other health-care facilities that suspect they have a patient with such an infection contact local public health authorizes and the CDC. They also recommend that patients carrying or infected with this organism have their own rooms, and that their rooms are thoroughly cleaned and disinfected every day with an EPA-registered, hospital-grade disinfectant that targets fungus. 
 
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 Zika infections last longer in pregnancy, monkey study shows ||||| This clinical alert has been updated. Please read the September 2017 C. auris Clinical Update with important information from investigations of U.S. cases of C. auris for clinicians, laboratorians, and public health officials. 
 
 Global Emergence of Invasive Infections Caused by the Multidrug-Resistant Yeast Candida auris 
 
 Summary: The Centers for Disease Control and Prevention (CDC) has received reports from international healthcare facilities that Candida auris, an emerging multidrug-resistant (MDR) yeast, is causing invasive healthcare-associated infections with high mortality. Some strains of C. auris have elevated minimum inhibitory concentrations (MICs) to the three major classes of antifungals, severely limiting treatment options. C. auris requires specialized methods for identification and could be misidentified as another yeast when relying on traditional biochemical methods. CDC is aware of one isolate of C. auris that was detected in the United States in 2013 as part of ongoing surveillance. Experience outside the United States suggests that C. auris has high potential to cause outbreaks in healthcare facilities. Given the occurrence of C. auris in nine countries on four continents since 2009, CDC is alerting U.S. healthcare facilities to be on the lookout for C. auris in patients. 
 
 Background 
 
 Candida auris is an emerging multidrug-resistant (MDR) yeast that can cause invasive infections and is associated with high mortality. It was first described in 2009 after being isolated from external ear discharge of a patient in Japan 1. Since the 2009 report, C. auris infections, specifically fungemia, have been reported from South Korea 2, India 3, South Africa 4, and Kuwait 5. Although published reports are not available, C. auris has also been identified in Colombia, Venezuela, Pakistan, and the United Kingdom. 
 
 It is unknown why C. auris has recently emerged in so many different locations. Molecular typing of strains performed by CDC suggests isolates are highly related within a country or region but highly distinct between continents 6. The earliest known infection with C. auris, based on retrospective testing of isolate collections, occurred in South Korea in 1996 2. C. auris may not represent a new organism so much as one that is newly emerging in various clinical settings. Although the causes for such emergence are unknown, they may include new or increasing antifungal selection pressures in humans, animals, or the environment. 
 
 C. auris infections have most commonly been hospital-acquired and occurred several weeks into a patient’s hospital stay. C. auris has been reported to cause bloodstream infections, wound infections, and otitis 2. It has also been cultured from urine and the respiratory tract; however, whether isolation from these sites represented infection verses colonization in each instance is unknown. C. auris has been documented to cause infections in patients of all ages. Patients were found to have similar risk factors for infections with other Candida spp. 6, 7, including: diabetes mellitus, recent surgery, recent antibiotics, and presence of central venous catheters 3. Co-infection with other Candida spp. and detection of C. auris while the patient was being treated with antifungals have also been reported 2. 
 
 Although no established minimum inhibitory concentration (MIC) breakpoints exist for C. auris, resistance testing of an international collection of isolates conducted by CDC demonstrated that nearly all isolates are highly resistant to fluconazole based on breakpoints established for other Candida spp. More than half of C. auris isolates were resistant to voriconazole, one-third were resistant to amphotericin B (MIC ≥2), and a few were resistant to echinocandins. Some isolates have demonstrated elevated MICs to all three major antifungal classes, including azoles, echinocandins, and polyenes, indicating that treatment options would be limited. 
 
 C. auris phenotypically resembles Candida haemulonii 1. Commercially available biochemical-based tests, including API strips and VITEK-2, used in many U.S. laboratories to identify fungi, cannot differentiate C. auris from related species. Because of these challenges, clinical laboratories have misidentified the organism as C. haemulonii and Saccharomyces cerevisiae. Some clinical laboratories do not fully identify all Candida to the species level, and C. auris isolates have been reported as “other Candida spp.” Clinical, state, and public health laboratories should be aware of this organism and of the limitations in its identification. 
 
 At least two countries have described healthcare outbreaks of C. auris infection and colonization involving more than 30 patients each. Analysis of isolates from these clusters demonstrate a high degree of clonality within the same hospital, supporting the idea that the organisms are being transmitted within those healthcare facilities. The precise mode of transmission within the healthcare facility is not known. However, experience during these outbreaks suggests that C. auris might contaminate the environment of rooms of colonized or infected patients. Good infection control practices and environmental cleaning may help prevent transmission. 
 
 Interim Recommendations 
 
 CDC is concerned that C. auris will emerge in new locations, including the United States. CDC and partners continue to work closely, and new information will be provided as it becomes available. CDC recommends the following actions for U.S. healthcare facilities and laboratories: 
 
 Reporting — Healthcare facilities who suspect they have a patient with C. auris infection should contact state/local public health authorities and CDC (candidaauris@cdc.gov). 
 
 Healthcare facilities who suspect they have a patient with C. auris infection should contact state/local public health authorities and CDC (candidaauris@cdc.gov). Laboratory Diagnosis — Diagnostic devices based on matrix-assisted laser desorption/ionization-time of flight (MALDI-TOF) can differentiate C.auris, but not all devices currently include C. auris in the reference database to allow for detection. Molecular methods based on sequencing the D1-D2 region of the 28s rDNA can also identify C. auris. CDC requests that laboratories identifying C. auris isolates in the United States notify their state or local health departments and CDC (candidaauris@cdc.gov). C. haemulonii isolates and other isolates from clinical specimens that cannot be identified beyond Candida spp. by conventional methods can be forwarded through state public health laboratories to CDC for further characterization. 
 
 Diagnostic devices based on matrix-assisted laser desorption/ionization-time of flight (MALDI-TOF) can differentiate C.auris, but not all devices currently include C. auris in the reference database to allow for detection. Molecular methods based on sequencing the D1-D2 region of the 28s rDNA can also identify C. auris. CDC requests that laboratories identifying C. auris isolates in the United States notify their state or local health departments and CDC (candidaauris@cdc.gov). C. haemulonii isolates and other isolates from clinical specimens that cannot be identified beyond Candida spp. by conventional methods can be forwarded through state public health laboratories to CDC for further characterization. Infection Control — Until further information is available, healthcare facilities should place patients with C. auris colonization or infection in single rooms and healthcare personnel should use Standard and Contact Precautions. In addition, state or local health authorities and CDC should be consulted about the need for additional interventions to prevent transmission. CDC is working with domestic and international partners to develop definitive infection control guidance. 
 
 Until further information is available, healthcare facilities should place patients with C. auris colonization or infection in single rooms and healthcare personnel should use Standard and Contact Precautions. In addition, state or local health authorities and CDC should be consulted about the need for additional interventions to prevent transmission. CDC is working with domestic and international partners to develop definitive infection control guidance. Environmental Cleaning – Anecdotal reports have suggested that C. auris may persist in the environment. Healthcare facilities who have patients with C. auris infection or colonization should ensure thorough daily and terminal cleaning and disinfection of these patient’s rooms using an EPA-registered hospital grade disinfectant with a fungal claim. 
 
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– The CDC warned American hospitals last year to keep an eye out for the emergence of a possibly fatal, drug-resistant yeast infection, and now the agency's fears may be realized. CDC officials tell the Washington Post that 35 patients in the US have been stricken with Candida auris, a fungus that can cause bloodstream, wound, and ear infections, with another 18 people harboring the microbe without becoming ill. Some strains of the pathogen don't respond to the three main classes of antifungal drugs, and based on the small number of cases health officials have had the chance to review, 60% of patients hit with C. auris have died (though the agency notes many of those patients had other serious medical issues they were contending with). The fungus is contagious and durable, especially in health care facilities, where it can stick around on furniture and other equipment for months. The first C. auris strain was reported in 2009 in a Japanese man, and it has since spread around the globe, including to Colombia, India, Israel, Kenya, Kuwait, Pakistan, South Korea, Venezuela, and the UK. The first US case was reported in 2013, and the CDC's latest report places 28 of the incidents in New York state, with other affected states including New Jersey, Maryland, Massachusetts, and Illinois. CDC Acting Director Anne Schuchat said at a recent briefing that "scary," "difficult to combat" drug-resistant microorganisms are on the rise, per the Post. Some good news is that C. auris hasn't morphed yet into new strains, and most people's chances of contracting it are very low, with it only affecting "the sickest of the sick," says CDC infectious disease specialist Tom Chiller. Also encouraging: a recent study IDing an antifungal that may prove useful. (No drug could save this Nevada woman.)