Identification of Candida auris

Reporting

Healthcare facilities or laboratories that suspect they have a patient with C. auris infection should contact state or local public health authorities and CDC (candidaauris@cdc.gov) immediately for guidance.

When to suspect C. auris

C. auris can be misidentified as a number of different organisms when using traditional phenotypic methods for yeast identification such as VITEK 2 YST, API 20C, BD Phoenix yeast identification system, and MicroScan.

The table below summarizes common misidentifications based on the identification method used. If any of the species listed below are identified, or if species identity cannot be determined, further characterization using appropriate methodology (see “How to identify Candida auris“) should be sought.

 Common misidentifications for c. auris
Identification Method Organism C. auris can be misidentified as
Vitek 2 YST Candida haemulonii
Candida duobushaemulonii
API 20C Rhodotorula glutinis (characteristic red color not present)
Candida sake
BD Phoenix yeast identification system Candida haemulonii
Candida catenulata
MicroScan Candida famata
Candida guilliermondii*
Candida lusitaniae*
Candida parapsilosis*
RapID Yeast Plus Candida parapsilosis*

Detailed algorithms for when to suspect C. auris based on identification methods.

*C. guilliermondii, C. lusitaniae, and C. parapsilosis generally make pseudohyphae on cornmeal agar. If hyphae or pseudohyphae are not present on cornmeal agar, this should raise suspicion for C. auris as C. auris typically does not make hyphae or pseudohyphae. However, some C. auris isolates have formed hyphae or pseudohyphae. Therefore, it would be prudent to consider any C. guilliermondii, C. lusitaniae, and C. parapsilosis isolates identified on MicroScan or any C. parapsilosis isolates identified on RapID Yeast Plus as possible C. auris isolates and forward them for further identification.

Please note that this list is based on current knowledge about C. auris misidentification. It may change from time to time as we learn more about misidentification of C. auris.

An increase in infections due to unidentified Candida species in a patient care unit, including increases in isolation of Candida from urine specimens, should also prompt suspicion for C. auris, since C. auris can be transmitted in healthcare settings.

The appearance and color of C. auris colonies in culture may aid in species identification, but cannot be used as the only identification method for C. auris since C. auris cannot be distinguished from other more common species of Candida without using other methods described in the section below. C. auris is a budding yeast, which almost never forms short pseudohyphae and does not form germ tubes. Some strains form aggregates of cells, whereas others do not. Unlike most other Candida species, it grows well at 40–42º C on CHROMagar. C. auris colonies appear white, pink, red, or purple.

. Mixed culture of Candida glabrata (purple), Candida tropicalis (navy blue), and Candida auris (white, circled in red) on CHROMagar Candida.

Mixed culture of Candida glabrata (purple), Candida tropicalis (navy blue), and Candida auris (white, circled in red) on CHROMagar Candida.

Candida auris on CHROMagar Candida, displaying multiple color morphs

Candida auris on CHROMagar Candida, displaying multiple color morphs.

Candida auris on CHROMagar Candida after Salt Sab Dulcitol Broth enrichment

Candida auris on CHROMagar Candida after Salt Sab Dulcitol Broth enrichment.

How to identify C. auris

Diagnostic devices based on matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) can differentiate C. auris from other Candida species, but not all the reference databases included in MALDI-TOF devices allow for detection. Currently, accurate identification of C. auris can be performed using the Bruker Biotyper brand MALDI-TOF using the updated Bruker FDA-approved MALDI Biotyper CA System library (Version Claim 4) or their “research use only” libraries (Versions 2014 [5627] and more recent) and using the bioMérieux VITEK (MALDI-TOF) MS using the FDA-approved IVD v3.2 or their “research use only” libraries  (with Saramis Ver 4.14 database and Saccharomycetaceae update).

Supplemental MALDI-TOF databases that include additional C. auris strains from all four of the phylogenetic clades may enable users to overcome identification challenges by providing consistently higher MALDI identification scores. MicrobeNet is one example of a free online MALDI database of rare and unusual pathogens that is curated by CDC experts. MicrobeNet users will have access to CDC C. auris MALDI spectral libraries as well as Bruker’s most up-to-date database (all free with your MicrobeNet login).

Candida auris screening protocols

Molecular methods based on sequencing the D1-D2 region of the 28s rDNA or the Internal Transcribed Region (ITS) of rDNA also can identify C. auris. The GenMark ePlex Blood Culture Identification Fungal Pathogen (BCID-FP) Panel is the first FDA-approved molecular test for C. auris identification. Various PCR methods have been developed for detecting C. auris and are available in the scientific literature.  The CDC PCR protocol is available here pdf icon[PDF – 11 pages]. When choosing a PCR method to validate, factors to consider include the sensitivity and specificity of the technique, available laboratory capacity and equipment, whether the method was clinically evaluated with a comparable clinical sample type, the cost, and the turnaround time to results.

VITEK 2 with software version 8.01 should also be able to accurately detect C. auris, though misidentifications of strains from certain clades have been reported and all Candida duobushaemulonii should be forwarded for further identification (see the identification algorithm pdf icon[PDF – 9 pages]).

As C. auris continues to gain recognition, updated versions of other yeast identification platforms may be able to identify C. auris; please consult the instrument manufacturer for more information.

Laboratories with capability to characterize isolates further when C. auris is suspected are encouraged to do so. Suspected isolates can also be sent to CDC’s AR Lab Network for identification and antifungal susceptibility testing.  This testing is performed free of charge and may require coordination through the State Public Health Department’s Healthcare-associated Infection (HAI) Program. Isolates should be submitted on slants shipped at room temperature. C. auris can grow on blood or chocolate agar slants; mycology specific media are not necessary if the laboratory does not have them. To learn more about using the AR Lab Network and to find a listing of AR Lab Network regional laboratories, visit How AR Lab Network Works.  Additionally, CDC and some state public health laboratories can assist with C. aurisisolate identification. All confirmed isolates of C. auris should be reported to local and state public health officials and CDC at candidaauris@cdc.gov.