30-day mortality and antifungal resistance in confirmed Candida auris bloodstream infections (BSI): a systematic review and meta-analysis.

BACKGROUND

Candida auris is a potentially multidrug-resistant nosocomial fungus that was classified as a WHO critical priority pathogen in 2022. Individual cohort studies report 30-day bloodstream infection mortality; however, prior meta-analyses have not restricted their primary pool to confirmed bloodstream infection cases.

METHODS

A PROSPERO-registered systematic review and meta-analysis was conducted (CRD420261418844). Studies enrolling patients with confirmed C. auris bloodstream infection and reporting 30-day or in-hospital all-cause mortality were included. Freeman-Tukey double arcsine transformation with DerSimonian-Laird random-effects modelling was applied to all proportion pools. Fluconazole and amphotericin B resistance were combined. Echinocandin resistance was synthesised narratively because of the zero-event problem. Subgroup analyses were pre-specified by geographic region and study designs.

RESULTS

Sixteen studies (N = 1,069 patients; 2016-2026) met the inclusion criteria. Pooled 30-day mortality from 13 studies (N = 813) was 39.6% (95% CI 32.4-47.0%; I2 = 75.5%). In-hospital mortality from three studies (N = 256) was 45.1% (95% CI 30.9-59.7). Pooled fluconazole resistance was 95.0% (95% CI 86.7-99.7%; I2 = 92.6%). Pooled amphotericin B resistance was 45.5% (95% CI 22.6-69.4%; I2 = 97.5%), with extreme heterogeneity driven by clade-specific variations. Echinocandin resistance ranged from 0 to 16% across the individual cohorts. Multinational consortia showed the highest regional mortality estimate (52.4%, 95% CI 41.4-63.3%).

CONCLUSIONS

Confirmed C. auris bloodstream infections have a pooled 30-day mortality rate of approximately 40%, along with near-universal fluconazole resistance. Echinocandins remain the first-line therapy, although mortality rates remain high. Susceptibility-guided therapy and enhanced infection control are essential.