Submitted:
27 April 2026
Posted:
28 April 2026
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Abstract
We conducted a literature review to evaluate global antifungal susceptibility patterns in Candida auris, an emerging multidrug-resistant fungal pathogen of growing clinical concern. A comprehensive search of the literature identified 29 studies reporting min-imum inhibitory concentrations (MICs) and resistance rates across major antifungal classes. Across studies, C. auris demonstrated consistently high resistance to fluconazole, with variable resistance observed among other azoles, amphotericin B, and echi-nocandins, alongside evidence of emerging multidrug resistance. These findings reflect significant geographic variability and highlight ongoing challenges in treatment selec-tion due to inconsistent susceptibility profiles and limited standardized breakpoints. Emerging antifungal agents, including ibrexafungerp and manogepix, demonstrate promising activity and may help address current therapeutic gaps. Overall, the global rise in antifungal resistance among C. auris isolates underscores the narrowing range of effective therapeutic options and reinforces the need for continued surveillance, improved susceptibility testing standardization, and development of novel antifungal agents.
Keywords:
Candida auris
; antifungal resistance
; antifungal susceptibility
; multidrug resistance
; panresistance
; global epidemiology
1. Introduction
Candida auris has emerged as a globally important multidrug-resistant fungal pathogen, prompting major public health agencies to classify it as an urgent threat due to its capacity for rapid spread, persistence, and high mortality [1]. Since its initial recognition, reports from India, South Africa, Europe, China, and the Americas have highlighted its widespread distribution and association with healthcare-associated outbreaks [2,3,4,5]. Early investigations revealed frequent misidentification and high levels of resistance to commonly used antifungals, complicating timely diagnosis and effective treatment [6,7].
Resistance patterns vary substantially across geographic regions and phylogenetic clades. Most isolates show high intrinsic resistance to fluconazole and elevated amphotericin B MICs, with up to 90% resistant to at least one antifungal [8,9]. Global clinical and genomic studies show emerging multidrug- and pan-resistant isolates, underscoring the need for ongoing surveillance of resistance evolution [4,10,11].
Given the increasing global burden, environmental persistence, and rising antifungal resistance, understanding current susceptibility patterns is essential. However, limited literature consolidates studies reporting MIC values and resistance rates across antifungal classes for C. auris. This review synthesizes contemporary resistance trends across antifungal classes and explores their implications for clinical management and infection-control strategies.
2. Materials and Methods
Criteria
We conducted a literature review of primary, peer-reviewed studies reporting antifungal susceptibility data for Candida auris. Eligible studies included clinical or surveillance isolates with minimum inhibitory concentration (MIC) data and/or resistance percentage for antifungals. Secondary sources such as literature reviews and systematic reviews were excluded. Only articles published in English between 1 January 2015 and 25 October 2025 were considered.
Definitions
Multidrug resistance (MDR) was defined as resistance to 2 separate agents. Pan-resistance was defined as resistance to azoles, echinocandins, and amphotericin B. MIC50 and MIC90 were defined as the MICs inhibiting 50% and 90% of isolates, respectively.
Objectives
The primary objective was to conduct a literature review to describe global trends in C. auris antifungal resistance, focusing on MIC distributions, resistance percentages, and MDR/pan-resistant phenotypes. The secondary objective was to evaluate the potential clinical relevance of these observations and identify how they may inform future practice.
Literature Review
A comprehensive search of PUBMED/MEDLINE, ScienceDirect, American Society for Microbiology, Multidisciplinary Digital Publishing Institute, Scientific Reports, Emerging Microbes and Infections, BMC and the CDC was performed from 7 August 2025 to 25 October 2025. Search terms included combinations of the keywords “Candida auris,” “antifungal resistance,” “antifungal susceptibility,” “MIC,” and “multidrug resistance.” Reference lists of articles were hand-searched. 96 articles were screened, of which 28 were ultimately included.
Analysis
Data including study location, setting, isolate number/source, identification and susceptibility methods, antifungals tested, MIC ranges, MIC50/MIC90, and reported resistance were extracted. When only MIC values for each isolate were provided, resistance percentages were calculated using CDC tentative breakpoint guidelines; fluconazole resistance was defined as MIC ≥32 µg/mL, amphotericin B resistance as MIC ≥2 µg/mL, anidulafungin resistance as MIC ≥4 µg/mL, caspofungin resistance as MIC ≥2 µg/mL, and micafungin resistance as MIC ≥4 µg/mL [12]. Resistance percentages were not calculated for studies that did not report MIC values for each individual isolate. MIC50 and MIC90 averages were calculated using the base numerical values provided (e.g., 64 rather than “>64”). For articles with multiple treatment periods, only the earliest was used for average calculations. When CLSI, EUCAST, and Vitek-2 MIC values were available, CLSI was used preferentially, followed by EUCAST and then Vitek-2. Articles reporting only median MIC values were excluded from average calculations.
3. Results
3.1. Study Selection
- A total of 96 primary, peer-reviewed articles were reviewed. Of those, 67 were excluded based on the following: non-human data, non-fungal data, secondary sources including literature reviews and C A reviews, articles written in languages other than English, and articles published before 1 January 2015. 28 studies were analyzed in this literature review.
3.2. Isolate Distribution
- Among the included studies, Candida auris isolates spanned four clades, with 13 articles reporting Clade I isolates, 4 Clade II, 5 Clade III, and 4 Clade IV. The geographic origins included Afghanistan, Bahrain, Bangladesh, China, Colombia, Egypt, India, Korea, Lebanon, Pakistan, Qatar, Saudi Arabia, South Africa, Spain, Turkey, United States, and Venezuela (Table 1).
3.3. Key Data Findings
Antifungals against Candia auris that displayed the highest average MIC50 values included fluconazole (n=27, 92.44 mg/L), ketoconazole (n=1, 32.00 mg/L), terbinafine (n=1, 16.00 mg/L), and flucytosine (n=14, 4.80 mg/L) (Table 2). Antifungals that displayed the lowest average MIC50 values included anidulafungin (n=19, 0.18 mg/L) and posaconazole (n=18, 0.16 mg/L) (Table 2). MIC90 values followed similar patterns with fluconazole, ketoconazole, terbinafine, and flucytosine having the highest average values.
Candida auris exhibited the highest average resistance to ketoconazole (100.0%), fluconazole (83.3%), itraconazole (62.5%), voriconazole (46.0%), flucytosine (35.57%), and amphotericin B (28.7%) (Table 2). Echinocandins showed generally low resistance rates, with anidulafungin (1.17%) and the novel rezafungin (3.80%) exhibiting the lowest percentages in comparison to caspofungin (10.73%) and micafungin (7.66%) (Table 2). One study reported a notably low resistance to posaconazole (0%).
Multidrug and pan-resistance were observed in multiple C. auris isolates across several studies. Multidrug resistance ranged from 6% to 92%, with an average of 43.06% (n=5) [1,8,11,13,14]. Pan-resistance was lower, ranging from 0.8% to 4%, with an average of 2.18% (n=3) [1,13,15]. Notably, one study reported that 8% of isolates from India were resistant to all echinocandins [16].
3.4. Ibrexafungerp and Manogepix
- The novel antifungal Ibrexafungerp was found to have a MIC50 value of 0.50 mg/L and MIC90 value of 2.00 mg/L against C. auris after assessing its in vitro activity against a collection of 434 European blood isolates, with a MIC range of 0.5 mg/L to 8 mg/L[10] (Table 1). These values are comparable to those observed with second-generation azoles and echinocandins. Additionally, a separate study evaluating serial isolates from a single patient reported a comparable Ibrexafungerp MIC of 0.25 mg/L for multiple isolates, further supporting its retained activity against C. auris even in the context of evolving resistance [9] (Table 1). Another novel antifungal, Manogepix, or APX001A, displayed an average MIC50 of 0.014 mg/L and an average MIC90 of 0.026 mg/L [14,17,18] (Table 2). Manogepix was active against 16 strains of C. auris and was also shown to be active against 6 pan-resistant isolates [18]. Manogepix also exhibited the lowest average MIC50 and MIC90 values among all antifungals evaluated.
3.5. Comorbidities and Isolate Origins
Candida auris isolates were obtained from a variety of infection sources, most frequently blood, urine, sputum, wounds, skin or soft tissue, bronchoalveolar lavage, and pleural fluid [1,3,4,5,7,14,15,16,17,19,20,21,22,23,24,25]. Less common sources included pus or abscesses, vaginal swabs, catheters, pericardial fluid, feces, ear canal, intra-abdominal fluid or tissue, aorta tissue, gangrenous tissue, lung tissue, bile, eye specimens, tracheal aspirate, and oral specimens [3,4,5,9,10,11,15,16,17,20,25].
4. Discussion
This review highlights variability in C. auris antifungal susceptibility and associated clinical challenges. Fluconazole showed the highest average MIC50 and MIC90, with resistance rates exceeding 80% across studies, supporting current recommendations that it is unreliable for both empiric and definitive treatment of suspected C. auris infections.
In contrast, echinocandins, particularly anidulafungin and rezafungin, exhibited low MIC values and minimal resistance, supporting their use as first-line agents in most clinical scenarios [28]. The low resistance observed for rezafungin suggests promise for next generation echinocandins, given its favorable pharmacokinetics and potential dosing advantages [29]. However, the emergence of echinocandin resistance, including pan-echinocandin resistant isolates and resistance rates exceeding 7% for micafungin and caspofungin, highlight the need for ongoing surveillance and informed clinical decision-making when using echinocandins [30].
Beyond fluconazole and echinocandins, other antifungals demonstrated overall limited and inconsistent activity against C. auris. Additional azoles were characterized by elevated MICs and substantial resistance, including complete resistance to ketoconazole and resistance rates exceeding 60% for itraconazole. Terbinafine showed minimal activity, flucytosine exhibited highly variable susceptibility, and amphotericin B demonstrated intermediate resistance with nearly one-third of isolates affected, raising concerns about its reliability as a second-line agent [31]. Collectively, these findings reflect the narrowing therapeutic landscape for C. auris and frame the significant clinical decision-making challenges ahead.
Novel antifungals offer cautious optimism. Ibrexafungerp demonstrated activity comparable to echinocandins, while manogepix showed exceptionally low MIC values, including activity against pan-resistant isolates [14,17,18]. These agents may expand therapeutic options for both routine and refractory C. auris infections. Multidrug resistance rates averaged over 40% across studies. As multidrug resistance in C. auris continues to expand, these findings underscore the need to consider novel antifungal agents and combination therapeutic strategies in future treatment approaches [32].
Several limitations should be noted. Heterogeneity in geography, study design, and susceptibility methods may limit uniform global conclusions. Incomplete antifungal susceptibility reporting led to variable sample sizes across agents and may bias resistance estimates toward better-characterized drugs. Restriction to English-language publications and limited patient-level clinical data further reduce generalizability and limit correlations with clinical outcomes.
Despite these advances, important gaps remain. Clinical outcome data linking MIC values to treatment success are limited, and standardized breakpoints for several agents are lacking. Real-world data on newer antifungals in diverse patient populations are also sparse. Continued surveillance, clinical trials, and integration of susceptibility data into clinical decision-making are critical to improving outcomes for patients with C. auris infections.
Author Contributions
N.M.B., R.P., and A.C. performed study conceptualization and methodology. Data acquisition and composition of the initial draft was performed by N.M.B., R.P., O.Z.H., G.R., and S.A. Revision and editing were conducted by N.M.B., R.P., and A.C. Supervision of the study was provided by N.M.B., R.P., and A.C. All authors reviewed and approved the final manuscript.
Funding
This work was supported by startup funds provided to A.C. by the University of Texas Medical Branch.
Informed Consent Statement
This study did not involve identifiable patient data or interventions requiring patient consent. Therefore, written patient consent was not applicable. The study design did not require review or approval by an institutional review board or ethics committee and conforms to ethical standards currently applied in the country of origin. .
Data Availability Statement
All data analyzed in this literature review were derived from previously published studies that are publicly available. No new data was generated or deposited for this study.
Acknowledgments
We thank Dr. Alfredo Torres for facilitating this collaboration.
Conflicts of Interest
All authors report no conflicts of interest.
References
- Lockhart, S.R.; Etienne, K.A.; Vallabhaneni, S.; et al. Simultaneous Emergence of Multidrug-Resistant Candida auris on 3 Continents Confirmed by Whole-Genome Sequencing and Epidemiological Analyses. Clin. Infect. Dis. 2017, 64(2), 134–140. [Google Scholar] [CrossRef]
- Calvo, B.; Melo, A.S.A.; Perozo-Mena, A.; et al. First report of Candida auris in America: Clinical and microbiological aspects of 18 episodes of candidemia. J. Infect. 2016, 73(4), 369–374. [Google Scholar] [CrossRef]
- Chowdhary, A.; Prakash, A.; Sharma, C.; et al. A multicentre study of antifungal susceptibility patterns among 350 Candida auris isolates (2009–17) in India: role of the ERG11 and FKS1 genes in azole and echinocandin resistance. J. Antimicrob. Chemother. 2018, 73(4), 891–899. [Google Scholar] [CrossRef]
- Arendrup, M.C.; Prakash, A.; Meletiadis, J.; Sharma, C.; Chowdhary, A. Comparison of EUCAST and CLSI Reference Microdilution MICs of Eight Antifungal Compounds for Candida auris and Associated Tentative Epidemiological Cutoff Values. Antimicrob. Agents Chemother. 2017, 61(6). [Google Scholar] [CrossRef]
- Zhu, Y.; O’Brien, B.; Leach, L.; et al. Laboratory Analysis of an Outbreak of Candida auris in New York from 2016 to 2018: Impact and Lessons Learned. J. Clin. Microbiol. 2020, 58(4). [Google Scholar] [CrossRef]
- O’Brien, B.; Liang, J.; Chaturvedi, S.; Jacobs, J.L.; Chaturvedi, V. Pan-resistant Candida auris: New York subcluster susceptible to antifungal combinations. Lancet Microbe 2020, 1(5), e193–e194. [Google Scholar] [CrossRef]
- Ninan, M.M.; Sahni, R.D.; Chacko, B.; Balaji, V.; Michael, J.S. Candida auris: Clinical profile, diagnostic challenge and susceptibility pattern: Experience from a tertiary-care centre in South India. J. Glob. Antimicrob. Resist. 2020, 21, 181–185. [Google Scholar] [CrossRef] [PubMed]
- Maphanga, T.G.; Naicker, S.D.; Kwenda, S.; et al. In Vitro Antifungal Resistance of Candida auris Isolates from Bloodstream Infections, South Africa. Antimicrob. Agents Chemother. 2021, 65(9), e0051721. [Google Scholar] [CrossRef]
- Jacobs, S.E.; Jacobs, J.L.; Dennis, E.K.; et al. Candida auris Pan-Drug-Resistant to Four Classes of Antifungal Agents. Antimicrob. Agents Chemother. 2022, 66(7), e0005322. [Google Scholar] [CrossRef] [PubMed]
- Quindós, G.; Miranda-Cadena, K.; San-Millán, R.; et al. In Vitro Antifungal Activity of Ibrexafungerp (SCY-078) Against Contemporary Blood Isolates From Medically Relevant Species of Candida: A European Study. Front Cell. Infect. Microbiol. 2022, 12, 906563. [Google Scholar] [CrossRef] [PubMed]
- Castanheira, M.; Deshpande, L.M.; Rhomberg, P.R.; Carvalhaes, C.G. Recent increase in Candida auris frequency in the SENTRY surveillance program: antifungal activity and genotypic characterization. Antimicrob. Agents Chemother. 2024, 68(10), e0057024. [Google Scholar] [CrossRef] [PubMed]
- Antifungal Susceptibility Testing for C. auris; CDC, 24 April 2024.
- Erdem, H.; Şakir-Yildirim, S.; Ankarali, H.; et al. Managing Candida auris fungemias: the results of a prospective and international study. Antimicrob. Agents Chemother. 2025, 69(8), e0035825. [Google Scholar] [CrossRef] [PubMed]
- Maphanga, T.G.; Mpembe, R.S.; Naicker, S.D.; Govender, N.P.; for GERMS-SA. In Vitro Antifungal Activity of Manogepix and Other Antifungal Agents against South African Candida auris Isolates from Bloodstream Infections. Microbiol. Spectr. 2022, 10(1), e0171721. [Google Scholar] [CrossRef] [PubMed]
- Akkaya, Y.; Erdin, B.N.; Yılmaz, A.M.; Kılıç, İ.H.; Toraman, Z.A. Identification and antifungal resistance profiling of Candida (Candidozyma) auris in a tertiary hospital in Istanbul, Türkiye. Ann. Saudi Med. 2025, 45(4), 207–217. [Google Scholar] [CrossRef]
- Kathuria, S.; Singh, P.K.; Sharma, C.; et al. Multidrug-Resistant Candida auris Misidentified as Candida haemulonii: Characterization by Matrix-Assisted Laser Desorption Ionization-Time of Flight Mass Spectrometry and DNA Sequencing and Its Antifungal Susceptibility Profile Variability by Vitek 2, CLSI Broth Microdilution, and Etest Method. J. Clin. Microbiol. 2015, 53(6), 1823–1830. [Google Scholar] [CrossRef]
- Zhu, Y.; Kilburn, S.; Kapoor, M.; Chaturvedi, S.; Shaw, K.J.; Chaturvedi, V. In Vitro Activity of Manogepix against Multidrug-Resistant and Panresistant Candida auris from the New York Outbreak. Antimicrob. Agents Chemother. 2020, 64(11). [Google Scholar] [CrossRef]
- Hager, C.L.; Larkin, E.L.; Long, L.; Zohra Abidi, F.; Shaw, K.J.; Ghannoum, M.A. In Vitro and In Vivo Evaluation of the Antifungal Activity of APX001A/APX001 against Candida auris. Antimicrob. Agents Chemother. 2018, 62(3). [Google Scholar] [CrossRef]
- Ruiz-Gaitán, A.C.; Cantón, E.; Fernández-Rivero, M.E.; Ramírez, P.; Pemán, J. Outbreak of Candida auris in Spain: A comparison of antifungal activity by three methods with published data. Int. J. Antimicrob. Agents 2019, 53(5), 541–546. [Google Scholar] [CrossRef]
- Lee, H.; Choi, S.H.; Oh, J.; et al. Comparison of Six Antifungal Susceptibilities of 11 Candida Species Using the VITEK2 AST-YS08 Card and Broth Microdilution Method. Microbiol. Spectr. 2022, 10(2), e0125321. [Google Scholar] [CrossRef]
- Ahmed, S.H.; El-Kholy, I.M.A.; El-Mehalawy, A.A.; Mahmoud, E.M.; Elkady, N.A. Molecular characterization of some multidrug resistant Candida auris in egypt. Sci. Rep. 2025, 15(1), 4917. [Google Scholar] [CrossRef]
- Wang, Y.; Lin, L.; Li, J.; et al. Epidemiological Trends and Antimicrobial Resistance of Candida auris: A Focus on 7 Cases in a Single Medical Institution of Southern China. Infect. Drug. Resist. 2025, 18, 2557–2568. [Google Scholar] [CrossRef]
- Koleri, J.; Petkar, H.M.; Rahman, S.; Al Soub, H.A.; Rahman, S.; AlMaslamani, M.A. Candida auris Blood stream infection- a descriptive study from Qatar. BMC Infect. Dis. 2023, 23(1), 513. [Google Scholar] [CrossRef]
- Kalkanci, A.; Erganis, S.; Sahin, E.A.; et al. Biocide, antifungal susceptibility and virulence characteristics of Clade 1 Candidozyma auris strains. Ann. Clin. Microbiol. Antimicrob. 2025, 24(1), 55. [Google Scholar] [CrossRef]
- Reslan, L.; Araj, G.F.; Finianos, M.; et al. Molecular Characterization of Candida auris Isolates at a Major Tertiary Care Center in Lebanon. Front Microbiol. 2022, 12. [Google Scholar] [CrossRef]
- Prayag, P.S.; Patwardhan, S.A.; Joshi, R.S.; Dhupad, S.; Rane, T.; Prayag, A.P. Comparative efficacies of the three echinocandins for Candida auris candidemia: real world evidence from a tertiary centre in India. Med. Mycol. 2024, 62(7). [Google Scholar] [CrossRef]
- Bing, J.; Du, H.; Guo, P.; et al. Candida auris -associated hospitalizations and outbreaks, China, 2018–2023. Emerg. Microbes Infect. 2024, 13(1). [Google Scholar] [CrossRef]
- Tóth, Z.; Forgács, L.; Locke, J.B.; et al. In vitro activity of rezafungin against common and rare Candida species and Saccharomyces cerevisiae. J. Antimicrob. Chemother. 2019, 74(12), 3505–3510. [Google Scholar] [CrossRef]
- James, K.D.; Laudeman, C.P.; Malkar, N.B.; Krishnan, R.; Polowy, K. Structure-Activity Relationships of a Series of Echinocandins and the Discovery of CD101, a Highly Stable and Soluble Echinocandin with Distinctive Pharmacokinetic Properties. Antimicrob. Agents Chemother. 2017, 61(2). [Google Scholar] [CrossRef]
- Misas, E.; Escandón, P.L.; Gade, L.; et al. Genomic epidemiology and antifungal-resistant characterization of Candida auris, Colombia, 2016–2021. mSphere 2024, 9(2). [Google Scholar] [CrossRef]
- Escandón, P.; Chow, N.A.; Caceres, D.H.; et al. Molecular Epidemiology of Candida auris in Colombia Reveals a Highly Related, Countrywide Colonization With Regional Patterns in Amphotericin B Resistance. Clin. Infect. Dis. 2019, 68(1), 15–21. [Google Scholar] [CrossRef]
- Valdez, A.F.; Bohner, F.; Goldman, J.P.; et al. Candida auris Antifungal Resistance, Virulence and Susceptibility to a Novel Nitric Oxide-Releasing Microparticle and Its Correlations to Clade Identification. Microbiol. Res. 2025, 16(1), 15. [Google Scholar] [CrossRef]
Table 1.
Reported Results of MIC50, MIC90, and Resistance Percentages of C. auris to Antifungals.
| Study | Time Period of Isolate Collection | N total isolates; Region; Clade (n) a | MIC50 (mg/L) | MIC90 (mg/L) | Resistance (%) |
| Prayag[26] | N/A | 82; India | Caspo: 0.25 Mica: 0.12 Anidula: 0.25 |
Caspo: 8.0 Mica: 5.0 Anidula: 5.0 |
Caspo: 35.36% Mica: 0% Anidula: 0% |
| Ruiz-Gaitan[19] | N/A | 73; Spain | Flu: >64 Itra: 0.12 Isavu: 0.06 Vori: 2.0 Posa: 0.06 AmpB: 0.12 Mica: 0.06 Anidula: 0.03 |
Flu: >64 Itra: 0.25 Isavu: 0.12 Vori: 4.0 Posa: 0.12 AmpB: 0.25 Mica: 0.06 Anidula: 0.06 |
Flu: 100% AmpB: 0% Caspo: 0% Mica: 0% Anidula: 0% |
| Toth[28] | 2005-2018 | 19; Hungary | Flu: >32 AmpB: 0.5 Caspo: 0.5 Mica: 0.25 Anidula: 0.06 Reza: 0.12 |
Flu: >32 AmpB: 1 Caspo: 1 Mica: 0.5 Anidula: 0.25 Reza: 0.25 |
Flu: 68.40% AmpB: 0% Caspo: 0% Mica: 0% Anidula: 0% |
| Lee[20] | 2022 | 45; Korea | Flu: 16 Vori: 0.06 AmpB: 0.5 Caspo: 0.12 Mica: 0.12 5-FC: 0.12 |
Flu: 64 Vori: 0.5 AmpB: 2.0 Caspo: 0.5 Mica: 0.5 5-FC: 0.25 |
Flu: 37.80% AmpB: 24.40% Caspo: 0% Mica: 0% |
| Chowdhary [3] | 2009-2017 | 350; India | Flu: 64 Itra: 0.125 Isavu: 0.03 Vori: 0.25 Posa: 0.03 Serta: 0.5 AmpB: 1.0 Caspo: 1.0 Mica: 0.125 Anidula: 0.25 5-FC: 0.125 Terbin: 16.0 Nystatin: 4.0 |
Flu: 64 Itra: 0.5 Isavu: 0.5 Vori: 2.0 Posa: 0.125 Serta: 8.0 AmpB: 1.0 Caspo: 2.0 Mica: 0.25 Anidula: 1.0 5-FC: 64 Terbin: 32.0 Nystatin: 4.0 |
Fluc: 90% AmpB: 8% Caspo: 2% Mica: 2% Anidula: 2% |
| Maphanga[8] | 2016-2017 | 92; South Africa;III (77), I (13) and IV (2) | Flu: 128 Itra: 0.12 Vori: 0.5 Posa: 0.06 AmpB: 1.0 Caspo: 0.06 Mica: 0.06 Anidula: 0.12 5-FC: 0.12 |
Flu: 256 Itra: 0.25 Vori: 2.0 Posa: 0.12 AmpB: 2.0 Caspo: 0.25 Mica: 0.12 Anidula: 0.25 5-FC: 0.25 |
Flu: 90% AmpB: 27% Caspo: 1% Mica: 0.50% Anidula: 0% |
| Castanheira [11]b | 2013-2022 | 78; global; I (40), IV (30), III (7), II (1) | Flu: 64 AmpB: 1.0 Caspo: 0.12 Mica: 0.12 Anidula: 0.25 Reza: 0.25 |
Flu: >128 AmpB: 2.0 Caspo: 0.25 Mica: 0.25 Anidula: 0.5 Reza: 0.5 |
Flu: 82.10% AmpB: 17.90% Caspo: 1.30% Mica: 1.30% Anidula: 1.30% Reza: 3.8% |
| Jacobs[9]c | 2020 | 19; United States; Id | Flu: >256 Vori: 2.0 Itra: 1.0 Isavu: 2.0 Posa: 0.5 AmpB: 1.0 Caspo: 0.25 Mica: 0.12 Anidula: 0.25 5-FC: 0.094 Ibrexa: 0.25 |
None reported | Flu: 100% AmpB: 0% Caspo: 0% Mica: 0% Anidula: 0% |
| Valdez[32] | N/A | 8; United States; I (7) and II (1) | Flu: >256 AmpB: 1.0 Caspo: 0.25 |
Flu: >256 AmpB: 1.0 Caspo: 0.25 |
Flu: 87.50% AmpB: 0% Caspo: 0% |
| Ahmed[21]e | N/A | 4; Egypt; | Flu: 32 Itra: >16 Keto: 32 Vori: 0.25 Posa: 0.25 AmpB: 1.0 Caspo: >8.0 Mica: >8.0 5-FC: >64 |
Flu: 32 Itra: >16 Keto: 32 Vori: 1.0 Posa: 1.0 AmpB: 1.0 Caspo: >8.0 Mica: >8.0 5-FC: >64 |
Flu: 100% Itra: 100% Keto: 100% Vori: 0% Posa: 0% AmpB: 0% Caspo: 100% Mica: 100% 5-FC: 100% |
| Wang[22] | 2023-2024 | 7; China; I (3) and III (4) | Flu: 128 Itra: 0.12 Vori: 0.5 Posa: 0.03 AmpB: 1.0 Caspo: 0.12 Anidula: 0.12 5-FC: 0.06 |
Flu: 256 Itra: 0.25 Vori: 1.0 Posa: 0.12 AmpB: 2.0 Caspo: 0.5 Anidula: 1.0 5-FC: 0.12 |
Flu: 100% AmpB: 42.90% Caspo: 0% Anidula: 0% |
| Misas[30] | 2016-2021 | 182; Colombia: IV | Flu: 16 AmpB: 0.5 Caspo: 0.12 Mica: 0.125 Anidula: 0.25 |
Flu: 256 AmpB: 2.0 Caspo: 0.25 Mica: 0.5 Anidula: 1.0 |
Flu: 37% AmpB: 21% Caspo: 1% Mica: 0% Anidula: 0.60% |
| Bing[27] | 2018-2023 | 312; China; I, II, and III | None reported | None reported | Flu: 98.70% AmpB: 4.20% Caspo: 2.20% |
| Koleri[23] | 2018-2021 | 33; Qatar; I | None reported (all Med MIC) | None reported (all Med MIC) | Flu: 91% AmpB: 84.80% Caspo: 9.10% Mica: 0% Anidula: 0% |
| Kathuria[16] | 2010-2014 | 90, India | Flu: 64 Itra: 0.125 Isavu: 0.25 Vori: 1 Posa: 0.06 AmpB: 1 Caspo: 0.5 Mica: 0.125 Anidula: 0.125 5-FC: 0.25 |
Flu: 64 Itra: 0.5 Isavu: 2 Vori: 8 Posa: 2 AmpB: 4 Caspo: 1 Mica: 0.25 Anidula: 0.5 5-FC: 8 |
AmpB: 15.50% Caspo: 8.90% |
| Calvo[2] | 2012-2013 | 18; Venezuela | Flu: 64 Vori: 4 AmpB: 1 Anidula: 0.125 5-FC: 0.5 |
Flu: 64 Vori: 4 AmpB: 2 Anidula: 0.125 5-FC: 0.5 |
Flu: 100% |
| Lockhart[1] | 2012-2015 | 54; Pakistan, India, South Africa, and Venezuela | Flu: 128 Itra: 0.5 Vori: 2 Posa: 0.5 AmpB: 1 Caspo: 0.25 Mica: 0.25 Anidula: 0.5 5-FC: 0.125 |
Flu: 256 Itra: 1 Vori: 8 Posa: 1 AmpB: 2 Caspo: 1 Mica: 2 Anidula: 1 5-FC: 0.5 |
Flu: 93% AmpB: 35% 5-FC: 6% |
| Zhu [5]f | 2016-2018 | 413; United States; I, II | Flu: >256 Itra: 0.5 Isavu: 0.5 Vori: 2 Posa: 0.25 AmpB: 2 Caspo: 0.12 Mica: 0.12 Anidula: 0.25 5-FC: 0.094 |
Flu: >256 Itra: 1 Isavu: 1 Vori: 2 Posa: 0.5 AmpB: 2 Caspo: 0.25 Mica: 0.25 Anidula: 0.5 5-FC: 0.125 |
Flu: 99% Vori: 81% AmpB: 61% Caspo: 0% Mica: 0% Anidula: 0% 5-FC: 0.70% |
| Erdem[13] | 2024 | 162; Turkey, India, Saudi Arabia, Egypt, Bahrain, Bangladesh, and Afghanistan | Flu: 32 Itra: 0.12 Vori: 1 Posa: 0.12 AmpB: 4 Caspo: 0.25 Mica: 0.12 Anidula: 0.12 5-FC: 0.5 |
Flu: 256 Itra: 16 Vori: 16 Posa: 4 AmpB: 32 Caspo: 2 Mica: 2 Anidula: 2 5-FC: 64 |
Flu: 90.3% AmpB: 70.1% Caspo: 14% Mica: 7.1% Anidula: 2.6% |
| Ninan[7] | 2016-2017 | 11; India | Flu: 32 Itra: 0.5 Vori: 0.5 Posa: 0.03 AmpB: 1.0 Caspo: 0.25 Anidula: 0.047 |
Flu: 64 Itra: 0.5 Vori: 1.0 Posa: 0.12 AmpB: 1.0 Caspo: 0.5 Anidula: 0.25 |
Flu: 91% |
| Akkaya[15] | 2023-2024 | 57; Turkey; I | Flu: 32 AmpB: 2 Caspo: 0.12 Mica: 0.06 Anidula: 0.12 |
Flu: 128 AmpB: 16 Caspo: 0.25 Mica: 0.12 Anidula: 0.5 |
Flu: 82% AmpB: 60% Caspo: 7% Mica: 5% |
| Kalkanci[24] | 2025 | 47; Turkey; I | Flu: 16 Itra: 1 Isavu: 0.12 Vori: 2 Posa: 0.12 AmpB: 0.5 Caspo: 0.12 |
Flu: 32 Itra: 2 Isavu: 0.5 Vori: 8 Posa: 0.5 AmpB: 1 Caspo: 0.25 |
Flu: 82% Amph B: 60% Caspo: 7% Mica: 5% |
| Quindos[10] | 2022 | 22; Europe | Flu: >=128 Caspo: 0.125 Mica: 0.125 Ibrexa: 0.5 |
Flu: >=128 Caspo: >8 Mica: 4 Ibrexa: 2 |
Flu: 31% Amph B: 4% |
| Quindos[24] | 2022 | N/A | Flu: >=128 Caspo: 0.125 Mica: 0.125 Ibrexa: 0.5 |
Flu: >=128 Caspo: >8 Mica: 4 Ibrexa: 2 |
Flu: 100% Caspo: 27.27% Mica: 18.18% |
| Reslan[25] | 2022 | Lebanon (I) | Flu: 32 Itra: 0.25 Vori: 0.25 Amph B: 8 Caspo: 0.25 Mica: 0.12 Flucyt: 1 |
Flu: >=32 Itra: 1 Vori: 0.25 Amph B: 8 Caspo: 0.25 Mica: 0.12 Flucyt: 1 |
Flu: 54% Itra: 25% Vori: 3% Amph B: 100% Caspo: 0% Mica: 0% |
| Arendrup[4]g | 2010-2015 | 123; India | CLSI: Flu: >=64 Itra: 0.125 Isavu: 0.125 Vori: 0.5 Posa: 0.016 AmpB: 0.5 Mica: 0.125 Anidula: 0.125 EUCAST: Flu: >=64 Itra: 0.125 Isavu: 0.125 Vori: 0.5 Posa: 0.032 AmpB: 1 Mica: 0.125 Anidula: 0.125 |
CLSI: Flu: >=64 Itra: 0.25 Isavu: 0.5 Vori: 4 Posa: 0.125 AmpB: 2 Mica: 0.25 Anidula: 0.5 EUCAST: Flu: >=64 Itra: 0.5 Isavu: 0.5 Vori: 2 Posa: 0.125 AmpB: 1 Mica: 0.25 Anidula: 1 |
Flu: 86% AmpB: 10% Mica: 6% Anidula: 5.69% |
| Hager[18] | 2018 | 16; Germany, Japan, South Korea, India, | Flu: 16*, >64** Itra: 0.5** Vori: 0.5*, 0.5** Posa: 0.25** AmpB: 2*, 4** Mica: 1* Mano: 0.004 |
Flu: >64*, >64** Itra: 1** Vori: 1*, 2** Posa: 1** AmpB: 4*, 8** Mica: 2* Mano: 0.031 |
None reported |
| Maphanga [14] | 2016-2017 | 394h; South Africa; III, I, IV | Flu: 128 Itra: 0.12 Vori: 0.5 Posa: 0.06 AmpB: 1 Caspo: 0.06 Mica: 0.06 Anidula: 0.12 5-FC: 0.12 Mano: 0.008 |
Flu: 256 Itra: 0.25 Vori: 2 Posa: 0.12 AmpB: 2 Caspo: 0.25 Mica: 0.12 Anidula: 0.25 5-FC: 0.25 Mano: 0.016 |
Flu: 90% AmpB: 27% Mica: 0.50% Anidula: 0% |
| Zhu [17] | 2017-2020 | 200; United States; I | Flu: 256 Itra: 0.5 Isavu: 1 Vori: 2 Posa: 0.25 AmpB: 1 Caspo: 0.12 Mica: 0.12 Anidula: 0.25 5-FC: 0.064 Mano: 0.03 |
Flu: 256 Itra: 1 Isavu: 1 Vori: 2 Posa: 0.5 AmpB: 2 Caspo: 0.25 Mica: 0.25 Anidula: 1 5-FC: 32 Mano: 0.03 |
Flu: 100% AmpB: 46.50% Caspo: 5.50% Mica: 5% Anidula: 5.50% |
Abbreviations: Flu, fluconazole; Itra, itraconazole; Isavu, isavuconazole; Vori, voriconazole; Posa, posaconazole; Serta, sertaconazole; Amph B, amphotericin B; Caspo; caspofungin; Mica, micafungin; Anidula, anidulafungin; Reza, rezafungin; Flucyt, flucytosine; Terbina, terbinafine; Nyst, nystatin; Ibrexa, ibrexafungerp; Mano, manogepix. *24-hour treatment period of C. auris strains. **48-hour treatment period of C. auris strains. aClade denotes the phylogenetic lineage of C. auris (Clades I–IV) based on whole-genome sequencing and geographic distribution; values in parentheses represent the number of isolates (n) within each clade when reported. bRezafungin resistance was calculated by the original author using provisional susceptibility breakpoints published by the CLSI (≤0.5 mg/L). cThe values listed were derived from the initial sample collected from the patient on hospitalization day 4 labeled as isolate 20-34. d All 19 isolates were derived from a single patient. MICs reflect the initial isolate obtained prior to antifungal therapy; later isolates showed increased resistance following treatment. eThe original author defined breakpoints for voriconazole (2 mg/L) and flucytosine (64 mg/L) using recommendations from prior published studies. The author also defined breakpoints for posaconazole, itraconazole, and ketoconazole by applying CLSI breakpoints established for multidrug-resistant Candida tropicalis and Candida parapsilosis. fMIC breakpoints of voriconazole and flucytosine were defined by the author as MIC ≥ 2.0 μg/ml and ≥32.0 μg/ml respectively. gMICs (in milligrams per liter) were determined using two methods: CLSI method M27-A3 and EUCAST E.Def 7.3. hThe isolates tested in this study were previously published in Maphanga 2021 [8].
Table 2.
Average MIC50, MIC90, and Resistance Percentages of Antifungals against C. auris.
| Antifungal | Average MIC50 (+/- SD) (Study n) | Average MIC90 (+/- SD) (Study n) | Average Resistance % (+/- SD) (Study n) |
| Fluconazole | 92.44 (+/- 79.79) (n=27) | 138.67 (+/- 96.54) (n=24) | 83.95 (+/- 21.29) (n=25) |
| Itraconazole | 1.33 (+/- 3.92) (n=16) | 2.72 (+/- 5.41) (n=15) | 62.50 (+/- 53.03) (n=2) |
| Isavuconazole | 0.51 (+/- 0.68) (n=8) | 0.80 (+/- 0.61) (n=7) | Not reported |
| Ketoconazole | 32.00 (n=1) | 32.00 (n=1) | 100.00 (n=1) |
| Voriconazole | 1.15 (+/- 1.03) (n=19) | 3.71 (+/- 4.01) (n=18) | 46.00 (+/- 51.98) (n=4) |
| Posaconazole | 0.16 (+/- 0.16) (n=18) | 0.74 (+/- 1.08) (n=19) | 0.00 (n=1) |
| Sertaconazole | 0.50 (n=1) | 8.00 (n=1) | Not reported |
| Amphotericin B | 1.40 (+/- 1.60) (n=24) | 4.01 (+/- 7.04) (n=23) | 28.67 (+/- 29.39) (n=23) |
| Caspofungin | 0.59 (+/- 1.67) (n=22) | 1.67 (+/- 2.70) (n=21) | 10.73 (+/- 23.10) (n=20) |
| Micafungin | 0.54 (+/- 1.72) (n=21) | 1.33 (+/- 2.09) (n=20) | 7.66 (+/- 22.80) (n=19) |
| Anidulafungin | 0.18 (+/- 0.11) (n=19) | 0.87 (+/- 1.13) (n=19) | 1.17 (+/- 1.97) (n=15) |
| Rezafungin | 0.19 (+/- 0.09) (n=2) | 0.38 (+/- 0.18) (n=2) | 3.80 (n=1) |
| Flucytosine | 4.80 (+/- 17.04) (n=14) | 18.08 (+/- 27.58) (n=13) | 35.57 (+/- 55.86) (n=2) |
| Terbinafine | 16.00 (n=1) | 32.00 (n=1) | Not reported |
| Nystatin | 4.00 (n=1) | 4.00 (n=1) | Not reported |
| Ibrexafungerp | 0.38 (+/- 0.18) (n=2) | 2.00 (n=1) | Not reported |
| Manogepix | 0.014 (+/- 0.014) (n=3) | 0.026 (+/- 0.008) (n=3) | Not reported |
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