At a glance
All C. auris isolates should undergo antifungal susceptibility testing following Clinical and Laboratory Standards Institute (CLSI) guidelines. Breakpoints are defined based on those established for closely related Candida species and on expert opinion.
Current breakpoint guidelines
The Clinical and Laboratory Standards Institute (CLSI) has established guidelines for antifungal susceptibility testing. Those guidelines provide recommendations for determining susceptibility of yeasts, such as C. auris, to antifungal drugs.
There are currently no established C. auris-specific susceptibility breakpoints. Therefore, breakpoints are defined based on those established for closely related Candida species and on expert opinion. Correlation between microbiologic breakpoints and clinical outcomes is not known at this time. Therefore, the information below should be considered as a general guide and not as definitive breakpoints for resistance.
| Triazole Class Drugs | Tentative MIC Breakpoints (µg/mL) | Comment |
|---|---|---|
| Fluconazole | ≥32 | Modal minimum inhibitory concentration (MIC) to fluconazole among isolates tested at CDC was ≥256; isolates with MICs ≥32 were shown to have a resistance mutation in the Erg11 gene, making them unlikely to respond to fluconazole. |
| Voriconazole and other second generation triazoles | N/A | Consider using fluconazole susceptibility as a surrogate for second generation triazole susceptibility assessment. However, isolates that are resistant to fluconazole may respond to other triazoles occasionally. The decision to treat with another triazole will need to be made on case-by-case basis. |
| Polyene Class Drug | Tentative MIC Breakpoints (µg/mL) | Comment |
|---|---|---|
| Amphotericin B | ≥2 | Recent pharmacokinetic/pharmacodynamic analysis of C. auris in a mouse model of infection indicates that under standard dosing, the breakpoint for amphotericin B should be 1 or 1.5, similar to what has been determined for other Candida species. Therefore, isolates with an MIC of ≥2 should now be considered resistant. If using Etest for amphotericin B and an MIC of 1.5 is determined, that value should be rounded up to 2. |
| Echinocandin Class Drugs | Tentative MIC Breakpoints (µg/mL) | Comment |
|---|---|---|
| Anidulafungin | ≥ 4 | Tentative breakpoints are based on the modal distribution of echinocandin MICs of approximately 100 isolates from diverse geographic locations. |
| Caspofungin | ≥ 2 | |
| Micafungin | ≥ 4 |
Please note that a finding of an elevated minimum inhibitory concentration (MIC) for an antifungal drug should not necessarily preclude its use. This is especially true if the use of other antifungal drugs for the patient has been ineffective.
Based on these MIC breakpoints, many isolates are resistant to multiple classes of drugs. Some U.S. C. auris isolates have been found to be resistant to all three classes of antifungal drugs. CDC has received reports of pan-resistance found in other countries as well.
In the United States, about 90% of C. auris isolates have been resistant to fluconazole, about 30% have been resistant to amphotericin B, and less than 2% have been resistant to echinocandins. These proportions may include multiple isolates from the same individuals and may change as more isolates are tested.