Deadly Fungal Pathogen Candida auris Kills Half of Infected Patients in Palestinian Hospital Study

A retrospective cohort study conducted at An-Najah National University Hospital in Nablus, Palestine, has documented an alarmingly high burden of infection caused by Candida auris, an emerging multidrug-resistant fungal pathogen that has become one of the most feared threats in modern hospital medicine. The research, published in BMC Infectious Diseases, analyzed all patients with laboratory-confirmed C. auris infection admitted over a six-year period from January 2019 to December 2024, and found that half of them died in hospital. The findings offer one of the first detailed clinical portraits of this pathogen in the Palestinian healthcare system, where data on C. auris had been almost entirely absent until now.

Candida auris is a yeast species first identified in Japan in 2009 and has since spread to dozens of countries, earning a place on public health watchlists because of its unusual combination of traits. Unlike most Candida species, it persists on skin and hospital surfaces for weeks, resists routine disinfection, spreads between patients in intensive care units, and frequently shows reduced susceptibility to the antifungal drugs that clinicians rely on. Compounding the problem, the organism is notoriously difficult to identify in the laboratory: conventional biochemical methods often misidentify it as Candida haemulonii or other related species, which means accurate detection typically requires matrix-assisted laser desorption/ionization time-of-flight mass spectrometry, known as MALDI-TOF MS, or molecular sequencing. Misidentification delays both appropriate treatment and the infection control measures needed to contain outbreaks.

The Palestinian study included 36 patients with laboratory-confirmed C. auris infection treated at the tertiary care hospital. The mean age of the cohort was 54 years, with a standard deviation of 19.9 years, and 69 percent of the patients were female. The overwhelming majority, 89 percent, required intensive care unit admission, and their median ICU stay was strikingly long at 32 days, with an interquartile range of 18 to 58 days. This prolonged critical care exposure reflects both the severity of the underlying illnesses that predispose patients to invasive fungal infection and the persistent, difficult-to-eradicate nature of C. auris itself, which can colonize patients for weeks and complicate every subsequent hospitalization.

The researchers documented the invasive medical devices that characterize this patient population and that serve as classic gateways for fungal entry. Central venous catheters were present in 81 percent of patients, urinary catheters in 75 percent, and mechanical ventilation in 72 percent. These figures align with the international understanding of C. auris as a pathogen that exploits breaches in natural barriers and indwelling hardware in critically ill patients. The anatomical distribution of infection mirrored this device burden: the urinary tract was involved in 56 percent of cases, the respiratory tract in 50 percent, the bloodstream in 33 percent, and wounds in 17 percent, with some patients harboring the organism at multiple sites simultaneously.

The clinical trajectory of these infections was severe. Septic shock, the life-threatening circulatory collapse that represents the most extreme manifestation of sepsis, developed in 89 percent of the cohort. This extraordinary rate underscores how C. auris infection tends to emerge in patients already fighting for their lives, often superimposed on bacterial infections, organ failure, and prolonged ventilatory support. Distinguishing the specific contribution of the fungus to a patient’s deterioration from that of their underlying condition remains one of the central diagnostic challenges in invasive candidiasis, and the high septic shock rate in this cohort illustrates the grim context in which these infections typically declare themselves.

Treatment patterns revealed notable prescribing choices that the authors flag as potential stewardship targets. Definitive antifungal therapy consisted of azoles in 50 percent of patients, amphotericin B in 44 percent, and echinocandins in only 14 percent. This distribution is significant because international treatment guidelines generally recommend echinocandins, such as anidulafungin, caspofungin, or micafungin, as first-line agents for invasive Candida infections, including C. auris, due to their favorable efficacy and safety profile. The comparatively low echinocandin use and the prominent reliance on azoles, a class to which many C. auris strains exhibit reduced susceptibility, raise questions about antifungal stewardship practices, drug availability, cost constraints, and local susceptibility patterns that the authors suggest warrant further investigation.

The central outcome of the study was stark: all-cause in-hospital mortality reached 50 percent. On univariate analysis using Fisher’s exact test, two factors emerged as more frequent among non-survivors. Respiratory tract isolation of C. auris carried a crude odds ratio of 8.2, with a 95 percent confidence interval of 1.4 to 47.3 and a p-value of 0.008, while septic shock was also significantly associated with death, with a p-value of 0.034. The wide confidence interval around the odds ratio reflects the small sample size and the inherent imprecision of estimates drawn from 36 patients. The authors are careful to emphasize that these are exploratory, hypothesis-generating findings and should not be interpreted as independent predictors or causal relationships, since univariate comparisons cannot disentangle confounding factors such as illness severity, mechanical ventilation, or concurrent bacteremia.

From a methodological standpoint, the study followed the Strengthening the Reporting of Observational Studies in Epidemiology, or STROBE, framework and received ethical approval from the An-Najah National University Institutional Review Board, with a waiver of informed consent granted because of the retrospective design and the use of de-identified data. Laboratory confirmation relied on the hospital’s microbiology diagnostics, and susceptibility considerations were framed in terms of minimum inhibitory concentrations as defined by the Clinical and Laboratory Standards Institute. The retrospective cohort design, while efficient for characterizing a rare and recently emerged pathogen, carries limitations including reliance on documentation quality, the absence of a comparison group, and the possibility that some C. auris isolates were colonization rather than true infection, a distinction that even experienced clinicians find difficult in this population.

The significance of this work extends beyond a single institution. C. auris has been reported across the Middle East and globally, but granular clinical data from many regional health systems remain sparse, and this cohort provides a rare quantitative window into how the pathogen behaves in a tertiary hospital serving the Palestinian population. The 50 percent mortality figure sits within, though at the higher end of, the range reported in international literature, where mortality for invasive C. auris infection often falls between 30 and 60 percent depending on the population and the proportion of bloodstream infections. The heavy representation of urinary and respiratory tract isolates in this cohort, rather than predominantly bloodstream infection, may reflect local diagnostic and sampling practices as well as the patient mix.

The authors conclude that prospective, multicenter studies are needed to confirm these observations, define risk factors with adequate statistical power, and inform evidence-based antifungal stewardship and infection control policies in the region. In the meantime, the study delivers a clear message for clinicians and hospital epidemiologists: C. auris is established in this healthcare setting, it strikes patients who are already among the most vulnerable, and survival depends on early laboratory detection, judicious device management, rapid escalation to appropriate antifungal therapy, and rigorous adherence to the contact precautions and environmental disinfection protocols that are the only proven tools for interrupting its transmission within hospitals. As this pathogen continues its global expansion, cohorts like this one from previously underrepresented settings will be essential for building the collective evidence base needed to confront it.

Subject of Research: Clinical characteristics and in-hospital mortality of Candida auris infection in a Palestinian tertiary hospital cohort

Article Title: Candida auris infection in a palestinian tertiary hospital: 36-patient retrospective cohort with high mortality

Article References: Candida auris infection in a palestinian tertiary hospital: 36-patient retrospective cohort with high mortality. (n.d.). https://doi.org/10.1186/s12879-026-14648-x

Image Credits: AI Generated

DOI: 10.1186/s12879-026-14648-x

Keywords: Candida auris, fungal infection, antimicrobial resistance, in-hospital mortality, intensive care unit, septic shock, antifungal stewardship, Palestine, retrospective cohort, nosocomial infection, echinocandins, infection control