Five European countries — Italy, Spain, Greece, Romania, and the UK — should now be considered endemic for Candidozyma auris (also referred to as Candida auris), according to a narrative review published in March. C auris is a virulent fungal infection that can cause severe candidemia in critically ill patients and is resistant to several antifungal medicines.

The review looked at C auris literature between 2009 and 2025 and was published in Clinical Microbiology and Infection, the journal of the European Society of Clinical Microbiology and Infectious Diseases. It suggested that 13 countries in total across the world should be considered endemic, with the fungus demonstrating sustained transmission and persistence within their healthcare facilities.

Endemicity in Europe comes as new European cases are appearing more regularly in scientific literature from Scotland to Portugal. Four countries — Greece, Italy, Romania, and Spain — have reported that it is no longer possible to distinguish specific outbreaks due to regional endemicity. More than 4000 cases of C auris colonization or infection were reported by EU/European Economic Area countries between 2013 and 2023 with a significant jump from 2020. C auris colonization happens when the organism is present on or in the body without causing disease, while infection involves the organism invading tissue and causing clinical disease.

Multifactorial Reasons

Case numbers and outbreaks are growing in scale for many reasons, according to Nicholas Geremia, MD, an infectious disease specialist at Ospedale dell’Angelo, Venice, Italy, who has also recently published research on European outbreaks.

Treatment can be difficult because many isolates show resistance to multiple antifungal drugs, he told Medscape News Europe. Most C auris isolates are resistant to fluconazole, and resistance to amphotericin B and other triazoles has also been reported. Echinocandins are currently recommended as first-line therapy, he said.

Another major issue is the pathogen’s ability to persist in the hospital environment. “Candida auris can survive on surfaces and may be less susceptible to some commonly used disinfectants, which makes infection control particularly challenging,” Geremia said.

Both factors pose a significant problem, facilitating hospital transmission and outbreaks and enabling fungal spread across borders.

Several cases identified in Europe have arrived from South Africa, where C auris is now the second highest cause of life-threatening candidemia. “It’s replaced almost everything else,” said Nelesh Govender, MBBCh, MSc, professor of clinical microbiology and infectious diseases at the University of the Witwatersrand, Johannesburg, South Africa. Govender first identified the pathogen in South Africa in 2013, although he thinks it might have been in the country for several years before that.

Taking its name from the woman whose ear it was first isolated from in Japan in 2009, this relatively new pathogen has now been reported in most countries of the world. Rises in C auris infections is in part due to increasing numbers of immuno-compromised people, often as a result of COVID, according to Govender’s most recent research. He says scientists also think climate change plays a role. “Candida auris exploded in the recent past, although it’s probably been evolving for hundreds of years.”

It has spread rapidly in resource-constrained countries such as South Africa, where appropriate disinfectants, diagnostic capacity, and effective drugs are often prohibitively expensive. The pathogen is now in hundreds of hospitals, even in neonatal units, growing in drips and ventilators. “We found that 30%-40% of babies in one unit were colonized with C auris and their risk for developing invasive infection was high,” said Govender. “Premature newborn babies have such immature blood-brain barriers that when C auris gets into the bloodstream it can go straight into the brain. They can develop meningitis, so the mortality is very high.”

Containing the Spread in Europe

Yet containing the spread of C auris is possible, said Matteo Bassetti, MD, PhD, clinical director of infectious diseases at San Martino University Hospital in Genoa, Italy, where the pathogen was found in an ICU unit in 2021. At the time, many patients with COVID were intubated in the unit, but immediate efforts were launched to limit the organism’s spread. Patients were screened when admitted to the ICU and then once weekly until they left. Since C auris tends to colonize the skin first, patients who tested negative throughout their ICU stay were still screened when discharged and again when admitted to new nonendemic wards to detect late-occurring colonization. “So we isolate the patient, we clean the patient, we perform several measures in order to ensure colonized patients do not become infected,” he said. “That is very important.”

The unit reported 12 cases of candidemia in 2021, 50 in 2022, and none by 2024. The number of colonized patients, reported initially as 70, was also reduced. “It is important that all the doctors work together in a multidisciplinary approach with infection control, ICU and infectious disease specialists, clinical microbiologists, and registered nurses in order to build a strategy to limit the spread,” Bassetti told Medscape News Europe. “This was the secret of our success.”

Bassetti, who has published extensively on Candida, believes reports of C auris can sometimes be overblown. “Obviously it is not a good situation having C auris. But at the end, the mortality for C auris and for other types of Candida is exactly the same,” he said. “It’s not a kind of devastating threat for patients.” That is because, unlike some pan-drug-resistant microbes, several echinocandins, including caspofungin, micafungin, anidulafungin, and now rezafungin, still work effectively against C auris. “At least with C auris, mortality is easy to limit. We have options for treating this type of infection,” he said.

Geremia, Govender, and Bassetti reported having no relevant financial relationships.

Tatum Anderson is a global health and medical journalist. For more than 20 years, she has placed articles in publications from the Bulletin of the World Health Organization to The Lancet, BMJ, BBC News, Nature, SciDev.net, and The Economist.