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. 2026 Feb 7;26:535. doi: 10.1186/s12879-026-12739-3

Global prevalence, mortality, and comorbidities of patients with diabetes mellitus and proven Candida auris emerging infection: a systematic review & meta-analysis

Aydin Vaez 1,#, Arman Ghahremanzadeh 2,#, Farshad Zare 3, Sanam Nami 4, Faranak Zargari 5, Sina Najafi 1, Ainaz Zamani 6, Seyedyashar Pourebrahimian Leilabadi 3, Hesam Farajzadeh Asl 3, Hamid Morovati 4,✉
PMCID: PMC12977804  PMID: 41654747

Abstract

Background

Candida auris is an emerging multidrug-resistant yeast pathogen with several risk factors, including diabetes mellitus (DM). This study analyzed the epidemiological aspects of C. auris patients with DM (CaDM). We searched related databases without time and linguistic limitations for studies reporting DM among patients with proven C. auris infection (PCaI).

Methods

A meta-analysis was conducted using STATA (version 17) with the random-effects model based on DerSimonian and Laird methods, employing the metan and metaprop commands.

Results

A total of 43 studies were included. Our random effect model reached the pooled prevalence of 36% (p value: < 0.001) for DM among patients with PCaI. The prevalence of DM among PCaI patients is almost 40% higher than non-auris patients (OR: 1.40; p value: < 0.001). Men with DM were 46% lower susceptibility to C. auris infection compared to women (OR: 0.54; p value: 0.905). However, this was not statistically significant. Our results showed that 57% of unadjusted all-cause mortality were recorded among CaDM patients (p value: 0.03). Chronic kidney diseases (CKD), hypertension (HTN), and respiratory diseases (RD) were the most frequent comorbidities. Central venous catheter (CVC), ICU stay, and mechanical ventilation were the most frequent hospital-related factors.

Conclusions

We concluded that despite the significant advances in diagnosis and treatments, prevalence, risk, and mortality rates of C. auris infection and diabetes mellitus remained high.

Supplementary information

The online version contains supplementary material available at 10.1186/s12879-026-12739-3.

Keywords: Candida auris, Diabetes mellitus, Prevalence, Mortality, Epidemiology, Meta-analysis

Background

Candida auris is an emerging multidrug-resistant yeast pathogen first discovered in 2009 by Satoh et al. [1], from the ear discharge of a Japanese woman. Although C. auris is not considered an infectious pathogen when colonized in skin and non-sterile sites of the body, circumstances become increasingly concerning when this pathogenic yeast is isolated from sterile sites of the body and considered an infection [2]. This is due to the omnipotent abilities of C. auris in resistance to several classes of the current antifungals [3]. Bloodstream infections of C. auris are highly severe [4, 5]. Nosocomial outbreaks are reported more regularly and involve an increasing number of patients. They have replaced the sporadic invasive infections of the early years, causing substantial changes in the epidemiology of invasive C. auris infections [6]. This caused the WHO to classify C. auris as a critical priority that poses the greatest threat to public health [7]. The main virulence factors of C. auris are as follows: I: biofilm formation on both living and non-living surfaces via adhesion genes, which enhances adherence and antifungal resistance. II: Secretion of hydrolytic enzymes, including secreted aspartyl proteinases (SAPs), lipases, phospholipases, and proteases (YPS family), helps in tissue invasion and nutrient acquisition. III: Morphological plasticity, including both aggregating and non-aggregating phenotypes, as well as filamentation or pseudohyphae formation, may help it evade the immune system and persist. IV: Stress tolerance, such as thermotolerance, osmotolerance, and the ability to survive on dry and medical surfaces for extended periods, contributes to environmental persistence and transmission [6].

Besides these, C. auris has several risk factors, including immunosuppression, invasive medical devices, such as catheters, feeding and breathing tubes, ICU stay, chronic kidney disease (CKD), diabetes mellitus (DM), and long-term antibiotic or antifungal consumption [8, 9]. DM is a chronic metabolic and degenerative disorder in which the body does not produce enough or respond typically to insulin, causing abnormally high levels of blood sugar (glucose), known as hyperglycemia [10, 11]. DM causes long-term complications such as nephropathy, neuropathy, retinopathy, and vascular disorders. Eventually, these disorders will cause an immunosuppressed or immunocompromised situation, increasing susceptibility to fungal infections, especially candidiasis [10, 11]. Today, as announced by the International Diabetes Federation in 2019, 537 million adults live with DM. In 2020, DM was the ninth most common cause of death worldwide, accounting for 2 million deaths each year from both diabetes-related kidney disease and diabetes itself [10, 11]. However, there is no estimate for the global burden of DM and fungal infections, especially emerging multidrug-resistant C. auris yeast. Therefore, there is an emergent need to evaluate the burden of DM and C. auris infection.

We previously performed several meta-analysis projects to investigate the epidemiology of C. auris infection among patients with COVID-19 [12]. Here, we design a broad-spectrum meta-analysis to accurately evaluate the global burden of DM among patients with proven C. auris infection (PCaI).

Methods

Search strategy

The protocol of this study has been registered at PROSPERO (Register number: CRD420250632920). The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 guideline was followed in the conduct and reporting of this study [13] (Table S1). We applied a comprehensive search strategy to identify studies that reported DM among patients with PCaI. In our systematic review and meta-analysis, the search terms combined controlled vocabulary (e.g., MeSH terms) and free-text keywords related to “diabetic mellitus,” “diabetes,” “Candida auris,” “Candida auris candidemia,” “Candida auris infection,” “Candida infections,” “Candida AND diabetic mellitus,” “candidiasis AND diabetic mellitus,” “diabetic ketoacidosis,” “Candida AND diabetic ketoacidosis,” “candidiasis AND diabetic ketoacidosis,” and related terms and words for relevant studies published in PubMed, Web of Science, Scopus, Google Scholar, and ProQuest were used without any time limit and filtration, until 24 December 2024. Boolean operators (“AND,” “OR”) and truncation were applied to maximize the sensitivity and specificity of the search. No linguistic or geographical limits were applied. We hand-searched the bibliographies of all related articles for potentially eligible studies. Moreover, we contacted the corresponding authors for details of published or unpublished data if needed.

Selection criteria

Once reference titles and abstracts were verified, the full texts of possibly relevant papers were evaluated separately. Studies assessing a clearly defined DM and C. auris-infected population in any clinical setting were included if they had specific diagnostic criteria for both DM [14, 15] and proven C. auris infection [16]. These were predefined using clinical case definitions [17] or confirmed with laboratory testing using molecular assays, such as PCR, sequencing, and matrix-assisted laser desorption-ionization time-of-flight mass spectrometry (MALDI-TOF MS). Since C. auris can be part of the normal microbial flora, especially in skin folds, it is important to differentiate between colonization and infection more carefully. In this study, proven infection refers to cases isolated from sterile body sites (blood, tissue, cerebrospinal fluid, bone, catheter tip, and body fluids) and confirmed by standard diagnostic methods, including blood culture, pathology, microscopic diagnosis in sterile samples, endoscopy, and molecular diagnosis confirmed by sequencing, along with the presence of clinical symptoms, especially fever. Cases isolated from non-sterile body sites (urine, sputum, superficial and rectal swabs, tracheal aspirate, and stool) were excluded.

Inclusion criteria

Inclusion criteria were as follows: patients with DM and proven C. auris infection, all types of studies encompassing data about patients with DM and proven C. auris infection simultaneously, including clinical trials, retrospective, prospective, and cohort studies, grey literature including conference reports, etc.

Exclusion criteria

Exclusion criteria were as follows: all studies reported patients with DM and without proven C. auris infection or patients who have other fungal infections or patients without DM; all studies reported data about C. auris colonization or probable infection; all studies reported unclear data without distinguishing C. auris colonization, proven, and probable infection; all studies without classifying C. auris and non-C. auris infections; review-type studies (e.g., narrative, critical, systematic, meta-analysis, and mini-reviews); case reports and case series; all electronic retrospective studies (those used previously reported data); and all studies, including letters to the editor and editorials, without patient data.

Data extraction

Three authors independently extracted data and compared it for consistency [18, 19]. Discussion and consensus resolved the possible disagreements on final inclusions. The key variable was the proportion of the DM population among patients with PCaI. Prevalence was defined as the number of DM cases (nominator) among patients with PCaI (denominator). The following information was captured where available: DM among patients with and without PCaI, all related comorbidities, all hospital-related factors, patients who received antifungal and antibacterial therapies, age and gender of the target population, and overall C. auris positive cases, and the outcome of patients (mortality).

Quality assessment

This research involved studies concerning a minimum of three participants to minimize the small-study effect [18, 19]. The authors independently assessed the quality of the studies according to the checklist described by Hoy et al. [20, 21] (quality assessment checklist for prevalence studies). This checklist explored the various dimensions of empirical proof and methodological assumptions. Risk rates were scored from 0 (without risk) to 10 (highest risk). If necessary, other coauthors voted to reach a consensus to resolve disagreements between the researchers.

Data analysis

Meta-analysis was performed using the DerSimonian and Laird method [22, 23] and random-effects model [24] in case of considerable heterogeneity, defined as I2 > 75%. We evaluated heterogeneity using the chi2, I2, and Tau2 statistics (significant for p value 0 < 0.05). In accordance with the Cochrane Handbook, heterogeneity is explained in more detail: low (0–40%), moderate (30–60%), substantial (50–90%), and considerable (75–100%). The STATA version 17 (STATA corporation, USA) was used to perform calculations and the meta-analysis [25, 26]. Analysis via STATA was performed using the metan and metaprop commands [27, 28] for odds ratio (OR) and proportion analyses, respectively. OR analysis was performed for related prevalence patients’ age and gender data if their case(s) and control(s) details were available. Point estimates and 95% confidence intervals were derived from data for all the above-mentioned outcomes and indicated via the forest plots. The publication bias was shown via a funnel plot for each tested variable. Moreover, the regression-based Egger and Begg tests were applied for risk of bias assessment and small-study effects analysis [29]. A sensitivity analysis was conducted by excluding studies to assess the robustness of pooled estimates. Where standard errors (SE) were not provided, we incorporated confidence intervals into the formula, SE= (upper limit–lower limit)/3.92.

Evaluation the certainty of the evidences

The certainty of evidence for the principal outcomes of the study was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology [30]. For each outcome, considerations included risk of bias, inconsistency (heterogeneity), indirectness, imprecision, and publication bias. Certainty levels, including high, moderate, low, or very low were assigned in accordance with established GRADE guidelines; observational studies commenced at a ‘low’ certainty level and were subsequently downgraded or, in rare instances, upgraded based on domain-specific assessments. Comprehensive judgments and their justifications for each outcome are documented within the summary of findings table and its corresponding footnotes.

Results

Overall research findings

After searches in the databases and removing duplicate and irrelevant records, our meta-analysis included 43 eligible studies until 24 December 2024 (Table 1, Fig. 1) [31–73]. These studies were reported from 20 countries in North and South America, Europe, Asia, Africa, and the Middle East. The quality assessment results were added to Table 1. An overall score of 2.77 was reached for quality assessment, which means that analyzed studies had a low risk of bias (Table 1). A total of 5578 patients were included; PCaIs were found in 1460 (26.17%), and DM was reported in 1068 patients (19.15%). Also, 517 patients had positivity to C. auris infection and DM (CaDM) (517 from 1460: 35.41%). DM cases were reported among 551 patients with probable C. auris infection, colonized, other Candida spp infections, or negative C. auris infection (551 from 4118: 13.38%). Antifungals were used for 653 patients with PCaI and three CaDM patients. However, antibacterials were used for 969 PCaI patients and six CaDM patients. The data about CaDM patients were rarely discussed. Where available, we extracted the data about the isolation sites of C. auris, which were as follows: 480 isolates from blood, 116 isolates from urine, 73 isolates from respiratory fluids, 26 isolates from central venous catheters (CVC), 25 isolates from wounds, seven isolates from pleural fluids and empyema, four isolates from peritoneal fluid, and one isolate from vaginal discharges.

Table 1.

Patient characteristics of the study

Studies Total
Patients		 C. auris Patients Total DM CaDM Patients Age in C. auris/CaDM Patients (YO) Gender in C. auris/CaDM Patients (Males) AFT ABT Source QA [ref]
Tajane et al.; Oct 2024; India; Descriptive-Cross sectional 147 9 4 4 ND ND 6 9 B: 2; U: 5; CVC: 1; Vgl: 1 4 [31]
Subhi et al.; Sep 2024; UAE; Retrospective-Cohort 75 53 35 24

Mean: 57.1 ± 20.4

Med: 58

 34 23 52 B: 10; Sp: 15; U: 20; W: 8 3 [32]
Ombajo et al.; Sep 2024; Kenya; Observational 32 32 8 8 Med: 55 19 32 32 B: 32 3 [33]
Zhang et al.; Aug 2024; China; Observational 35 11 14 5 Mean: 67.2 (CaDM: 78.4) 7 (CaDM: 3) 11 ND ND 2 [34]
Politi et al.; Jun 2024; Greece; Retrospective 66 20 7 4 Med: 74 11 1 9 B: 20; U:7; RSP: 3; W: 2; CVC: 1; Ax/gr: 11; Sp: 1 2 [35]
Prayag et al.; Jun 2024; India; Retrospective 82 82 33 33 Mean: 51.84 ± 16.65 61 82 ND ND 2 [36]
Al Ajmi et al.; May 2024; Qatar; Retrospective 331 45 165 22 Mean: 43 38 ND 39 ND 2 [37]
Munshi et al.; Jan 2024; Saudi Arabia; Retrospective-Cross sectional 46 46 27 27 Mean: 64.67 ± 18.43 34 ND 42 B: 46 3 [38]
Koleri et al.; Aug 2023; Qatar; Retrospective-Observational 36 36 16 16 Mean: 52 (44–66) 33 ND ND ND 3 [39]
Benedict et al.; Jul 2023; USA; Retrospective 192 38 106 20 Mean: 61.8; Med: 66.5 17 29 ND B: 38 2 [40]
Ortiz-Roa et al.; Jun 2023; Colombia; Retrospective 512 134 97 30 Mean: 54.3 86 ND 132 1 [41]
Kaki; Jun 2023; Saudi Arabia; Retrospective 27 27 16 16 Mean: 58.07 18 ND ND B: 17; CVC: 17; UTC: 3; Cath: 7; Other: 10 2 [42]
Alvarez-Moreno et al.; Mar 2023; Colombia; Retrospective 74 22 9 4 Mean: 43.3 ± 28.7 12 11 19 ND 3 [43]
Simon et al.; Feb 2023; USA; Retrospective 196 83 93 37 Med: 76 (64–88) 48 63 72 ND 2 [44]
St Maurice et al.; Sep 2022; USA; Retrospective 45 13 28 9 Med: 69 (59–73) 5 12 ND B: 9; U: 3; PLF: 3; RSP: 2; W: 2 4 [45]
Allaw et al.; May 2022; Lebanon; Case control 186 56 74 21 Mean: 69.45 29 ND 56 B: 8; RSP: 26; W: 4; U: 20; PLF: 1 2 [46]
Zerrouki et al.; May 2022; Algeria; Retrospective-Observational 87 7 4 4 Mean: 57.42 (CaDM: 62) 5 (CaDM: 3) ND ND U: 1; RSP: 4; W: 1; PRF: 1 4 [47]
Parak et al.; Jan 2022; South Africa; Retrospective-Case control 135 45 17 4 Med: 32 (26–46) 32 ND 42 B: 26; Tissue: 2; Bone: 1; Body fluid: 1; Cath: 15 2 [48]
Pandya et al.; Oct 2021; India; Retrospective-Observational 54 54 34 34 Med: 64.5 29 47 52 B: 41; Skin: 6; RSP: 5; U: 2 2 [49]
Hanson et al.; Sep 2021; USA; Case control 15 15 7 7 Mean: 48.12 (CaDM: 54.3) 10 (CaDM: 3) 3 12 B: 8; U: 2; W: 3; Cath: 1 4 [50]
Almeida Jr et al.; Jul 2021; Brazil; Cross sectional 20 11 8 3 Med: 71 (CaDM: 76.6) 8 (CaDM: 1) 4 10 CVC: 2; Ax: 1; B: 3; U: 1 3 [51]
Bacchani et al.; Jul 2021; India; Retrospective 576 24 6 6 Med: 48 20 19 22 B: 9 3 [52]
Magnasco et al.; Jan 2021; Italy; Retrospective-Cross sectional 92 9 2 2 Mean: 61.7 (CaDM: 68.5) 9 (CaDM: 2) 1 1 BAL: 5; PLF: 1; B: 1 3 [53]
Alfouzan et al.; Nov 2020; Kuwait; Retrospective-Observational 71 17 39 9 Med: 71 10 17 Ax: 2; Gr: 1; Nares: 1 3 [54]
Chowdhary et al.; Nov 2020; India; Retrospective-Observational 596 10 8 6 Mean: 67.1 (CaDM: 72.3) 7 (CaDM: 4) 10 (CaDM: 6) 10 (CaDM: 6) B: 10 (CaDM: 6) 1 [55]
Garcia-Bustos et al.; Nov 2020; Spain: Retrospective-Cohort 206 37 20 2 Mean: 57.97 24 26 37 B: 37 3 [56]
Shaukat et al.; Nov 2020; Qatar; Retrospective 13 5 3 2 Mean: 76.6 (CaDM: 75) 5 (CaDM: 2) 5 ND B: 1; RSP: 1; Tissue: 1; U: 2 3 [57]
Mohsin et al.; Sep 2020; Oman; Descriptive-Observational 23 23 8 8 Mean: 52.5 16 ND 21 ND 4 [58]
Barantsevich et al.; Aug 2020; Russia; Retrospective 38 38 22 22 Mean: 55 28 ND ND B: 31; U: 13 4 [59]
Caceres et al.; Aug 2020; Colombia; Retrospective 90 40 10 7 Mean: 23 24 37 B: 40 2 [60]
Bayona et al.; Aug 2020; Spain; Retrospective 287 47 13 13 Mean: 61 ± 16.3 35 14 43 3 [61]
Arensman et al.; May 2020; USA; Case control 28 12 2 2 Mean: 64.33 (CaDM: 64) 8 (CaDM: 0 M) ND ND U: 2; B: 7; CVC: 1; W: 1; Body fluid: 1 4 [62]
Taori et al.; Dec 2019; UK; Retrospective 34 14 18 5 Mean: 57.5 (23–85) 8 11 11 ND 3 [63]
Adam et al.; Aug 2019; Kenya; Retrospective 224 77 17 17 Mean: 58 ± 20 43 19 72 ND 3 [64]
Armstrong et al.; Jul 2019; Colombia; Retrospective 40 40 7 7 Med: 23 (1–56) 24 7 ND ND 2 [65]
Sayeed et al.; May 2019; Pakistan; Retrospective 92 65 26 18 ND 35 44 88 B: 38; U: 19; PRF: 3; EMP: 1; W: 1; KRT: 1 2 [66]
Adams et al.; Oct 2018; USA; Retrospective 631 51 18 18 Med: 72 26 25 42 ND 4 [67]
Tian et al.; Jul 2018; China; Retrospective-Cohort 45 15 11 5 Mean: 68 ± 11.9 8 15 12 U: 10; B: 1; Sp: 1; Cath: 2; Drainage: 1 3 [68]
Khan et al.; Jun 2018; Kuwait; Retrospective 17 15 5 5 Mean: 60.6 (CaDM: 62.6) 9 (CaDM: 2) 15 (CaDM: 5) ND RSP: 6 (CaDM: 2); U: 3 (CaDM: 1); W: 3; BAL: 1 (CaDM: 1); CVC: 3 (CaDM: 1) 1 [69]
Morales-Lopez et al.; Jan 2017; Colombia; Observational 17 17 3 3 Med: 36 9 12 15 B: 13; PLF: 1; CSF: 1; Bone: 1; U: 1 4 [70]
Lockhart et al.; Dec 2016; Multinational; Retrospective 41 41 17 17 Med: 54 26 41 ND B: 25; U: 7; RSP: 2; Other: 7 3 [71]
Chowdhary et al.; Dec 2013; India; Retrospective 12 12 5 5 Mean: 56.2 (CaDM: 68.6) 9 5 12 B: 7; Tissue: 3; BAL: 1; CVC: 3; Pus: 1 3 [72]
Chowdhary et al.; Oct 2013; India; Observational 12 12 6 6 Mean: 53.38 (CaDM: 62) 5 (CaDM: 3) 6 (CaDM: 3) 5 ND 3 [73]
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Abbreviations: DM: diabetes mellitus, CaDM: Candida auris and diabetes mellitus positive, YO: years old, AFT, antifungal therapy, ABT: antibacterial therapy, QA: quality assessment, ND: not defined, Med: median, ref: reference, B: blood, U: urine, CVC: central venous catheter, Vgl: vaginal, Sp: sputum, W: wound, RSP: respiratory, Ax/gr: axilla and groin, UTC: urinary tract catheter, Cath: catheter, PLF: pleural fluid, BAL: bronchoalveolar lavage fluid, PRF: peritoneal fluid, EMP: empyema, KRT: keratitis, PUS: pustule

Fig. 1.

Fig. 1

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The flowchart of study identification and selection process

The pooled prevalence of DM among PCaI patients

All 43 included studies were tested in this analysis. Our random effect model reached the pooled prevalence of 36% (95% CI: 30 to 41;) for patients with CaDM. Considerable heterogeneity was observed (I2: 80.72%; p value < 0.001) (Table 1, Fig. 2, Fig. S1). Moreover, the percent rate by country indicated that the top five countries with the highest prevalence for CaDM patients are as follows: India (18.18%), the USA (17.98%), Colombia (9.84%), Saudi Arabia (18.31%), and Qatar (7.73%) (Fig. 3). Overall, 29.01% of CaDM were from Middle Eastern countries, 23.59% were from non-Middle Eastern Asian countries, 17.98% were from North America, 10.44% were from South America, 9.28% were from Europe, and 6.38% were from African countries (Fig. 3). The detailed results of meta-analysis tests, including OR, proportion, heterogeneity, and risk of bias assessments, are abstracted in Table 2.

Fig. 2.

Fig. 2

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The forest plot for the pooled prevalence of DM among C. auris patients

Fig. 3.

Fig. 3

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Worldwide distribution of CaDM patients

Table 2.

The detailed results of meta-analysis tests, including OR, proportion, heterogeneity, and risk of bias assessments

Variables # Of studies Patients number Size Effect (%)
(95%CI)		 Heterogeneity Indicators Bias Indicators
Chi2 * I2(%)
(95% CI)		 Tau2 Egger’s test Begg’s test
Prevalence of CaDM 43

PCaI: 1460 (43 studies)

DM: 1068 (43 studies)

CaDM: 517 (43 studies

PRP: 36%

(30 to 41)

217.81

(df = 42)

80.72%

P = 0.00

 0.02

Coef: 2.750; Std. Err: 0.756; t: 3.64;

(95% CI): (1.223 to 4.275); P = 0.001;

Root MSE: 2.004

Kendall’s Score: 153;

Std. Dev. of Score: 95.55;

z: 1.6
Prevalence of DM among negative or non-proven C. auris infections 20

PCaI: 1460 (43 studies)

DM: 1068 (43 studies)

CaDM: 517 (43 studies

PRP: 31%

(21 to 41)

962.57

(df = 19)

98.03%

P = 0.00

 0.04

Coef: 6.153; Std. Err: 1.078; t: 5.71;

(95% CI): (3.888to 8.417); P = 0.00;

Root MSE: 4.362

Kendall’s Score: −8;

Std. Dev. of Score: 30.82;

z: −0.26
OR prevalence 18

PCaI: 1460 (43 studies)

DM: 1068 (43 studies)

CaDM: 517 (43 studies

OR:1.40

(0.88 to 2.24)

54.36

(df = 17)

68.7

P = 0.00

 0.62

Coef: 4.92; Std. Err: 8.66; t: 0.57;

(95% CI): (−13.45 to 23.29); P = 0.578;

Root MSE: 14.87

Kendall’s Score: 91;

Std. Dev. of Score: 26.40;

z: 3.45
Mortality 11

PCaI: 139 (11 studies)

CaDM: 75 (11 studies)

PRP: 0.57

(0.45 to 0.69)

20.43

(df = 10)

51.05

P = 0.03

 0.02

Coef: 0.096; Std. Err: 0.769; t: 0.13;

(95% CI): (−1.618 to 1.820); P = 0.903;

Root MSE: 1.435

Kendall’s Score: 1;

Std. Dev. of Score: 14.58;

z: 0.07

Gender

(Men)

 8

PCaI: 1175 (42 studies)

DM: 941 (42 studies)

CaDM: 23 (10 studies)

OR: 0.54

(0.24 to 1.21)

2.77

(df = 7)

0

P = 0.905

 0.00

Coef: −0.277; Std. Err: 0.672; t: −0.41;

(95% CI): (−1.546 to 2.741); P = 0.137;

Root MSE: 0.332

Kendall’s Score: −1;

Std. Dev. of Score: 8.08;

z: −0.12

Age

(mean years old)

 8

PCaI: 58.18 (28 studies)

CaDM: 67.66 (11 studies)

OR for SMD: −0.66

(−1.09 to −0.23)

6.15

(df = 7)

0

P = 0.522

 0.00

Coef: 2.397; Std. Err: 1.594; t: 1.5;

(95% CI): (−1.504 to 6.299); P = 0.183;

Root MSE: 0.863

Kendall’s Score: 12;

Std. Dev. of Score: 8.08;

z: 1.48
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Abbreviations: DM: diabetes mellitus, CaDM: Candida auris and diabetes mellitus, PCaI: proven Candida auris infection, PRP: proportion, OR: odds ratio, MSE: mean squared error, Coef: coefficient, Std. Err: standard error, SMD: standard mean error, Std. Dev: standard deviation

The pooled prevalence of DM among patients with non-proven or negative C. auris infections

In this section, related data were available in 29 studies. However, 9 of them were not qualified by the STATA for the proportion analysis; therefore, 20 studies were included in the final analysis. Our random effect model reached the pooled prevalence of 31% (95% CI: 21 to 41) for DM among non-auris patients. Very high heterogeneity was observed (I2 = 98.03%; p value < 0.001) (Tables 1 and 2, Fig. 4, Fig. S2).

Fig. 4.

Fig. 4

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The forest plot for the pooled prevalence of DM among non-C. auris patients

Relationship between DM and C. auris infection

Results of the OR analysis by random effect model in 18 included studies indicated that patients with proven C. auris infection had higher odds of having DM compared with non-C. auris patients (OR 1.40). However, the 95% CI (0.88–2.24) included the null value, indicating that this association was not statistically significant. Moderate heterogeneity was present (I2 = 68.7%; p < 0.001) (Tables 1 and 2, Fig. 5, Fig. S3).

Fig. 5.

Fig. 5

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The OR forest plot for the relationship between DM and C. auris infection

Relationship between patients’ age, C. auris infection, and DM

The data about patients’ ages were available in 28 studies. PCaI patients had a mean age of 57.18. However, CaDM patients had a mean age of 67.66 from 11 studies. We performed an OR analysis using the metan command to compare the mean age between patients with proven C. auris infection and CaDM patients. Eight studies were qualified to be included in this analysis. Our results showed that CaDM patients were on average 10 years older than PCaI patients (MD − 0.66, 95% CI −1.09 to −0.23). Although the mean difference was statistically significant, the overall heterogeneity was negligible (I2 = 0.0%; p = 0.522) (Tables 1 and 2, Fig. 6, Fig. S4).

Fig. 6.

Fig. 6

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The forest plot for the relationship between patients’ age, DM, and C. auris infection

Relationship between patients’ gender, C. auris infection, and DM

The data from 42 studies indicated that 1,175 PCaI patients and 941 DM patients were men. CaDM patients’ gender was available in 10 studies, which resulted in 23 men (Table 1). The STATA did not qualify the two studies for the OR analysis; therefore, eight were included in the final analysis. We performed an OR analysis using the metan command to compare the gender of PCaI and CaDM patients. Our results showed that men with DM had lower odds of proven C. auris infection compared with women (OR 0.54). However, this association was not statistically significant, as the 95% CI (0.24–1.21) included unity. No heterogeneity was detected (I2 = 0.0%; p = 0.905) (Tables 1 and 2, Fig. 7, Fig. S5).

Fig. 7.

Fig. 7

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The OR forest plot for the relationship between patients’ gender, DM, and C. auris infection

Comorbidities of PCaI and CaDM patients

Table 3 lists the comorbidities among study patients. The data about CaDM patients were rarely discussed. Overall, 16 comorbidities were repeatedly discussed in the included studies. Four out of 246 patients with CKD had CaDM (1.62%). Seventeen from 191 PCaI patients (8.9%) had hypertension (HTN) plus DM. Respiratory diseases (RD) were reported in 169 and 4 PCaI and CaDM patients, respectively (2.36%). The rest of the related comorbidities are as follows: ischemic heart disease (IHD) (164 in PCaI, 9 in CaDM: 5.48%), hemodialysis (HD) (161 in PCaI, 5 in CaDM: 3.1%), COVID-19 (145 in PCaI, 6 in CaDM: 4.14%), immunosuppression (117 in PCaI, 8 in CaDM: 6.84%), malignancies (52 solid tumors, 33 hematologic, and 81 not defined malignancies) among PCaI patients, cerebral vascular accident (CVA) (75 in PCaI, 5 in CaDM: 6.66%), chronic liver diseases (CLD) (73 in PCaI, 1 in CaDM: 1.37%), chronic obstructive pulmonary diseases (COPD) (51 in PCaI, 2 in CaDM: 3.92%), end-stage renal diseases (ESRD) (49 in PCaI), congestive heart failure (CHF) (38 in PCaI, 5 in CaDM: 13.15%), HIV (2 in PCaI, 1 in CaDM: 50%), solid organ transplant (SOT) (22 in PCaI), and neutropenia was reported among seven PCaI patients. Figure 8 illustrates the frequency of study comorbidities.

Table 3.

Comorbidities and hospital-related factors of the study patients

Studies Comorbidities HRF Mortality
HTN CVA IHD CHF CKD ESRD HD CLD Malignancy COVID-19 COPD RD HIV NTP IMSP SOT CBI Steroids Surgeries CVC UTC MV TPN ICU
Tajane et al.; Oct 2024; India; Descriptive-Cross sectional 2 ND ND ND 3 (CaDM: 2) ND ND 2 ND ND ND ND ND ND ND ND ND ND ND 2 9 6 ND ND 6 (CaDM: 4)
Subhi et al.; 23 Sep 2024; UAE; Retrospective-Cohort 21 9 11 ND 3 3 1 ND ND ND ND ND ND ND ND ND 49 ND 39 46 ND ND 8 39 28
Ombajo et al.; Sep 2024; Kenya; Observational 12 6 3 3 4 ND 14 ND HM: 7 ND 3 3 1 ND ND 1 16 22 6 31 31 22 29 32 18
Zhang et al.; Aug 2024; China; Observational 7 (CaDM: 4) 1 in CaDM 7 (CaDM: 3) 7 3 ND ND ND ND ND 3 22 ND ND ND ND 28 ND 34 ND ND ND ND ND 8 (CaDM: 4)
Politi et al.; Jun 2024; Greece; Retrospective ND ND ND 4 2 ND ND ND 4 6 1 ND ND ND 2 ND 11 ND ND ND ND 3 ND 5 13
Prayag et al.; Jun 2024; India; Retrospective ND ND ND ND 11 ND ND 4 9 ND ND ND ND 3 ND ND ND 27 11 50 ND ND 11 ND 27 (CaDM: 15)
Al Ajmi et al.; May 2024; Qatar; Retrospective 25 ND 9 ND 11 ND ND 2 ND ND ND 11 ND ND ND 8 ND ND ND 32 31 39 ND 41 17
Munshi et al.; Jan 2024; Saudi Arabia; Retrospective-Cross sectional 34 ND 22 ND 25 ND ND ND ST: 4 10 6 6 ND ND 29 ND 8 ND 14 46 ND 41 6 43 22
Koleri et al.; Aug 2023; Qatar; Retrospective-Observational ND ND ND ND 6 ND 9 2 2 32 ND ND ND ND ND 2 ND ND 0 35 ND 32 ND 35 15
Benedict et al.; Jul 2023; USA; Retrospective ND ND ND ND 17 ND ND ND ND ND ND 32 ND ND ND ND 25 ND ND 29 ND 18 ND ND ND
Ortiz-Roa et al.; Jun 2023; Colombia; Retrospective 15 ND 44 7 14 ND 18 ND 13 47 12 ND ND ND ND ND 100 ND 17 117 ND 83 33 64 66
Kaki; Jun 2023; Saudi Arabia; Retrospective 13 10 13 ND 11 ND 5 10 6 2 ND 2 2 ND 10 ND 8 ND 11 ND ND ND ND 22 18
Alvarez-Moreno et al.; Mar 2023; Colombia; Retrospective ND ND ND ND 9 6 ND ND ST: 3 ND ND ND 3 ND ND 0 ND 2 7 20 18 16 6 ND 8
Simon et al.; Feb 2023; USA; Retrospective ND 24 26 ND 21 21 ND 34 HM: 1; ST: 7 ND 3 34 ND 1 ND ND 50 ND 14 43 60 ND 3 ND 37
St Maurice et al.; Sep 2022; USA; Retrospective ND ND ND ND ND 4 4 1 1 ND ND 8 ND ND 2 ND 5 ND ND 8 5 ND ND ND 3
Allaw et al.; May 2022; Lebanon; Case control ND ND ND ND 8 ND 14 ND HM: 6; ST: 12 32 ND 12 ND ND ND ND ND ND 18 50 56 43 9 ND 34 (CaDM: 12)
Zerrouki et al.; May 2022; Algeria; Retrospective-Observational 1 ND 1 ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND 0
Parak et al.; Jan 2022; South Africa; Retrospective-Case control ND ND ND ND 8 ND 18 ND 2 ND ND ND 9 ND ND 2 29 16 35 42 38 37 22 44 19
Pandya et al.; Oct 2021; India; Retrospective-Observational ND ND ND 16 28 ND 13 ND ND ND 21 ND ND ND 14 ND 26 19 ND 43 37 20 12 37 24
Hanson et al.; Sep 2021; USA; Case control 7 (CaDM: 4) ND ND ND ND 1 ND ND HM 1 in CaDM; ST: 1 ND ND ND ND ND ND ND 11 10 ND ND ND ND ND 12 7 (CaDM: 4)
Almeida Jr et al.; Jul 2021; Brazil; Cross sectional 1 in CaDM ND ND 1 ND ND 3 (CaDM: 2) ND ND ND ND 1 ND ND ND ND ND 10 3 10 (CaDM: 3) 10 3 in CaDM ND 7 3 in CaDM (1 C. auris death)
Bacchani et al.; Jul 2021; India; Retrospective 9 ND 4 ND 2 ND ND 4 3 ND ND 4 ND ND 3 1 ND 4 ND ND ND ND ND 16 2
Magnasco et al.; Jan 2021; Italy; Retrospective-Cross sectional 6 ND 2 ND ND ND ND 1 ND ND 1 in CaDM 1 ND ND 1 ND ND ND ND ND ND ND ND 1 ND
Alfouzan et al.; Nov 2020; Kuwait; Retrospective-Observational 10 3 7 ND ND ND ND ND ND ND ND 11 ND ND ND ND 2 ND ND ND ND ND ND 1 10
Chowdhary et al.; Nov 2020; India; Retrospective-Observational 7 (CaDM: 5) ND 2 (CaDM: 1) ND 2 ND ND 3 (CaDM: 1) ND 10 (CaDM: 6) 1 in CaDM 2 (CaDM: 1) ND ND ND ND ND 8 (CaDM: 5) ND 10 (CaDM: 6) 10 (CaDM: 6) 6 (CaDM: 2) ND 10 (CaDM: 6) 6 (CaDM: 4)
Garcia-Bustos et al.; Nov 2020; Spain: Retrospective-Cohort ND ND 1 ND 2 ND 7 0 3 ND ND 2 ND ND 4 ND 20 ND 27 37 36 33 31 ND ND
Shaukat et al.; Nov 2020; Qatar; Retrospective ND 1 ND ND ND ND ND ND ND 1 ND 1 ND ND ND ND 4 ND ND ND ND ND ND ND 3 (CaDM: 1)
Mohsin et al.; Sep 2020; Oman; Descriptive-Observational ND ND ND ND ND ND ND ND ND ND ND ND ND 1 9 2 ND ND ND 23 23 ND 4 19 9
Barantsevich et al.; Aug 2020; Russia; Retrospective ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND 36 ND ND 4 ND ND ND ND 21
Caceres et al.; Aug 2020; Colombia; Retrospective ND ND ND ND 9 ND 15 ND HM: 2; ST: 3 ND ND ND ND ND 12 ND 33 16 28 40 ND 36 19 30 23
Bayona et al.; Aug 2020; Spain; Retrospective ND 5 7 ND ND ND ND ND 12 5 ND 3 ND ND ND ND 10 ND 38 39 38 29 7 ND 11
Arensman et al.; May 2020; USA; Case control ND 1 ND ND ND 6 ND ND ND ND ND ND ND ND ND ND 6 ND ND ND ND ND 1 ND 2
Taori et al.; Dec 2019; UK; Retrospective ND ND ND ND ND ND 7 ND 1 ND ND ND ND 1 3 3 5 ND 9 12 9 4 5 12 4
Adam et al.; Aug 2019; Kenya; Retrospective 17 ND ND ND 30 ND ND ND 7 ND ND ND 4 ND ND ND ND ND ND 65 ND 17 61 22
Armstrong et al.; Jul 2019; Colombia; Retrospective ND 1 ND ND 9 ND 15 ND HM: 2; ST: 2 ND ND ND ND ND 10 2 35 18 28 40 ND 35 19 ND 23
Sayeed et al.; May 2019; Pakistan; Retrospective ND ND ND ND ND ND ND ND 13 ND ND ND ND ND ND ND 22 ND 39 81 ND ND ND 23 30 (19 C. auris death)
Adams et al.; Oct 2018; USA; Retrospective ND ND ND ND ND 8 7 ND HM: 11; ST: 5 ND ND ND ND ND ND 1 ND ND ND 31 ND 17 ND ND 23
Tian et al.; Jul 2018; China; Retrospective-Cohort ND 10 ND ND 2 ND 3 4 3 ND ND 10 ND ND 1 ND ND 5 8 8 15 14 6 ND ND
Khan et al.; Jun 2018; Kuwait; Retrospective 4 (CaDM: 3) 2 in CaDM ND ND 1 ND ND 1 HM: 2; ST: 6 ND ND 3 (CaDM: 3) 1 ND ND ND 4; In CaDM:0 ND 1 4 (CaDM: 1) ND ND ND ND 9 (CaDM: 3) 8 C. auris death
Morales-Lopez et al.; Jan 2017; Colombia; Observational ND ND ND ND ND ND 5 ND 2 ND ND ND 1 ND ND ND ND ND 7 16 15 10 8 15 6
Lockhart et al.; Dec 2016; Multinational; Retrospective ND ND ND ND ND ND ND 4 ST: 6 ND ND ND ND ND ND ND ND 10 21 30 25 ND ND ND 24
Chowdhary et al.; Dec 2013; India; Retrospective ND 2 in CaDM 5 in CaDM ND 3 (CaDM: 2) ND ND ND HM: 1; ST: 2 ND ND ND ND 1 9 ND 7 ND ND 8 11 ND 8 11 4 (CaDM: 1)
Chowdhary et al.; Oct 2013; India; Observational ND ND ND ND 2 ND 3 in CaDM 1 ST: 1 in CaDM ND ND 1 1 in CaDM ND 8 in CaDM ND 4; 2 in CaDM ND 2 in CaDM 2 (CaDM: 1) 6 (CaDM: 5) ND 0 3 (CaDM: 1) 5 (CaDM: 3)
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Abbreviations: ND: not defined, HRF: hospital-related factor, HTN: hypertension, CVA: cerebral vascular accident, IHD: ischemic heart diseases, CHF: congestive heart failure, CKD: chronic kidney diseases, ESRD: end-stage renal diseases, HD: hemodialysis, CLD: chronic liver diseases, COPD: chronic obstructive pulmonary diseases, RD: respiratory diseases, NTP: neutropenia, IMSP: immunosuppression, SOT: solid organ transplant, CBI: concurrent bacterial infection, CVC: central venous catheter, UTC: urinary tract catheter, MV: mechanical ventilation, TPN: total parenteral therapy, ICU: intensive care unit, ST: solid tumor, HM: hematologic malignancy

Fig. 8.

Fig. 8

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The frequency of comorbidities and HRFs among study patients

Hospital-related factors (HRF)s of PCaI patients

Table 3 lists the HRFs among study patients. Overall, eight HRFs were captured in the included studies. The data about CaDM patients were rarely discussed. Central venous catheter (CVC) was the most prevalent HRF applied in 1,054 PCaI and 11 CaDM patients. 583 PCaI and seven CaDM patients were hospitalized in ICUs. 564 PCaI and five CaDM patients received mechanical ventilation (MV). 554 PCaI and two CaDM patients had concurrent bacterial infections (CBI). Urinary tract catheters (UTC) were applied in 483 PCaI and 11 CaDM patients. 417 PCaI and two CaDM patients had surgeries during hospitalization. Moreover, 167 PCaI and five CaDM patients had steroid consumption, and finally, 247 PCaI patients received total parenteral nutrition (TPN) as their therapeutic strategy. Figure 8 illustrates the frequency of HRFs in the study.

Relationship between mortality, C. auris infection, and DM

A total of 39 studies, including 1,361 PCaI and 488 CaDM patients, reported data about unadjusted all-cause mortality (Table 3). Among them, 610 (44.82%) death events were recorded in PCaI patients. The data about the mortality of CaDM patients were captured from 11 studies. Among them, we captured 139 death events for PCaI patients and 75 death events for CaDM patients. We performed a proportion analysis via the metaprop command to survey the relationship between mortality, C. auris infection, and DM. Our results showed that the pooled mortality among CaDM patients was 57% (95% CI: 45–69), which was statistically significant. Moderate heterogeneity was observed (I2 = 51.05%; p = 0.03) (Table 3, Fig. 9, Fig. S6).

Fig. 9.

Fig. 9

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The forest plot for the pooled prevalence of mortality of CaDM patients

Results of the GRADE assessment

The certainty of the evidence varied across outcomes. The pooled prevalence of diabetes mellitus (DM) among patients with confirmed C. auris infection, as well as among those with non-confirmed C. auris infections, was rated as very low certainty due to significant inconsistency (high I2) and evidence of publication bias. The pooled OR for DM in PCaI vs non-PCaI patients (OR = 1.40, 95% CI 0.88–2.24) was considered of low to moderate certainty due to inconsistency and imprecision. The pooled mortality estimate among CaDM patients (57%, 95% CI 45–69) was rated as low certainty because of moderate heterogeneity. The mean age difference (MD − 0.66 years) was classified as moderate certainty, as it was consistent, precise, and free from bias. The gender comparison (OR = 0.54, 95% CI 0.24–1.21) was assessed as low certainty due to imprecision. See Table S2.

Discussion

DM, alongside immunosuppression, invasive medical devices, such as catheters, feeding and breathing tubes, ICU stay, chronic kidney disease (CKD), and long-term antibiotic or antifungal consumption are risk factors for candidiasis [8, 9]. Candida auris is an alarming threat to public health. The US Center for Disease Control and Prevention (CDC) announced that C. auris is an “urgent threat” to public health due to its potent ability to resist several classes of current antifungals [74]. There have been several efforts to understand and resolve the resistance problem deeply [75–77]. However, there is no promising news about that.

We reached a 36% pooled prevalence of DM among PCaI patients (95% CI: 30 to 41; I2: 80.72%; p value: < 0.001). This rate was 31% for non-PCaI patients (95% CI: 21 to 41; I2: 98.03%; p value: < 0.001). These findings indicated that DM is prevalent among PCaI patients. Also, our OR analysis results showed that DM patients had a 40% higher susceptibility to being infected with C. auris (OR: 1.40; 95% CI: 0.88 to 2.24; I2: 68.7%; p value: < 0.001); however, there is no statistically association between DM and C. auris infection in this study. Considerable heterogeneity was observed across studies. DM has previously been discussed as a risk factor for fungal infections, especially candidiasis [10, 11]. Patients with DM develop several disorders, such as neuropathies, nephropathies, retinopathy, and vascular disorders, that can ultimately lead to immunosuppression or dysregulation, which finally causes the susceptibility of the host to fungal infections [10, 11].

The data from 28 studies indicated that PCaI patients had a mean age of 57.18. However, CaDM patients had a mean age of 67.66 from 11 studies. This simple calculation showed that the mean age of CaDM patients is higher than that of PCaI patients. Our OR analysis for this data confirmed our hypothesis. We found that CaDM patients were on average 10 years older than PCaI patients (−0.66; 95% CI: −1.09 to −0.23; I2: 0.0%; p value: 0.522). Senescence is recognized as a risk factor for several fungal infections. It may be due to the severe changes in hosts’ physiological imbalance and weakened immunity, which lead to susceptibility to fungal infections [78]. Our findings regarding the patients’ age were similar to those of the previously reported studies [79]. DM is more prevalent among older people and rarely among young patients. This fact can affect our findings.

Our OR analysis for the patient gender data revealed that men with DM had 46% lower susceptibility to C. auris infection than women (OR: 0.54; 95% CI: 0.24 to 1.21; I2: 0.0%; p value: 0.905). There was no statistically significant relationship between the gender of DM patients and susceptibility to C. auris infection. However, this finding rejected our hypothesis, which predicted the higher susceptibility of men with DM to C. auris infection than women.

We found several comorbidities to be more repeated in our analysis. Also, we sorted comorbidities and HRFs in separate sections. CKD was the most frequent morbidity among our studied PCaI patients, followed by HTN, RD, IHD, HD, COVID-19, immunosuppression, malignancies, CVA, CLD, COPD, ESRD, CHF, HIV, SOT, and neutropenia, respectively. The imbalance of functional arms of immune response is a key response to our question about how these comorbidities lead to the host’s susceptibility to C. auris infection. However, it is unclear to us why HIV, neutropenia, or malignancies were not the most frequent comorbidities. One primary response to this question may be the low frequency of the papers that reported data about these comorbidities. HIV and neutropenia data were reported from eight and five studies, respectively. We previously performed a meta-analysis for the prevalence of C. auris infection among COVID-19 patients [12]. We found that among 1942 patients with COVID-19, 129 had positivity for C. auris infection and reached a pooled prevalence of 5.7%. Our results in the current study are in accordance with those of the previous research. Also, we found that HTN was the most prevalent comorbidity among patients with COVID-19-associated C. auris (CACa) infection, with 59.37% of the patients, followed by DM (52.89%), and cardiovascular diseases (31.39%) [12]. Unfortunately, there was no similar meta-analysis in the field to compare the current study’s findings.

Also, we found that the application of CVC was the most frequent HRF, followed by ICU hospitalization, MV, CBI, UTC application, surgeries, steroids therapy, and TPN therapy. It was previously recommended that medical device interventions be one of the most prevalent risk factors for fungal infection, especially candidiasis [80–83]. Catheter application is one of the main risks for C. auris infection. This may be due to triggering the imbalance between local immunity, which includes physical barriers, and innate and cellular responses [84, 85]. Also, another reason is triggering the imbalance between the local mycobiome and microbiome [84, 85].

We found that 57% of overall death events were recorded among CaDM patients (95% CI: 0.45 to 0.69; I2: 51.05%; p value: 0.03). It can be concluded that the risk for mortality among CaDM patients is higher than PCaI patients. We cannot declare that DM raised the mortality frequency among CaDM patients due to other comorbidities. However, our previous meta-analysis studies indicated a mortality rate of 67.849% (95% CI: 46.122 to 86.136; I2: 7.41%; p value: 0.3561) for CACa patients [12]. Now, we can compare the results of our previous meta-analysis studies with the results of the current study. This comparison confirmed our previous findings about the higher mortality rate of C. auris-positive patients with DM than those without DM.

The main limitation of this study was the lack of data about CaDM patients. We tried to minimize the effect of this limitation by choosing a broad-spectrum study search. Regarding our exclusion criteria, numerous studies were excluded from our analysis; however, we ultimately included 43 studies in our final analysis, which was acceptable. High heterogeneity (I2 > 80% for prevalence estimates) suggests that pooled effects might not apply universally across different settings, possibly due to variations in DM definitions, diagnostics, regional epidemiology, or unadjusted confounders across studies (e.g., ICU admission, catheter use). Therefore, in this study, DM should not be considered an independent risk factor.

This study had several methodological limitations, which we recommend addressing and highlighting for future research. The first limitation is that the overall certainty of the evidence across outcomes was rated low due to the predominance of retrospective observational study designs, resulting in substantial heterogeneity and imprecise pooled estimates. These findings underscore the importance of early detection, comprehensive clinical management, and targeted preventive measures for diabetic populations at risk of C. auris infection. The second limitation is the inability to conduct subgroup analyses or meta-regression to explore potential sources of heterogeneity. Due to the limited number of eligible studies in some subgroups and inconsistent reporting of covariates (such as antifungal treatment strategies, comorbidity stratification, and country-level epidemiological data), reliable subgroup analyses or meta-regression were not possible. The third limitation concerns about the use of alternative random-effects estimators, such as the Sidik-Jonkman method.

One of the study’s strengths is the diverse assays of data analysis. We performed several meta-analyses, including four proportion analyses for prevalence, age, and mortality, two OR analyses for the relationships between DM, susceptibility to C. auris infection, and patients’ gender. Also, we performed plenty of frequency calculations for involved countries and geographical regions, comorbidities, and HRFs.

Conclusions

Candida auris is still a serious public health concern, especially among people with weakened immune systems. Estimation of the exact number of C. auris patients with diabetes mellitus is merely challenging. However, we tried to design and present an epidemiologic package covering a global scale. We concluded that despite the significant advances in diagnosis and treatments, prevalence, risk, and mortality rates of C. auris infection and diabetes mellitus remained high. Therefore, health policy-makers should revise and update the control and management strategies on a worldwide scale. Also, we recommended designing and performing another large-scale meta-analysis every three years and avoiding publishing plenty of descriptive and narrative review-type papers.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1 (141KB, docx)
Supplementary Material 2 (130.3KB, docx)
Supplementary Material 3 (127KB, docx)
Supplementary Material 4 (121.6KB, docx)
Supplementary Material 5 (126.8KB, docx)
Supplementary Material 6 (125.6KB, docx)
Supplementary Material 7 (32.2KB, docx)
Supplementary Material 8 (15KB, docx)

Acknowledgements

The authors are grateful to the Department of Medical Mycology and Parasitology, Internal Medicine, and Infectious Diseases, Faculty of Medicine, Tabriz University of Medical Sciences, for the excellent support.

Author contributions

Conceptualization and methodology, H.M., A.V. and A.G.; software, H.M.; validation, H.M., Sa.N., F.Zare. and F.Z.; formal analysis, H.M.; investigation, H.M., A.V., A.G., F.Zare., Sa.N., F.Z., S.N., A.Z., S.P.L., H.F.A.; resources, Sa.N., F.Zare. and F.Z.; data curation, H.M., A.V. and A.G.; writing—original draft preparation, H.M., Sa.N., S.N., A.Z., S.P.L., H.F.A.; writing—review and editing, H.M., A.V. and A.G.; visualization, H.M.; supervision, H.M.; project administration, H.M.; funding acquisition, N/A. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Data availability

The original contributions presented in this study are included in the article/supplementary material.

Declarations

Ethics and consent to participate

Not applicable.

Consent for publication

This study was based on prior published studies, and no consent was necessary.

Generative AI and AI-assisted technologies in the writing process

The authors declare no competing interests.

Competing interests

The authors declare no competing interests.

Footnotes

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Aydin Vaez and Arman Ghahremanzadeh these authors contributed equally to this work.

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Associated Data

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Supplementary Materials

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Data Availability Statement

The original contributions presented in this study are included in the article/supplementary material.

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