Clinical Practice Recommendations for the Treatment of Candida auris Infection in Korea

Abstract

Candida auris is an emerging multidrug-resistant fungal pathogen associated with invasive infections and high mortality. In Korea, C. auris infections have historically been caused predominantly by Clade II isolates; however, recent reports of invasive infections due to Clade I indicate an evolving epidemiology with potential implications for antifungal resistance and treatment strategies. To provide practical guidance for clinicians, we developed evidence-based recommendations for the management of C. auris infections in Korea through review of current international guidelines and available epidemiologic and clinical data, with multidisciplinary expert consensus. Antifungal therapy is not recommended for asymptomatic colonization. Echinocandins are recommended as first-line therapy for suspected or confirmed invasive C. auris infection, whereas amphotericin B deoxycholate is preferred for neonates and young infants. Antifungal susceptibility testing should be performed whenever invasive infection is suspected, although initiation of empirical therapy should not be delayed while awaiting results. Treatment should be reassessed according to susceptibility results, infection sites, and clinical response, with specialist consultation for refractory or complicated infections. These recommendations are based on the currently available evidence and epidemiology, warranting continued surveillance of epidemiologic changes and emerging clinical data.

Key Messages

• • Treatment is not recommended for asymptomatic Candida auris colonization.

• • Use echinocandins as first-line therapy for suspected or confirmed C. auris infection.

• • Perform antifungal susceptibility testing (AFST) for all C. auris isolates, particularly in patients with invasive infection or inadequate response to initial therapy.

• • Reassess antifungal therapy based on AFST results and clinical response.

• • Consult an infectious diseases specialist for refractory or complicated C. auris infections.

Background

Candida auris, recently reclassified as Candidozyma auris, is an emerging multidrug-resistant fungal pathogen with limited therapeutic options that causes invasive infections associated with substantial morbidity and mortality [1,2]. The major phylogenetic clades exhibit distinct geographic distributions and differ in their epidemiologic characteristics and antifungal resistance profiles (Table 1) [1,2,3,4]. Since C. auris was first reported in Korea in 2009, sporadic cases have predominantly involved Clade II isolates, which are commonly associated with colonization of the external auditory canal [5]. More recently, however, invasive infections caused by Clade I isolates, including severe multidrug-resistant cases, have been reported [6,7], indicating that the epidemiology of C. auris in Korea is evolving. This shift is clinically important because different clades may exhibit distinct antifungal susceptibility profiles [4]. Although epidemiologic data regarding transmission routes, disease burden, clinical manifestations, and antifungal resistance patterns in Korea remain limited, the increasing emergence of invasive disease highlights the need for practical guidance to support timely diagnosis and appropriate antifungal therapy. Given the multidrug-resistant nature of C. auris, particularly its high rates of azole resistance, echinocandins are recommended as empirical first-line therapy, consistent with current international recommendations [8,9,10,11]. The key recommendations are summarized in the simplified treatment algorithm shown in Figure 1.

Table 1. Major characteristics of Candida auris^a clades.

Clade	Major geographic distribution	Common sites of isolation	Antifungal resistance profile	Transmission and outbreak characteristics
I (South Asian)	India, Pakistan, USA, Spain, UK	Blood, urine, soft tissue, and other clinical specimens	High frequency of fluconazole resistance; occasional amphotericin B resistance; echinocandin resistance remains uncommon	Major global epidemic clade associated with widespread healthcare-associated transmission and hospital outbreaks
II (East Asian)	Japan, Korea, China, Taiwan	Predominantly external auditory canal; bloodstream infections are uncommon	Lower multidrug resistance than other clades; echinocandin resistance is rare; fluconazole resistance remains relatively common	Healthcare-associated outbreaks have not been reported, and invasive infections are rare compared with other clades
III (African)	South Africa, East Africa	Blood and other clinical specimens	High frequency of fluconazole resistance; occasional echinocandin resistance	Healthcare-associated transmission has been reported in selected regions
IV (South American)	Colombia, Venezuela, Mexico	Blood and other clinical specimens	High frequency of fluconazole resistance; occasional amphotericin B resistance; generally susceptible to echinocandins	Healthcare-associated transmission has been reported in selected regions

^aAlthough Candida auris has recently been reclassified into the genus Candidozyma, the conventional name is retained throughout this document to maintain consistency with current clinical practice and public health terminology. The nomenclature will be updated if an official consensus is established by the international scientific community and relevant professional societies.

Figure 1. Treatment algorithm for Candida auris infection.

^aConsider AFST in patients with suspected invasive infection, a suboptimal response to antifungal therapy, or suspected antifungal resistance. ^bFor deep organ involvement, individualize therapy according to the site of infection and clinical response; infectious diseases consultation and combination antifungal therapy should be considered. For uncomplicated candidemia, continue antifungal monotherapy for at least 2 weeks after documented clearance of fungemia.

MDR, multidrug resistant; AFST, antifungal susceptibility testing; ID, infectious diseases.

These recommendations are intended to provide standardized guidance for the management of C. auris infections, particularly in healthcare settings where infectious diseases expertise may not be readily available. The initial recommendations were drafted based on relevant international guidelines and Korean epidemiological and clinical literature identified through a targeted PubMed search conducted from database inception through January 2026 using the terms “Candida auris” AND “Korea”. They were subsequently refined through iterative review and discussion by a multidisciplinary expert panel until consensus was reached. Although they primarily reflect the Korean healthcare setting, the general treatment principles may also be applicable to similar settings. As the epidemiology and antifungal susceptibility patterns of C. auris continue to evolve, these recommendations should be revised periodically to incorporate emerging clinical evidence. This document was finalized on March 24, 2026, and was developed in consultation with, and endorsed by, relevant academic societies and professional organizations, including the Korean Society of Infectious Diseases, Korean Society of Pediatric Infectious Diseases, Korean Convalescent Hospital Association, Korean Society of Clinical Microbiology, Korean Society for Laboratory Medicine, and Korean Society of Antimicrobial Therapy. Recently published guidance from the World Health Organization, the US Centers for Disease Control and Prevention (CDC), the UK Health Security Agency, and European Confederation for Medical Mycology were reviewed and considered in the development of the document [8,9,10,11]. A concise Korean-language brochure summarizing these recommendations for healthcare professionals is available for download from the Korea Disease Control and Prevention Agency website [12], and an English-language version is provided as Supplementary Material. Given the continued widespread use of the name C. auris in clinical and public health settings, the former nomenclature is retained throughout these recommendations to minimize confusion in clinical practice. The terminology will be updated once the revised nomenclature is broadly adopted by the international scientific community and relevant professional societies.

Indications for antifungal therapy and initial treatment recommendations

C. auris, like other Candida species, may colonize the human body without causing clinical infection. Antifungal therapy is not recommended when C. auris is isolated from the urinary tract, skin, external auditory canal, upper respiratory tract, or other nonsterile sites in the absence of clinical signs or symptoms of infection [11]. However, antifungal therapy should be promptly initiated when invasive infection is suspected or when compatible clinical manifestations are present. This is particularly important in patients with confirmed or strongly suspected invasive C. auris infections, including candidemia, infective endocarditis, abscesses, or osteomyelitis. Whenever feasible, treatment decisions should be made in consultation with an infectious diseases specialist.

Echinocandins are recommended as first-line therapy for invasive C. auris infections based on the current epidemiology and antifungal susceptibility patterns in Korea. However, because echinocandins have limited penetration into the urinary tract and central nervous system, the choice of antifungal agent should be guided by the site of infection. Initial treatment with an echinocandin is recommended for adults and children aged ≥2 months, though the recommended age for pediatric patients varies from ≥1 to ≥4 months depending on the specific agent. For neonates and infants aged <2 months, amphotericin B deoxycholate (1 mg/kg/day) is recommended. Although recent international guidelines include liposomal amphotericin B and echinocandins as alternative treatment options for neonates [11], amphotericin B deoxycholate is preferred in this document because echinocandins are not approved in Korea for neonates or young infants, amphotericin B deoxycholate is reported to be less nephrotoxic in neonates and young infants [13], and a previous observational study reported higher mortality with lipid formulations of amphotericin B than with amphotericin B deoxycholate in neonates [14,15]. Antifungal therapy should be reassessed during treatment according to antifungal susceptibility testing (AFST) results, the site of infection, and the patient's clinical response. When appropriate, therapy may be modified or switched to an alternative antifungal agent, including amphotericin B formulations. Recommended antifungal agents for the treatment of C. auris infection are summarized in Table 2.

Table 2. Recommended antifungal agents and dosages for Candida auris infection.

Class	Antifungal agent	Recommended dosage		Remarks
		Adult	Pediatric
Echinocandins	Anidulafungin	Loading dose: 200 mg IV once, followed by 100 mg IV daily	Infants aged ≥1 month, children and adolescents:	Standard adult dosage
			Loading dose: 3 mg/kg IV once (max. 200 mg), followed by 1.5 mg/kg/day (max. 100 mg) IV
	Caspofungin	Loading dose: 70 mg IV once, followed by 50 mg IV daily	Infants aged ≥3 months, children and adolescents:	Dose adjustment is required in patients with hepatic impairment
			Loading dose: 70 mg/m2 IV once, followed by 50 mg/m2 IV daily (max. 70 mg)
	Micafungin	100 mg IV daily (may be increased to 150 mg daily if clinically indicated)	Infants aged ≥4 months, children and adolescents:	Dose escalation may be considered based on infection severity and antifungal susceptibility
			2 mg/kg IV daily (max. 100 mg)
Polyenes	Amphotericin B deoxycholate	-	1 mg/kg IV daily	Preferred in neonates and infants <2 months
	Liposomal amphotericin B	5 mg/kg IV daily		May be considered in patients with severe infection or treatment failure
Azoles	Fluconazole	Use only after susceptibility has been confirmed		Because resistance is common, empiric use is not recommended
	Voriconazole	Use only after susceptibility has been confirmed		Empiric monotherapy is not recommended; selective use may be considered based on susceptibility results

Combination antifungal therapy or alternative antifungal agents may be considered in patients with an inadequate clinical response, suspected antifungal resistance, or severe infection, preferably in consultation with an infectious diseases specialist.

IV, intravenous.

Antifungal susceptibility testing and treatment considerations

AFST should be performed in patients with suspected invasive C. auris infection because antifungal resistance is common [8,9]. Empiric antifungal therapy should not be delayed while awaiting AFST results. Once susceptibility results become available, antifungal therapy should be reassessed accordingly, particularly in patients with a suboptimal or delayed clinical response. Laboratory methods and interpretation of AFST results should be guided by the recommendations of the US CDC and other relevant professional guidelines [16,17,18].

Antifungal monotherapy is the standard treatment for C. auris infection [11]. In particular, uncomplicated candidemia without evidence of metastatic organ involvement can generally be managed effectively with a single antifungal agent. In patients with C. auris candidemia, removal of central venous catheters should be considered whenever clinically feasible. A dilated ophthalmologic examination should also be considered to evaluate for ocular involvement, and follow-up blood cultures should be obtained until clearance of fungemia is documented. The duration of antifungal therapy should be individualized according to the site of infection, the patient's immune status, clinical response, and the timing of documented blood culture clearance. For candidemia without metastatic complications, antifungal therapy should be continued for at least 2 weeks after the first documented negative blood culture, provided that clinical signs and symptoms have resolved [11]. For patients with a poor clinical response, persistent candidemia, confirmed or strongly suspected antifungal resistance, or severe or complicated infections (e.g., central nervous system infection), combination antifungal therapy or alternative antifungal agents may be considered in consultation with an infectious diseases specialist.

Limitations and future directions

This document was developed based on currently available international guidelines and the best available evidence at the time of writing. As new evidence emerges and the epidemiology of C. auris continues to evolve, these recommendations should be interpreted in the context of changing clinical circumstances. Although not yet available in Korea, several novel antifungal agents, including ibrexafungerp and fosmanogepix, have shown promising activity against C. auris and may expand future therapeutic options, particularly for infections caused by multidrug-resistant isolates. This document will be updated as needed to reflect newly available antifungal agents, evolving epidemiology, and changes in antifungal resistance patterns.

SUPPLEMENTARY MATERIAL

Brochure summarizing these recommendations for healthcare professionals (a concise English-language version).