Potential Environmental Reservoirs of Candida auris: A Systematic Review

Candida auris, a multidrug-resistant yeast, poses significant challenges in healthcare settings worldwide. Understanding its environmental reservoirs is crucial for effective control strategies. This systematic review aimed to review the literature regarding the natural and environmental reservoirs of C. auris. Following the PRISMA guidelines, published studies until October 2023 were searched in three databases: PubMed, Web of Science, and Scopus. Information regarding the origin, sampling procedure, methods for laboratory identification, and antifungal susceptibility was collected and analyzed. Thirty-three studies published between 2016 and 2023 in 15 countries were included and analyzed. C. auris was detected in various environments, including wastewater treatment plants, hospital patient care surfaces, and natural environments such as salt marshes, sand, seawater, estuaries, apples, and dogs. Detection methods varied, with molecular techniques often used alongside culture. Susceptibility profiles revealed resistance patterns. Phylogenetic studies highlight the potential of environmental strains to influence clinical infections. Despite methodological heterogeneity, this review provides valuable information for future research and highlights the need for standardized sampling and detection protocols to mitigate C. auris transmission.


Introduction
Candida auris is a multidrug-resistant yeast first identified in the ear of a Japanese patient in 2019 [1].A member of the Candida/Clavispora clade, closely related to Candida lusitaniae and Candida haemulonii, it has emerged in recent years as a cause for healthcarerelated infections, complicating treatment protocols and increasing patient morbidity and mortality rates [2].It has been identified in more than 40 countries, with outbreaks reported on multiple continents, with notable impacts in countries such as the United States, India, South Africa, and several European nations, including the United Kingdom Spain, France, and Italy (Figure 1) [3,4].In 2022, the World Health Organization designated this fungal pathogen as a priority due to its rapid transmission in healthcare settings and high mortality rate [5,6].C. auris is implicated in a range of serious conditions including bloodstream and urinary tract infections, otitis, post-surgical complications, skin abscesses often related to catheter use, myocarditis, meningitis, osteomyelitis, and various wound infections [19].However, it can also colonize noninvasive body sites, like skin, without causing active infection.Invasive infections caused by C. auris pose a significant mortality risk in hospital se ings, with death rates varying between 30% and 60% [20].Certain factors increase the likelihood of C. auris infection, including male gender, premature birth history in infants, underlying health conditions such as diabetes, kidney or hearing impairments, physical injuries, previous central venous catheter insertions, and extensive use of broad-spectrum antibiotics [21].
Phylogenetic studies obtained by whole-genome sequencing (WGS) techniques have identified four distinct clades, namely, clades I, II, III, and IV (South Asia, East Asia, Africa, and South America, respectively) [22].A fifth and a sixth clade, separated from the others by more than 36,000 single-nucleotide polymorphisms (SNPs), were confirmed to have appeared in patients from Iran and Singapore, respectively [23,24].
C. auris has become a significant concern due to its multidrug-resistant nature.Of C. auris isolates, 44.29% are resistant to fluconazole, followed by 15.46% to amphotericin B, 12.67% to voriconazole, 3.48% to caspofungin, and 1.95% to flucytosine [25].In the United States, the prevalence of resistance among these fungal pathogens has been observed to be 90% against fluconazole, 30% against amphotericin B, and 5% against echinocandins, with a tendency to rise over time [26,27].Although resistance rates vary depending on the clade, country, and healthcare se ing, C. auris has shown resistance to fluconazole, amphotericin B, and echinocandins [6,28].
Identifying C. auris isolates through conventional laboratory methods has proven to be challenging, often leading to its misidentification [4].As a result, matrix-assisted laser desorption/ionization-time of flight (MALDI-TOF) and molecular identification via sequencing the ITS and/or D1/D2 DNA sequence seem to be good options for its identification [25].
C. auris thrives in environments with elevated salinity and high temperature, ideally between 37 °C and 40 °C [29,30].Yeasts typically possess a keen sensitivity to ambient temperatures, often displaying a diminished ability to survive at the elevated temperatures in the human body [31].The rise in global temperatures may have caused certain species, such as C. auris, to evolve and thrive in warmer climates [32].This C. auris is implicated in a range of serious conditions including bloodstream and urinary tract infections, otitis, post-surgical complications, skin abscesses often related to catheter use, myocarditis, meningitis, osteomyelitis, and various wound infections [19].However, it can also colonize noninvasive body sites, like skin, without causing active infection.Invasive infections caused by C. auris pose a significant mortality risk in hospital settings, with death rates varying between 30% and 60% [20].Certain factors increase the likelihood of C. auris infection, including male gender, premature birth history in infants, underlying health conditions such as diabetes, kidney or hearing impairments, physical injuries, previous central venous catheter insertions, and extensive use of broad-spectrum antibiotics [21].
Phylogenetic studies obtained by whole-genome sequencing (WGS) techniques have identified four distinct clades, namely, clades I, II, III, and IV (South Asia, East Asia, Africa, and South America, respectively) [22].A fifth and a sixth clade, separated from the others by more than 36,000 single-nucleotide polymorphisms (SNPs), were confirmed to have appeared in patients from Iran and Singapore, respectively [23,24].
C. auris has become a significant concern due to its multidrug-resistant nature.Of C. auris isolates, 44.29% are resistant to fluconazole, followed by 15.46% to amphotericin B, 12.67% to voriconazole, 3.48% to caspofungin, and 1.95% to flucytosine [25].In the United States, the prevalence of resistance among these fungal pathogens has been observed to be 90% against fluconazole, 30% against amphotericin B, and 5% against echinocandins, with a tendency to rise over time [26,27].Although resistance rates vary depending on the clade, country, and healthcare setting, C. auris has shown resistance to fluconazole, amphotericin B, and echinocandins [6,28].
Identifying C. auris isolates through conventional laboratory methods has proven to be challenging, often leading to its misidentification [4].As a result, matrix-assisted laser desorption/ionization-time of flight (MALDI-TOF) and molecular identification via sequencing the ITS and/or D1/D2 DNA sequence seem to be good options for its identification [25].
C. auris thrives in environments with elevated salinity and high temperature, ideally between 37 • C and 40 • C [29,30].Yeasts typically possess a keen sensitivity to ambient temperatures, often displaying a diminished ability to survive at the elevated temperatures in the human body [31].The rise in global temperatures may have caused certain species, such as C. auris, to evolve and thrive in warmer climates [32].This evolutionary develop-ment has allowed for C. auris to overcome the human body's innate temperature defenses, thereby enabling colonization and leading to subsequent infection.
C. auris can exhibit the capacity to persist for extended periods on various surfaces due to its ability to form biofilms, like glass, fabric, plastic, wood, and steel, tending to flourish in moist environments [33].Consequently, these materials pose a potential source of infection within hospital settings, emphasizing the importance of thorough disinfection protocols to interrupt the transmission of C. auris [4].The significance of microbiological sampling of healthcare environment surfaces is emphasized in the literature, as it aids in understanding contamination levels and informs cleaning protocols.General recommendations have been proposed for designing routine protocols for surface sampling in healthcare environments [34].
The aim of this paper was to undertake a thorough systematic review to clarify the environmental reservoirs of C. auris in natural and hospital settings.Recognizing the environmental reservoirs of C. auris is a crucial aspect of comprehending pathogen transmission and will contribute to understanding the dynamics of the disease, leading to the development of more effective control strategies.

Materials and Methods
This systematic review was carried out in strict accordance with the Cochrane Handbook for Systematic Reviews of Interventions [35] and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [36] checklist of the review was followed (Supplementary Material-S1).

Data Source and Search Strategy
The electronic bibliographic databases of PubMed, Scopus, and Web of Science were searched using a combination of MeSH terms and keywords: ("Candida auris" OR "C.auris") AND ("environment" OR "environmental" OR "globalization" OR vector* OR "travel" OR "imported" OR "ecological" OR reservoir* OR "One Health" OR Ecosystem* OR "Climate Change" OR "Global warming" OR Niche*) Studies were selected and screened until October 2023.The search included all publication types except reviews or systematic reviews, and no language restrictions were applied.

Eligibility Criteria
Studies were included in this review if they met the following criteria: (1) C. auris detected and isolated from natural environments or animals; (2) studies identified the presence of C. auris in urban environments outside of a hospital setting; (3) studies reporting the presence of C. auris from hospital environmental surfaces or materials.The exclusion criteria were (1) studies regarding hospital disinfection procedures or surface decontamination efficacy, (2) studies not addressing the detection of C. auris, and (3) systematic reviews, editorials, and grey literature.

Data Extraction and Synthesis
A total of 929 references were obtained in the three databases.The extracted studies were uploaded to EndNote and Rayyan software [37] for duplicate removal, quality assessment, and further selection.In a blinded, standardized manner, a screening of the title, abstract, and full text was performed and guided based on inclusion and exclusion criteria by two independent reviewers (IS and SCO).Thirty-three studies were included in the systematic review (Figure 2).
A protocol was defined to synthesize the data collected from the selected studies uniformly and consistently.Data such as year of publication, country, study time frame, sample type, collecting procedure, laboratory methods for strain identification, clade determination, and susceptibility profile were extracted from the included publications.IS and SCO extracted the above information independently.

Risk of Bias (ROB) Assessment
To evaluate the risk of bias in the studies included in this review, the National Institute of Health (NIH) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies was used [38].A 3-point scale was used to grade the potential source of bias as good, fair, or poor.No studies were excluded based on quality.ROB assessment was performed independently by SCO and IMM.

Results
Tables 1 and 2 show the characteristics of the 33 studies included in this analysis, spanning the publication years from 2016 to 2023 and conducted within a sampling timeframe extending from 2013 to 2022.These studies were carried out across 15 countries, namely, the United Kingdom, the United States of America, Qatar, South Africa, Colombia, Spain, Kuwait, Oman, India, France, Hong Kong, Greece, China, the Netherlands, and the Republic of Korea.
Among the 33 studies included, 4 centered on natural environments, 3 examined urban non-hospital environments, 1 centered on both (Table 1), and 25 focused on isolation of C. auris within hospital se ings (Table 2).

Risk of Bias (ROB) Assessment
To evaluate the risk of bias in the studies included in this review, the National Institute of Health (NIH) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies was used [38].A 3-point scale was used to grade the potential source of bias as good, fair, or poor.No studies were excluded based on quality.ROB assessment was performed independently by SCO and IMM.

Results
Tables 1 and 2 show the characteristics of the 33 studies included in this analysis, spanning the publication years from 2016 to 2023 and conducted within a sampling timeframe extending from 2013 to 2022.These studies were carried out across 15 countries, namely, the United Kingdom, the United States of America, Qatar, South Africa, Colombia, Spain, Kuwait, Oman, India, France, Hong Kong, Greece, China, the Netherlands, and the Republic of Korea.
Among the 33 studies included, 4 centered on natural environments, 3 examined urban non-hospital environments, 1 centered on both (Table 1), and 25 focused on isolation of C. auris within hospital settings (Table 2).

Potential Natural Environmental Reservoirs
Regarding the five studies that investigated C. auris in natural environments, four of these articles employed a similar approach for strain identification, beginning with its isolation through culture techniques and subsequent confirmation through genomic amplification [39][40][41][42].The only study that deviated from this method attempted to identify previously misidentified C. auris strains from the Sequence Read Archive at the National Center for Biotechnology Information [43].Generally, the collected samples were inoculated in Sabouraud Dextrose Agar, CHROMagar Candida, Yeast nitrogen, and Malt Extract agar at 24-42 • C.
C. auris was detected in diverse environmental substrates, including ears and skin from dogs [39], stored apples purchased from vendors [40], soil from a salt marsh, beach sand, and seawater in India [41], as well as water from estuaries in Colombia [42].Genomic amplification alone enabled the identification of C. auris in unique contexts, such as on the skin of Lissotriron vulgaris and Triturus cristatus in a natural reserve in the UK, in the ear of a dog with otitis in Spain, and in airborne dust from Kuwait [43].Among the reviewed studies, only the three conducted in India identified the clade of C. auris (South Asian clade) [39][40][41].

Potential Urban Non-Hospital Environmental Reservoirs
Out of the 33 articles included, only 4 reported the identification of C. auris in urban non-hospital environments [43][44][45][46].Two of these studies solely relied on genomic amplification for identification, without performing culture [43,44].The remaining two studies combined culture and PCR techniques [45,46].They utilized CHROMagar medium at 42 • C, Sabouraud Dextrose Agar at 24 • C, and Malt Extract Agar at 24 • C for culture, successfully identifying C. auris in wastewater from various sources in Florida [45] and swimming pools in the Netherlands [46].The other two studies identified C. auris solely through PCR, detecting its presence in activated sludge and membrane biofilm from a wastewater treatment plant in the Republic of Korea [43] and in pelleted solids from wastewater in the state of South Nevada, USA [44].Whole-genome sequencing (WGS), polymerase chain reaction (PCR), quantitative polymerase chain reaction (qPCR).

Susceptibility of Natural and Hospital Environmental Samples
Table 3 presents the susceptibility profiles to various antifungal agents commonly used and gene mutations responsible for reduced susceptibility in all studies included in this analysis.Among the studies included, eleven tested the susceptibility profiles for antifungals, with four conducted in natural environments [39][40][41][42] and seven in hospital settings [47,50,51,56,57,60,69].Of these, nine studies utilized the Clinical & Laboratory Standards Institute broth microdilution method to estimate minimum inhibitory concentrations [39][40][41][42]50,51,56,69], one employed the MICRONAUT-AM broth microdilution procedure [57], one used Sensititre YeastOne plates [47], and one did not specify the method used [60].Although there are currently no established susceptibility breakpoints specific for C. auris, and there is still no clear correlation between microbiologic breakpoints and clinical outcomes, the CDC has proposed tentative minimal inhibitory concentration (MIC) breakpoints for fluconazole (≥32 mg/L), amphotericin B (≥2.0 mg/L), and anidulafungin (≥4 mg/L) based on closely related Candida species and expert opinion [71].
The susceptibility profile of the strains isolated from natural environmental samples to antifungal drugs was tested in four studies.Arora and colleagues found that sand/beach samples had high MIC values for fluconazole (MIC > 32 mg/L) and amphotericin B (>2 mg/L), but soil samples from the salt marsh had low MIC values for both drugs [41].Salt marsh samples also grew slower and preferred lower temperatures than the others.Apple samples stored in a warehouse showed low MIC values for amphotericin B (<2 mg/L), but fluconazole MIC values varied [40].Water samples from Colombian estuaries had low MIC values for fluconazole and amphotericin B [42].Samples from dog's ears and skin showed high MIC values for fluconazole and low for amphotericin [39].All samples showed low MICs to anidulafungin across all studies.

Risk of Bias-Quality Assessment
Due to the heterogenicity of the studies regarding natural environments, quality assessment was performed only in hospital environmental studies.All analyzed studies were classified as "Good", being methodologically robust, with clear objectives, thorough methods for sample collection and analysis, and significant contributions to understanding the molecular epidemiology and drug resistance (Supplementary Material-S2).

Discussion
The present systematic review, conducted per PRISMA guidelines, provides an update on potential environmental reservoirs of C. auris.This is necessary to understand the disease's epidemiology and important niches, which in turn helps with its prevention and management.

Sampling and Detection
Our study's findings highlight the differences concerning environmental sampling procedures found both within and across nations.Few studies have compared the most efficient method for environmental sampling recovery for Candida auris.One study found that culture recovery is best with swabs instead of sponges, with 8.4% and >0.1% in culture recovery, respectively [72].Additionally, using a polyurethane sponge seems to be better for C. auris recovery than cellulose sponges.Another article has proven that inoculating C. auris samples in Salt Sabouraud Enrichment Broth is better for C. auris isolation than directly plating it in CHROMagar [30].The enrichment broth procedure inhibits the growth of another organism by creating a high-temperature and high-salinity environment, so it should only be used when trying to isolate C. auris specifically.Most studies in this review used both culture and molecular/proteomic techniques to detect and identify C. auris in the environment.One of the most effective identification methods used for detecting C. auris in cultured isolates is MALDI-TOF MS, which reduces the processing period to less than three hours compared to traditional and DNA-based methods [73].Researchers can use the Bruker and Vitek MALDI-TOF MS systems to correctly identify C. auris [74].Vitek 2 technology, with software version 8.01, may misidentify C. auris as C. duobushaemulonii [74].Therefore, additional testing is necessary to rule out C. auris when using this technology.A reliable way to distinguish C. auris from other yeast species is to sequence the rDNA regions (internal transcribed spacer and D1/D2 region of large subunit) [75].PCR/real-time PCR assays are a dependable method to rule out negative samples when additional analysis is required for further investigation [76].

Potential Natural Environmental Reservoirs
As shown in Table 1, C. auris was isolated from a wide range of natural habitats, indicating a potential reservoir of C. auris in the environment and/or intermediate host.
According to reports from two countries located on separate continents at the time of this analysis, aquatic environments appear to be a source of C. auris.Furthermore, amphibians known to live in aquatic environments have been shown to contain this yeast's DNA.These findings imply that numerous hosts can become contaminated by the aquatic environment and may play a role in C. auris' persistence in this habitat, like other yeasts.
This analysis reports the occurrence of C. auris infections in animals, which is consistent with the literature documenting similar cases caused by other Candida species [77].In humans, the majority of Candida infections arise from colonizing strains rather than through transmission, rendering the likelihood of zoonotic disease minimal [78].Even with the diminished likelihood of zoonotic transmission, animals could still play a role in disseminating C. auris within the environment, which may subsequently result in human colonization.
Researchers have found C. auris on the surfaces of apples bought in local food markets in India, but not on freshly harvested apples from orchards [79].This indicates that contamination with C. auris may occur during transportation or storage.Identifying the stage at which contamination occurs may be important in understanding its impact and risk to human contamination and subsequent infection.
Finding C. auris in aquatic environments supports the hypothesis that it may have natural reservoirs outside human-made environments.The presence of C. auris in these settings suggests that it might have adapted to survive or even thrive in aquatic conditions.Notably, isolation of the drug-susceptible C. auris strain from aquatic habitat with no known human activity probably indicates that C. auris existed as a drug-susceptible pathogen and developed multidrug-resistant traits after its adaptation in humans [41].

Potential Urban Non-Hospital Environmental Reservoirs
C. auris, known to colonize the skin and found in human excrement, has the potential to infiltrate plumbing systems via skin shedding and fecal disposal, eventually arriving at wastewater treatment facilities [80].It is, therefore, unsurprising that it has been identified in such facilities and sewage systems across multiple countries.This situation, however, presents certain challenges.Firstly, sewage discharge can facilitate the propagation of microbes, including C. auris, into marine ecosystems due to the coastal and estuarine outflows of wastewater treatment plants and sewer overflow [81,82].Secondly, in the face of water shortages, the prospect of utilizing wastewater effluents for irrigation and drinking water production is being explored [83].This could potentially amplify the spread of microbiological agent into the environment, thus requiring careful management strategies [84].
One study reported finding C. auris in air dust samples from Kuwait.Previous research showed that airborne microorganisms can travel far and settle on human skin, affecting human health and causing diseases [85,86].C. auris was also found in swimming pools in Netherlands; it is known that recreational swimming pools can also pose the threat of water-borne yeast infection, particularly in immunocompromised patients [87].

Potential Hospital Environmental Reservoirs
The role of hospital surfaces in the transmission of healthcare-associated infection has been highlighted by several authors [88].Environmental surfaces that are close to or frequently touched by colonized patients are more likely to harbor these organisms [89].Nevertheless, we should be aware that most of the studies included were conducted in the context of outbreak investigations, and the level of contamination in non-outbreak situations remains uncertain.While it is true that five studies found that the environmental samples were identical to the clinical samples, it is important to note that they did not establish a correlation between this contamination of the environment and the transmission of C. auris to other patients.Only one study explicitly correlated the contamination of the environment (temperature probes) as a source of transmission of C. auris, leading to an outbreak [61].Therefore, it is essential to apply strict hygiene measures and disinfect the environment using an Environmental Protection Agency-registered hospital-grade disinfectant proven effective against C. auris or disinfectants known to be effective against Clostridium difficile spores to avoid transmission [90][91][92].
This yeast was also detected in areas not within reach by humans, such as air vents and very high curtains.Like Acinetobacter and Staphylococcus aureus, C. auris may disperse through the air by shedding skin flakes that contain the fungus and are carried by air currents [93,94].It was also found outside patients' rooms, and on computer keyboards and medical carts, which may suggest that the medical staff are not sanitizing their hands properly [89,90].

Susceptibility and Phylogeny
C. auris poses a significant challenge within the domain of mycotic diseases due to its resistance to multiple drugs and complicating therapeutic approaches [20].Echinocandin treatment is considered the first-line option [95].However, in cases of echinocandin resistance, treating C. auris infections often involves combination antifungal therapy.Combining echinocandins with other antifungal agents such as triazoles or polyenes may enhance efficacy, broaden the antifungal spectrum, and reduce the potential for resistance development [20].To ensure effective control of C. auris infections, diligent patient monitoring must be observed for signs of clinical recovery during antifungal therapy.
Of the included studies in this review, gene sequencing for various isolates showed mutations in ERG11 and TAC1B, known to contribute to reduced azole susceptibility [96,97], and showed mutations in the CDR1 gene: these changes are known to contribute to antifungal resistance [98].In addition to the mutations identified in the included studies, other relevant ones are highlighted in the literature.Mutations in the ERG3 and ERG5 genes have been found to impact susceptibility to amphotericin B, while mutations in the FKS1 gene affect susceptibility to echinocandins [20].
Clades I, III, and IV are associated with outbreaks of invasive and multidrug-resistant infections [99].Clade II frequently exhibits susceptibility to all antifungal medications, with the majority of instances presenting as ear infections.To date, there have been no associations with outbreaks.Clade II strains exhibit a different karyotype, with large sub-telomeric deletions and rearrangements, and are less commonly linked to invasive infections.Clade V and VI isolates have not been extensively studied, and their clinical implications remain to be fully understood [23,24].

Strategic Surveillance Approach
Based on our findings, it is evident that C. auris frequently contaminate areas surrounding the patient's bed.Therefore, to assess effective disinfection, priority should be given to these zones, with particular attention to bedside tables and hand-rails.Additionally, mobile medical devices should be included in routine investigations due to their potential for cross-contamination between patients [61].Ensuring proper disinfection protocols for these devices with proper hand hygiene measures is essential in minimizing the risk of transmission of pathogens, including C. auris [100].
In terms of environmental sampling for C. auris, an effective method would involve swabbing surfaces [72] and inoculating them in Salt Sabouraud Enrichment Broth [30], followed by MALDI-TOF MS or PCR analysis [76].Positive samples should then undergo culture to confirm viability and perform antifungal susceptibility testing.This comprehensive approach allows for the detection of viable fungal organisms and ensures an accurate assessment of environmental contamination levels.

Limitations
This study has some important limitations that should be noted.A limited number of studies has been conducted on isolation in natural settings, and therefore, this review can only offer a snapshot of the potential reality.Choosing where to collect samples in an environment can significantly impact the relevance and applicability of the data obtained.Another limitation is the heterogeneity of the methods used in the articles that were reviewed, such as the study design and the environmental sampling techniques for C. auris detection.Also, these differences could affect the consistency and validity of the results and the implications derived from them.Furthermore, the research had some limitations that prevented a comprehensive understanding of the reservoir behavior, such as the inability to identify the strain involved and not performing susceptibility assays.It is important to emphasize that only studies regarding the hospital environmental detection of C. auris in the context of an outbreak were considered.

Conclusions
Despite these limitations, the present review demonstrates potential environmental reservoirs of C. auris in clinical and non-clinical environments.In addition, it offers a broad perspective on various aspects that need more research, providing guidance for future studies on C. auris.
It is worth mentioning that global warming may pose a substantial health risks concerning the proliferation of fungal infections [101].The gradual increase in temperature promotes an environment that favors the evolution of yeasts, allowing for them to acquire thermotolerance [102].This adaptation allows for a broader geographic distribution of pathogenic yeasts and their carriers since warmer climates make previously inhospitable regions susceptible to fungal diseases [101].Climate-induced phenomena such as floods, storms, and hurricanes increase the risk of fungal infections.These events have the potential to spread fungal spores on a large scale and aerosolize them, which increases the possibility of human contact.In addition, the injuries caused by these disasters serve as a gateway for fungal pathogens, introducing new or uncommon species into humans [101].Therefore, the continued rise in global temperatures may lead to an expansion of the natural habitat of C. auris, further increasing the risk of this infection in humans [103].Tackling the interplay between climate change and fungal infections, including C. auris, requires proactive measures to mitigate climate change and improve surveillance, prevention, and control strategies for emerging fungal pathogens.

Figure 2 .
Figure 2. PRISMA flow chart representing the systematic identification of studies search via databases and registers.

Figure 2 .
Figure 2. PRISMA flow chart representing the systematic identification of studies search via databases and registers.

Table 1 .
Potential non-hospital environmental reservoirs of C. auris.

Table 2 .
Sites of detection of C. auris in hospital environment.

Table 3 .
Results of antifungal susceptibility testing and gene mutations.