The first invasive Candida auris infection in Taiwan

Figures & data

Figure 1. Phylogenetic tree generated by Maximum likelihood analysis using (A) ITS and (B) D1/D2 region of the Candida auris strains with closely related Candida species. The percentages of replicate trees in which the associated taxa clustered together in the bootstrap test (10,000 replicates) are indicated at the branches. The scale bar indicates the nucleotide substitutions per site. Two isolates in the present study are highlighted in red and two isolates are related to C. auris as it falls in the same clade.

Figure 2. (A) Sequence alignments of ERG11 gene in C. auris isolates. (B) Sequence alignments of FKS1 hot spot 1 region in C. auris isolates. Mutations in ERG11 or FKS1 were not detected in either isolate.

Figure 3. Short tandem repeat genotypes of 44 Candida auris isolates. Unweighted pair group method with arithmetic averages dendrogram of both isolates (KMUH and CMMC) and representative isolates from the South Asian clade and four clades are shown. Abbreviations: UK, United Kingdom; SA, South Africa.

Table 1. Characteristics and antifungal susceptibility profiles of Candida auris isolates in Taiwan.

Isolate No.	Year of isolation	Specimen site	Antifungal MIC in mg/L (Interpretation^a)								ERG11 mutation^b	FKS1 mutation^c
			AMB	FLC	ISA	POS	VRC	AFG	MFG	5FC
KMUH	2021	blood	1 (S)	8 (S)	0.06 (NA)	0.12 (NA)	0.12 (NA)	0.12* (S)	0.06* (S)	≤0.06* (NA)	ND	ND
CMMC	2018	wound	0.5 (S)	16 (S)	0.25 (NA)	0.25 (NA)	0.25 (NA)	0.5-1‡ (S)	0.25-0.5‡ (S)	≤0.06 ‡ (NA)	ND	ND

Abbreviations: S, susceptible; R, resistant; NA, not applicable; AMB, amphotericin B; FLC, fluconazole; ISA, isavuconazole; POS, posaconazole; VRC, voriconazole; AFG, anidulafungin; MFG, micafungin; 5FC, 5-flucytosine; ND, not detected.

^a Interpretation is based on the US CDC tentative MIC breakpoints for C. auris: Fluconazole ≥ 32 μg/mL (R), amphotericin B ≥ 2 μg/mL (R), anidulafungin ≥ 4 μg/mL (R), micafungin ≥ 4 μg/mL (R).

^b Only Y132, K143, F126 were screened for azole resistance.

^c Only S639 was screened for echinocandin resistance.

*Performed by Sensititre YeastOne.

‡Adapted from reference of Tang et al. [14].

Figure 4. Distribution of reported C. auris cases in Southeast Asia and neighbouring regions/countries. Case counts were based on an epidemiological report [22] and studies from Japan [28], South Korea [29], Taiwan [14] (including the present study), China [25], Hong Kong [30], Malaysia [10], Singapore [12], Thailand [11], Bangladesh [31], and India and Pakistan [5].

Table A1. GenBank accession numbers, ERG11 and FKS1 genotypes, and clade information of representative strains included in this study.

Strain/isolate	Clade	ERG11
		Accession no.	Genotype
AR0382	South Asian	MK294628	WT
AR0381	East Asian	MK294627	WT
AR0389	South Asian	MK294635	Y132F
AR0388	South Asian	MK294634	K143R
AR0383	South African	MK294629	F126L
Strain/isolate	Clade	FKS1
		Accession no.	Genotype
Reference		XM_018312389	WT
CBS 10913	East Asian	MK059967	WT
KW60/18		OM649840	WT
KW3584/17		OM649839	WT
KW3525/17		OM649838	WT
KW3506/17		OM649837	WT
VPCI 1132/P/13	South Asian	MK059973	WT
VPCI 1133/P/13	South Asian	MK059974	S639F
KW87/1/18		OM649841	S639T
KW93/18		OM649842	S639Y
KW108/18		OM649843	S639T

WT, wild type.

Table A2. Sequences of primers used in the study.

Gene	Primer probe		Sequence
ITS	ITS1	Forward	5’-TCC GTA GGT GAA CCT GCG G-3’
	ITS4	Reverse	5’-TCC TCC GCT TAT TGA TAT GC-3’
D1/D2 region	NL-1	Forward	5’-GCA TAT CAA TAA GCG GAG GAA AAG-3’
	NL-4	Reverse	5’-GGT CCG TGT TTC AAG ACG G-3’
ERG11 (Amplify)	CauErg11F	Forward	5’-GTG CCC ATC GTC TAC AAC CT-3’
	CauErg11R	Reverse	5’-TCT CCC ACT CGA TTT CTG CT-3’
ERG11 (Sequencing)	CauERG11dF	Forward	5’-TGG GTK GGY TCW GCT GTT G-3’
	CauERG11dR	Reverse	5’-TTC WGC TGG YTC CAT TGG-3’
FKS1 (Amplify)	CauFKS1_F	Forward	5’-ATG TCT TAC GAT AAC AAT C-3’
	CauFKS1_R	Reverse	5’-TTA GAA TGC CTT TGT AGT ATA G-3’
FKS1 (Sequencing)	CauFKS1_F1256-77	Forward	5’-AGA GAT ACA TGA GAT TGG GTG-3’
		Reverse

ITS: internal transcribed spacers.

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