Africa: ‘You Can’t Fight What You Can’t See’ – Why Drug-Resistant Candida auris Threat Is Alarming Experts

“You can’t fight what you can’t see. We need better diagnostics to stop C. auris from spreading.”

Fungal pathogens are a major threat to public health as they are becoming more prevalent and resistant to treatment. These pathogens often lack rapid, sensitive, and widely accessible diagnostics, making effective treatment challenging, especially in resource-limited settings.

Some fungal infections like toenail or vaginal yeast infections are treatable, but more severe forms can be life-threatening. Fungal disease can be spread from person to person by touching, sharing clothes, or inhaling spores from an environment. Patients with significant underlying immune system conditions, as well as those with severely ill patients, are often affected by these fungal infections. The most vulnerable populations to invasive fungal infections include cancer patients, HIV/AIDS patients, organ transplant recipients, chronic respiratory patients, and tuberculosis patients.

Over the past decade, a far more alarming threat has emerged.

Candida auris , or C. auris, is a multi-drug-resistant fungus spreading rapidly across the globe and has caused large outbreaks in hospitals. C. auris poses a serious challenge due to its resistance to multiple antifungal drugs, its ability to persist on surfaces, and its high transmissibility among vulnerable patients. Its main challenge is its treatment.

C. auris is one of several known types – or species – of the Candida fungus, which is responsible for causing infections in humans, said Dr. Loice Ombajo, an infectious disease specialist and Co-Director at the Center for Epidemiological Modelling and Analysis (CEMA) at the University of Nairobi.

C.auris has been called an emerging fungus that poses a serious global health threat.

She said that C. auris is a type of candida fungus that primarily causes bloodstream infections and other severe infections, particularly in vulnerable hospitalized or immunocompromised patients. Dr. Ombajo said that C.auris can cause a range of severe infections, including those in the bloodstream, abdomen, throat, or skin, and most often affects already vulnerable patients, such as those hospitalized, on antibiotics, or with weakened immune systems. She said that these infections are common in hospital settings and carry a high mortality rate.

Dr. Ombajo said that C. auris is especially concerning since it is resistant to most of the drugs typically used to treat candida infections, making it a serious threat both in Kenya and worldwide.

The rise of C. auris infections has led to increased mortality rates, as many strains show resistance to first-line and even second-line antifungal treatments, complicating clinical management and infection control efforts. As a result, cases of the drug-resistant fungus C. auris are now climbing at an “alarming” rate in health care facilities and becoming harder to treat, leading to higher mortality rates among vulnerable patients.

C-auris symptoms are often non-specific, making diagnosis difficult.

“The drugs that we use to treat general Candida infections often do not work for C.auris. For example, fluconazole – the most commonly and most readily available antifungal – is 100% ineffective against C.auris,” said Dr. Ombajo. “So in many resource-limited settings, where fluconazole may be the only available option, if someone develops C.auris in the bloodstream, it often means death because we are not able to treat it.”

Treating the fungus is the main challenge. In most cases, it is antimicrobial resistant, according to Dr. Ombajo. C. auris can sometimes become resistant to all classes of antifungals, making it impossible to treat.

Even with treatment, she said, the mortality rate remains alarmingly high, adding that many studies have shown that about 40 to 50% of those with severe infections caused by Candida and C.auris may not survive, even despite treatment.

Dr. Ombajo warned that C.auris poses an urgent threat in Kenya due to its resistance to treatment and its ability to spread in hospital settings. “The fact that C.auris is increasingly resistant to drugs used to treat fungal infections causes high mortality,” she said. “But it also tends to spread within hospitals, making it a very urgent threat that we must think about how to deal with so that we can prevent its spread.”

This resistance means that infections with C.auris in such settings are often fatal.

She said that although some outbreaks have been detected, most hospitals still lack the laboratory infrastructure needed to accurately identify the fungus and test its resistance to antifungal drugs.

She explained that while small hospital outbreaks have previously been detected in Kenya, many health facilities still lack the capacity to identify C.auris. “You require specialized tests to grow the fungus from blood – what we call culture – and then identify the correct species. Most facilities in the country do not have this capacity,” she said. “You also need to perform antifungal susceptibility testing to determine which drug might work, and again, this is not widely available.”

This limitation poses a major challenge in managing the infection effectively.

She added, “In our work to strengthen hospital capacity to detect C.auris, the biggest challenge has been this lack of lab infrastructure. To work around it, we’ve trained healthcare and lab workers to grow the fungus from blood and created a network where samples from lower-capacity hospitals are referred to better-equipped labs for accurate identification and drug susceptibility testing.”

Dr. Ombajo said that efforts to contain C.auris in Kenya have included supplying resources, training lab personnel, and implementing quality assurance measures. These steps, she said, are essential for accurately identifying the fungus, choosing effective antifungal drugs, and guiding patient treatment.

“It’s been a lot of work getting to this point,” she said.

She said that they also found that C.auris has spread fairly around the country in hospitals across several regions, including Nairobi, Mombasa, and western Kenya. “… and this really is a wake-up call for us that you cannot continue to use the same antifungals we’ve been using or do things the same way,” said Dr. Ombajo.

She stressed the urgent need to rethink how healthcare systems respond to the fungus. “Once we have C.auris established in our facilities, then we have to think about: how do we ensure we can identify it? What antifungals do we stock in our pharmacies that would actually work? But also – how do we stop its spread? And I think the next question you asked was about infection control, which really is the most important tool that we have.”

“Once you begin to identify C.auris, you have to be sure that you stop its spread,” said Dr. Ombajo.”If it spreads, it’s difficult to treat, and mortality is high. So we really have to put every effort in place to ensure that it does not spread within hospitals or to other parts of the country where we have not yet identified it.”

Infection prevention and control (IPC) play a key role here.

IPC, she said, is critical but faces significant challenges in Kenya and other resource-limited countries, particularly in implementing measures to prevent infections from spreading within healthcare environments.

Dr. Ombajo said that effective infection control for C.auris starts with the basic practices such as proper hand hygiene and thorough cleaning of hospital spaces, beds, and equipment with disinfectants strong enough to eliminate drug-resistant fungi.

“It also means being able to identify the infection, we can separate a patient who has this fungus from other patients to reduce the spread, which we call isolating a patient. And all those systems have to be in place. Where we identify it, we must have what we call protective equipment or protective personal equipment so that healthcare workers and others within the hospital environment do not spread the fungus from patient to patient.”

Despite this, challenges remain.

In Africa, limited diagnostic capacity, fragile health systems, and restricted access to effective antifungals heighten the threat.

“The challenges we have in resource-limited settings are that, many times, facilities are crowded. There are many patients in a single ward. There isn’t the capacity to isolate a patient because we do not have isolation rooms,” said Dr. Ombajo. She also noted challenges in consistently providing personal protective equipment (PPE) and adequate cleaning supplies.

“This is something we’ve had to work on in many facilities around, just sensitizing and strengthening what healthcare workers do in terms of maintaining hand hygiene, and working with teams that clean hospitals to ensure that patient environments and equipment are properly cleaned to avoid spread. It’s also about thinking through how to quickly identify C.auris so that we can put in place measures to reduce its spread.”

“You can’t fight what you can’t see,” she said.

She also pointed out that a major obstacle in fighting C.auris is the lack of laboratory capacity in many health facilities, which makes it difficult to detect the fungus early. Without the right tools, trained personnel, and supplies, she said, infections go unnoticed – and therefore unchecked.

She added that even when infections are detected, treatment remains a challenge if facilities lack access to effective antifungal drugs. Dr. Ombajo called for improved procurement and supply systems to ensure that the necessary medications are stocked where they are needed most. Beyond diagnosis and treatment, she said that infection prevention and control is a key defense, though often under-resourced. Many healthcare facilities struggle with insufficient staffing, often relying on the same nurses to manage multiple patient care tasks alongside IPC responsibilities.

Furthermore, she said that cleaning hospital environments to eliminate C.auris requires more than soap and water. They need specialized disinfectants, like chlorine-based solutions, and the cleaning staff must be trained and supported to prevent transmission within hospital environments.

Kenya has become a leading voice in tackling this emerging threat with its Monitor and Prevent Antimicrobial Resistance (MAP-AMR) fungal surveillance project, which is recognised as a model for outbreak preparedness and AMR control in low-resource settings.

“One of the things I’d say about the work we’ve been doing is that we’ve been supporting some of this surveillance in the country for close to four years now,” she said. “We were very fortunate to get funding from the U.S. CDC to support this work.” She expressed concern about the inconsistency of such funding and stressed the need for governments to take ownership and allocate resources to sustain this work, which is critical for improving patient outcomes.

Despite the challenges, Dr. Ombajo said she remains hopeful.

“We’ve worked with excellent teams of healthcare workers, be it from the lab, be it clinicians, be it nurses in the wards, and the teams are ready to do the right thing, are willing to do the right thing, have excellent knowledge, and if enabled, would be able to do the right thing,” she said.

By Melody Chironda