Genomic epidemiology of Candida auris introduction and outbreaks in the United Kingdom

Background: Candida auris is a globally emerging fungal pathogen that causes nosocomial invasive infections, particularly in intensive care units (ICU). Four prominent genetic clades originating from distinct geographic regions have been identified: South Asia (Clade I), East Asia (Clade II), Africa (Clade III) and South America (Clade IV) with each clade presenting differing antifungal resistance profiles. We aimed to elucidate the epidemiology of this infection in the United Kingdom (UK) 2014 - 2019 using genomic approaches. Methods: Genome sequences from 24 isolates from six patients in four London hospitals were combined with genome sequences from 183 additional outbreak isolates from nine UK hospitals. These data were used to assess the numbers and timings of C. auris lineage introductions into the UK and to infer subsequent patterns of inter- and intra-hospital transmission. Findings: We found evidence for at least three introductions of C. auris into the UK, one from Clade I and one from Clade III. The evolutionary rate of C. auris Clade I and Clade III were estimated at 2.764 x 10-4 and 3.186 x 10-4 substitutions per polymorphic site per year, respectively, with entry into the UK as 2013 and 2016 for Clades I and III respectively. We observed temporal and geographical evidence for multiple transmission events between hospitals and identified local within-hospital patient-to-patient transmission events. Interpretation: These data confirm that C. auris is a newly emerged infection in the UK with at least three original introductions into this country. Our analysis shows that hospital outbreaks are linked and confirms that transmission amongst patients has occurred, explaining local hospital outbreaks. Our findings argue that enhanced surveillance of C. auris infection within the UK is necessary in order to protect healthcare and to curtail expansion of this emerging infection. ### Competing Interest Statement JR and AA have received honoraria from Gilead Sciences