Emergence and Comparative Analysis of Candidozyma auris Versus Candida spp. Candidemia in a Romanian Tertiary Hospital: A 7-Year Study on Resistance, Mortality and Independent Prognostic Factors

Background: Candidemia remains a major cause of morbidity and mortality among hospitalized patients. The emergence of Candidozyma auris has added further complexity due to its persistence in healthcare settings and its high rates of antifungal resistance. Comparative real-world data between Candidozyma auris and Candida spp. candidemia remain limited. Methods: We conducted a retrospective cohort study that included adult patients with candidemia, admitted to a tertiary infectious diseases hospital in Romania between August 2018 and August 2025. Risk factors, including medical history, previous hospitalizations, clinical characteristics, laboratory parameters, antifungal susceptibility patterns, treatment, and outcomes, were compared in patients with Candidozyma auris- and Candida spp.-positive blood cultures. Overall survival and prognostic factors were evaluated using univariable and multivariable Cox-proportional hazards models. Results: Sixty-one patients with candidemia were included; out of them, 24 (39.3%) had Candidozyma auris-positive blood cultures. Candidozyma auris infections, which emerged later during the study period, occurred after a significantly longer period of hospitalization compared with Candida spp. candidemia (median 52.5 vs. 20 days, p < 0.001). Azole resistance was almost universal among Candidozyma auris isolates (95.8%), whereas Candida species displayed significantly lower resistance rates and a broader susceptibility spectrum (p < 0.001). Inflammatory markers were comparable between groups; however, Candidozyma auris candidemia was associated with lower neutrophil counts and lower neutrophil-to-lymphocyte ratios at diagnosis (p = 0.020). Persistent candidemia at day 7 occurred more frequently in Candidozyma auris infections (6 vs. 2 patients; p = 0.05) and was universally fatal. Overall, in-hospital mortality was high (70.5%) and did not differ between Candidozyma auris and Candida spp. candidemia. In multivariable analysis, thrombocytopenia < 100,000/μL was independently associated with mortality (HR 2.34, 95% C.I. 1.20–4.56; p = 0.012). Conclusions: In this 7-year study at a Romanian tertiary center, Candidozyma auris emerged as a major healthcare-associated pathogen affecting patients with significantly prolonged hospitalization (median 52.5 days). Despite near-universal azole resistance (95.8%), mortality was exceptionally high (70.5%) and was comparable between groups, with pathogen type not independently associated with outcome after multivariable adjustment. Moderate thrombocytopenia (<100,000/μL) and persistent candidemia identified patients at particularly high risk of death, underscoring the need for early risk stratification, optimized antifungal management, and enhanced diagnostic vigilance, both in intensive care and general wards.