Background: Antimicrobial resistance (AMR) in Candida species is an emerging global health threat. This study aims to document the implementation of standardized surveillance tools from the Global Antimicrobial Resistance and Use Surveillance System (GLASS) and to describe the distribution and antifungal resistance profiles of Candida species in bloodstream infections generated through the study outputs.
Methods: The GLASS-Fungi pilot was a multicentre observational demonstration study where twenty-four laboratories were invited to collect and share Candida bloodstream infections (BSIs) data with the World Health Organization (WHO) using a standardized surveillance protocol and WHONET software. Data were collected for patients with laboratory-confirmed Candida bloodstream infections between January 2017 and July 2021. Participating sites were trained to collect, deduplicate, and report clinical and microbiological data. Patient demographic and microbiological data were summarized using descriptive statistics. The percent distribution of Candida species and resistance profiles were analysed with a 95% confidence interval (CI) calculated using robust standard errors clustered at the site level. Participating sites shared experiences with using the standardised GLASS surveillance tools and procedures through structured feedback forms and consultative meetings. This study was not designed to support causal inference or population-level generalization; analyses are descriptive and intended to illustrate outputs generated through pilot surveillance implementation.
Findings: Fourteen laboratories from 13 countries contributed data from 3447 patients with candidemia. Overall, Candida albicans was the predominant species (37.6%; 95% CI: 33.8-41.5). C. albicans was most common in the Americas, Europe, and Africa, whereas Candida tropicalis was more prevalent in Southeast Asia. Candida auris was detected by two laboratories in Southeast Asia and Africa. Among isolates with interpretable antifungal susceptibility testing (AFST) results and corresponding established breakpoints, 13.6% (95% CI: 10.1-17.2%) were resistant to at least one antifungal, with fluconazole resistance highest among C. parapsilosis isolates (29.7%; 95% CI: 18.2-41.2). Challenges to scaling up fungal AMR surveillance globally included limited fungal laboratory testing capacity, restricted access to antifungal susceptibility testing, and lack of sustained funding, particularly in low and middle-income countries.
Interpretation: The study was a global, multi-centre initiative to systematically collect and report surveillance data on Candida BSIs using standardised data collection tools and reporting procedures. The study identified major training capacity and infrastructure gaps. Addressing those is an essential step for anticipating and responding to emerging invasive fungal infections.
Funding: This work was supported by the United States Centers for Disease Control and Prevention.
Keywords: AMR; Candidemia; GLASS.
© 2026 Published by Elsevier Ltd.