Candida auris: Truth and Fearmongering

Recently, a website I used to respect posted an item on a problem with a relatively new fungal pathogen called Candida auris and how it poses a problem for Las Vegas in particular. I would like to talk about this issue in a balanced and truthful way.

My credentials: or, why should you listen to me? I am a Registered Nurse (RN) Infection Preventionist. I am a member of the Association for Professionals in Infection Control and Epidemiology. I hold two certifications: Certified Rehabilitation Registered Nurse and Certified in Infection Control. Furthermore, I work in Las Vegas and live in a suburb of Las Vegas. Go Knights Go.

Some Resources by Actual Professionals: I actively encourage you to see what the CDC, the WHO, the NIH, medical journal JAMA, my professional organization APIC, healthline, okay fine Wikipedia, and the State of Nevada have to say. The public might have a right to be skeptical about what the CDC has to say, which is why I want to provide multiple sources (that all say mostly the same things).

And Now Some Sensationalist News Items: It gets pretty crazy. Of course some sources are better than others, but sensationalist news gets attention.

An important thing to remember: I’m going to stop for just a moment to explain a technical detail. You probably know what an infection is: it’s when a germ is making you sick. But most people don’t know what colonization means: that’s when a germ is there but it’s just hanging out and not making anybody sick. There is of course the risk it could cause an infection, but it isn’t right now. Most of the C.auris cases you’re hearing about are colonization, not infection.

But what would the symptoms of infection be if it’s not colonization? Depends where the germs are. If it’s in the urinary tract, UTI symptoms. If it’s in a wound, symptoms of an infected wound. You get the picture. An infection in the blood is particularly bad regardless of what organism is involved since the bloodstream is effectively a superhighway around the body.

Oh, and one more thing: I am always careful to specify Candida auris or C.auris to distinguish it from it’s itchy but mostly harmless cousin, Candida albicans — which causes thrush and what most people would call a “yeast infection.” There are other Candida species that are rare and not a huge public health threat.

Why it seems like Nevada and Vegas have so much of this stuff: Maybe you’ve heard the saying “you can’t find a fever if you don’t take a temperature”? Well the idea that you don’t find things you aren’t looking for cuts both ways. Most places aren’t looking for it — it’s a special test that in most places has to be sent away to a lab with special equipment (and by the way not all FedEx offices will accept biological specimens for shipment). Your local Quest or LabCorp might come back with “yeast” and nothing more. Last year, the State of Nevada insisted on testing all residents in Long Term Care, Long Term Acute Care, Skilled Nursing Facilities, and on patients in many other hospitals. They tested; they found more of it than most people expected. Why Vegas in particular? Because roughly 80% of the state population lives in Clark County.

Why test those facilities? Because people in the kind of places where they call them “residents” instead of “patients” have severe medical problems to begin with. They’re in and out of acute care hospitals. They have plenty of chronic conditions and often end up with complications. They’re at risk for opportunistic infections from lots of different organisms, including C.auris. Sure, they tested a few people who were just fine until the motor vehicle accident, but that was the exception.

Ok, so how do you test for it? Per the CDC “The nurse or doctor will wipe or rub a cotton swab on the skin near your armpits and the area where your leg joins your body (groin). The test is not painful. The swab will be sent to a lab, and in 1 to 2 weeks, the lab will tell your doctor the results.” Ok so remember that we are looking for it in armpits and crotches when it comes to colonization. That will come up again later.

A quick summary of the bad news: It’s hard to test for, it’s a lot more common than most people know (and not just in Las Vegas!), it’s resistant to many antifungals (it’s not a bacteria so it wouldn’t be susceptible to antibiotics), there’s no proven decolonization strategy, and yes an infection could potentially be deadly.

Is there any good news? Yes! First, it’s a big heavy germ that does not and cannot float in droplets or the air. A C.auris cell is 2.5-5 micrometers, twice the size of the typical bacterium and ten times the size of a tuberculosis germ. Someone with a C.auris infection or colonization does not require droplet or airborne precautions, just contact precautions (gloves and gown) while in the hospital. It is not, I repeat NOT, lurking in casino air ducts waiting to reach out and make you sick! More good news: bleach will kill it on surfaces. Note: do not clean granny’s groin and armpits with bleach.

What can I do to keep from getting it? Remember that we test for colonization in the groin and armpits? Keep adult activities clean and in clean places. Don’t go to the casino floor naked (they frown on that anyway). If you or a family member have chronic conditions, make cleanliness your habit. If you find yourself or a loved one in a hospital, be that person that reminds others to clean their hands. That includes visitors, doctors, and staff! If a staff member rolls her eyes, that’s exactly the person you needed to remind so don’t let her get to you. And a pet peeve, gloves are not a substitute for hand cleaning and must be changed between patients!

By the way, World Hand Hygiene Day is May 5, right between May the Fourth be With You and Nurses Week. My building will be celebrating all three.

A few thoughts on Voting

It’s that time of year again! If you are in a state that does early voting like Nevada, get moving! If you are in a state where you must vote on Election Day, make a plan! Just for fun, here’s some actual data on American voters.

This time of year also brings out some perennial ideas about how and when we should vote. Let’s look at a few of them:

Election Day as a National Holiday. Sounds like a great idea, everybody has the day off, everybody can get their butts to the polling place. Clearly this idea was hatched and is supported by people in nice little Monday through Friday jobs who never worked someplace that was open Christmas. This will not help people who work at airports, railroads, hotels, restaurants, firehouses, or hospitals. That includes the 4.2 million Registered Nurses nationwide, a highly educated and largely female block of voters who often work twelve hour shifts. If I were conspiracy minded (I like to think I’m not), I’d suspect this idea is meant to disenfranchise all those people whose jobs can’t shut down for Christmas and Election Day.

Online Voting. I know, you’d think that in a world where I can pay my bills, order almost any legal product online, have news of the world at my fingertips, hold a videoconference with colleagues in other time zones, and make friends on almost any continent, voting online should be a no-brainer. Still, many consider it a “huge risk” with “security concerns.” Really no idea why it’s ok for me to spend thousands of dollars online but not okay to cast one vote. That’s above my pay grade.

Voter ID. Many people think you should have to show valid identification to vote. I’ll support that on two conditions: the state must issue an appropriate ID completely free of charge; the agency issuing those IDs must be open from early morning until 10 at night, at least 6 days a week and preferably seven, with sufficient staffing at all times to handle all applicants in a prompt manner. That way people who work long hours and people with very tight budgets can get their ID. Otherwise, it sure looks like an attempt to make sure only the “right people” can vote.

Early Voting. For the record, we do this in Nevada and I freaking love it. There’s polling places all over town in convenient places like shopping malls and supermarkets, computer linked to prevent voting in more than one location. It helps people with hectic schedules and/or medical needs. Because there’s many locations and the voting load is spread out, there’s rarely a big line to go vote — handy for both convenience and limiting the spread of things like influenza (yes, it’s flu season). Only someone who “wants to control who is able to vote” would possibly be against it.

Vote By Mail and/or Absentee Ballots. Yes, vote by mail has always been a thing for people who physically can’t get to the polling place, either because they are hospitalized, or because they are deployed in our military. Saying no to vote by mail is saying you don’t want our Soldiers, Sailors, Marines, and Airmen voting. Go on, say it, I dare you. Yes, there are potential security concerns. That doesn’t change the necessity. During the pandemic, Nevada also made it possible for every registered voter to vote by mail. As an added benefit, voters are able to research their candidates and ballot questions well before voting.

Drive

Ford Mach E, courtesy of Ford Motor Company https://www.ford.com/

There’s lots of talk these days about electric cars. Europe says it’s gonna happen — well, except for five countries. California says it’s gonna happen. Most of the rest of the states are not so enthusiastic. There are of course pros and cons.

Not everyone should be considering them. But it looks very much like I am the poster child for who should be considering one:

I drive a regular daily commute of under 20 miles one way. Furthermore, I drive that reliably 5 days a week.

I have a garage where it’s easy to install an outlet. Plug it in Friday night when I get home from work and don’t worry about it.

Surge pricing for power you say? Fine, most home charging systems can be set up with a timer to start in the wee hours of the morning.

I live in a town with reliable electric infrastructure. Even if Lake Mead dries up and Hoover Dam is no longer producing lots of electricity, the sun is still shining and solar power will continue to work. If the sun stops shining, we all have much bigger problems than charging our electric cars.

Thanks to the casino industry, chargers are everywhere. Looks like there’s a dozen public charging stations near me, each with multiple charging units. Malls have them. Some big employers have them. It wouldn’t surprise me if hospitals started installing them since I’ve met many doctors who love their Teslas (heh, and one pharmacist who hates his). And the car or your phone will have an app telling you where the nearest chargers are.

Let’s also address some of the arguments against electric cars. Road trips? There’s a gas car in the family so that’s a non-issue for me. That vehicle is a small SUV with a towing package, shutting down the “but what about hauling” argument before it begins.

“Just as dirty as gas cars, but moving the pollution elsewhere”? Electricity can be made more cleanly than it is today. Petroleum based solutions cannot.

But what about maintenance? This may still be a valid argument regarding Tesla and Rivian. But now you can buy electric vehicles from VW, Nissan, Ford, Chevy, Cadillac, Hyundai, Kia, Volvo…. and you can get your electric car serviced at the many places that sell those cars.

And what about the price? There are some models under $30k. Not many I concede. This is not yet a solution for people making less than $15/hr and living in apartments.

I’m not saying it’s the answer for everyone. I’m not saying California is on to something. I still think “can I make it from Vegas to LA without stopping for a charge” is a valid metric. But it may be time for people to start looking at whether it’s a good option to consider for one of the family vehicles.