OPINION
DOCTORS' Lounge
(continued from page 35)
with a PCR method was described in Oct.
2018 in the International Journal of Medical
Microbiology, Dr. Ruiz-Gaitan et al.
As for the rapid appearance on multiple
continents of multidrug-resistant yet dis-
tinctly different genetic forms: we think that
fungicides might be the problem. Agro-in-
dustrial fungicide use is a multi-billion-dol-
lar business in this country alone. These fun-
gicides are used all over the world. Studies
of those used have shown correlations with
development of the distinct genetic classes
of resistance among Candida species. The
rise of ever more powerful fungicides has
coincided with the rise of fungal organ-
isms that can sicken and kill more of us as
time goes by. Farmers lose large portions
of their crops to invasive pests. To protect
their crops and their livelihoods, they have
resorted more and more not just to pesti-
cides but to fungicides.
There are agricultural organizations that
strive to get farmers to rotate crops and use
other methods of preventing fungal crop
destruction without resorting to heavier use
of more powerful chemicals. The success of
this effort at using more biologically safe
methods of control remains to be seen. The
organizations note somewhat pessimistical-
ly that “It is easier to spray than change.”
Large farming conglomerates spend huge
sums on these chemicals, which provides
a cost incentive to find alternative methods.
As with other multidrug-resistant or-
ganisms, what cannot be presumed is that
in-vitro sensitivity translates to in-vivo ef-
fectiveness. Even with drug combinations,
not all of the superior anti-fungals have
good penetration into the CSF or urine,
for instance.
As for the development of multidrug
resistance, I am among the myriad thou-
36
LOUISVILLE MEDICINE
sands of doctors who remain guilty of giving
people oral fluconazole instead of the indi-
cated topical agents. Just as the farmers do,
doctors reach for the more powerful, faster
and easier oral agents. I’m hoping that what
you are about to read about antisepsis and
the removal of this organism will cure all
of us of that habit.
Resistance is not the only awful part.
We have agents in development that will
probably help. The worst part is killing the
organism where we all live, in the hospitals
and clinics where the sick people are. This
organism can live on plastic for at least 14
days. The rate of recovery of this over a pe-
riod of a week after “normal cleaning” was
higher than that of Candida albicans on
both moist and dry surfaces. The North
Brompton hospital eventually closed its in-
tensive care unit and moved everyone out as
the only effective way to reduce transmis-
sion of this fungus. That is how they finally
stopped the outbreak.
Mr. Richtel notes in The New York Times
article that in a case at the Brooklyn Mount
Sinai Hospital, fungal spores were recovered
from the ceiling, the windows, the curtains,
the bathroom, the floors etc. They hid in
the crevices, the phone and the bedside
table, on the computer and the IV tubing.
The usual disinfectant that hospitals use
contains hydrogen peroxide in wipes and
liquid cleaners; however, a room “termi-
nally” cleaned with this solution did not
kill all the spores. In London, fumigation
with sodium hypochlorite vapor and then
closing the room for a period of days still
resulted in recovery of some spores in a
petri dish, which is how the CDC consultant
first identified the cause of that outbreak.
Repeated applications of problematically
high (enough to irritate everyone’s respira-
tory tract) concentrations of bleach may be
necessary, along with repeated fumigation
with hydrogen peroxide vapor and irradi-
ation with ultraviolet light.
I foresee that hospitals of the future will
return to all-white environments, the better
to bleach them with. The good news is that
of 258 health care workers in one outbreak,
only one was found to be colonized, had not
transmitted it to anyone else, and cleared the
colonization with oral and topical antifun-
gals, chlorhexidine and nasal ointments.
How to avoid fungicide? In the future,
it might be best to grow a lot of your own
food. Ask your farmers at the farmers’ mar-
ket about what their animals eat and what
chemicals are on the pastures. I cannot
promise you that the grapes in the wine you
drink were not subject to fungicide, since
fungus is death to the vines. But what comes
out of your own backyard or your commu-
nity allotment will not have preservatives
or chemicals, unless you put them there.
It’s still planting season in Kentucky. Get
out there and grow something.
Dr. Barry practices Internal Medicine with
Norton Community Medical Associates-Bar-
ret. She is a clinical associate professor at the
University of Louisville School of Medicine,
Department of Medicine.