Over the past decade, we have seen an increase in the number of fungal infections worldwide. Of course, this leads to the question, why? As always, the answer is multifactorial. Risk factors that promote the risk of fungal infections include more patients with immunocompromised states, increased hospitalizations, and more patients with chronic conditions.
As we can see, part of the problem is the sin of our success. Improvements in medical technologies over the years have allowed patients with these chronic medical conditions, which in the past were considered death sentences, to survive for many years. That survival, unfortunately, comes with a cost. New and elaborate medical problems, such as these fungal infections, are not the only issue—now we have highly resistant antibiotic infections.
This was witnessed early on in the AIDS epidemic before the introduction of highly effective antiretroviral therapy. Before effective therapies, all that could be offered were prophylactic therapies to prevent opportunistic infections from occurring. Unfortunately, as the disease progressed and T-cells fell, more elaborate infections began to occur. The worst I saw early on in my infectious disease career was CMV meningitis. It presented as if it were bacterial meningitis, but was due to the virus CMV, cytomegalovirus. This is a childhood herpes virus that, once you are infected with it, stays in your system for the rest of your life and only reactivates when you are severely immunocompromised.
Most patients with CMV meningitis have a T-cell count of 1 or 2. Treatment was dual antiviral therapy for CMV. Regardless, even with this aggressive treatment, the mortality rate with CMV meningitis back in the mid-nineties was 100%. As I have said many times, there is no substitute for a healthy immune system.
For many years, there has been a huge emphasis on antibiotic stewardship to prevent the development of antibiotic resistance. Though an important concept, it completely missed the mark. No amount of antibiotic stewardship will help a patient who is repeatedly being admitted to the hospital with recurrent infections due to their underlying chronic state. What worsens this dilemma is if the patient has multiple chronic conditions.
Here are some statistics on chronic conditions in the United States. In 2018, more than half of the adults here had at least one chronic condition (51.8%). Worse is that 27.2 %, over a quarter of the population, has multiple chronic conditions, or MCCs.
Recently, a new resistant species of fungus has been identified that is becoming concerning to the infectious disease community. Candida auris has emerged as a pathogen that is seen mostly in hospitals and long-term care facilities, and it does not respond to conventional therapy. My fear is that C. auris will become more of an issue as time goes on and more people present with chronic conditions.
My belief is that if we wish to get ahead of the rise in fungal infections, not only here in the United States but worldwide, we need to change our focus. We need to focus not only on treatment options but also on prevention. As I said earlier, there is no substitute for a healthy immune system. It’s time to make America healthy again.
