October 2021

Official Publication of SDCMS OCTOBER 2021

COVID-19 AND ITS DIFFERENT IMPACTS

The Infectious Diseases Issue • COVID Breakthrough Infections for Healthcare Workers • • Post-COVID Conditions in Adults • COVID Impact on STDs • Candida auris •

Editor: James Santiago Grisolia, MD Editorial Board: James Santiago Grisolia, MD; David E.J. Bazzo, MD; Robert E. Peters, MD, PhD; William T-C Tseng, MD Marketing & Production Manager: Jennifer Rohr Art Director: Lisa Williams Copy Editor: Adam Elder OFFICERS President: Sergio R. Flores, MD President–Elect: Toluwalase (Lase) A. Ajayi, MD Secretary: Nicholas (Dr. Nick) J. Yphantides, MD, MPH Treasurer: Heidi M. Meyer, MD Immediate Past President: Holly B. Yang, MD, MSHPEd, HMDC, FACP, FAAHPM

Contents OCTOBER

VOLUME 108, NUMBER 9

GEOGRAPHIC DIRECTORS East County #1: Catherine A. Uchino, MD East County #2: Rakesh R. Patel, MD Hillcrest #1: Kyle P. Edmonds, MD Hillcrest #2: Steve H. Koh, MD (Board Representative to the Executive Committee) Kearny Mesa #1: Anthony E. Magit, MD, MPH Kearny Mesa #2: Alexander K. Quick, MD La Jolla #1: Preeti S. Mehta, MD (Board Representative to the Executive Committee) La Jolla #2: David E.J. Bazzo, MD, FAAFP La Jolla #3: Sonia L. Ramamoorthy, MD, FACS, FASCRS North County #1: Arlene J. Morales, MD North County #2: Christopher M. Bergeron, MD, FACS North County #3: Nina Chaya, MD South Bay #1: Paul J. Manos, DO South Bay #2: Maria T. Carriedo-Ceniceros, MD AT–LARGE DIRECTORS #1: Thomas J. Savides, MD #2: Kelly C. Motadel, MD, MPH #3: Irineo (Reno) D. Tiangco, MD #4: Miranda R. Sonneborn, MD #5: Stephen R. Hayden, MD (Delegation Chair) #6: Marcella (Marci) M. Wilson, MD #7: Karl E. Steinberg, MD, FAAFP #8: Alejandra Postlethwaite, MD ADDITIONAL VOTING DIRECTORS Medical Student: Jimmy Yu Resident: Nicole L. Herrick, MD Young Physician: Brian J. Rebolledo, MD Retired Physician: Mitsuo Tomita, MD CMA OFFICERS AND TRUSTEES Robert E. Wailes, MD William T–C Tseng, MD, MPH Sergio R. Flores, MD Holly B. Yang, MD, MSHPEd, HMDC, FACP, FAAHPM AMA DELEGATES AND ALTERNATE DELEGATES District I: James T. Hay, MD District I Alternate: Mihir Y. Parikh, MD At-Large: Albert Ray, MD At-Large: Robert E. Hertzka, MD At-Large: Theodore M. Mazer, MD At-Large: Kyle P. Edmonds, MD At-Large: Holly B. Yang, MD, MSHPEd, HMDC, FACP, FAAHPM At-Large Alternate: David E.J. Bazzo, MD, FAAFP CMA DELEGATES District I: Karrar H. Ali, DO, MPH District I: Steven L.W. Chen, MD, FACS, MBA District I: Franklin M. Martin, MD, FACS District I: Vimal I. Nanavati, MD, FACC, FSCAI District I: Peter O. Raudaskoski, MD District I: Kosala Samarasinghe, MD District I: James H. Schultz, MD, MBA, FAAFP, FAWM, DiMM District I: Mark W. Sornson, MD District I: Wynnshang (Wayne) C. Sun, MD District I: Patrick A. Tellez, MD, MHSA, MPH RFS: Rachel Buehler Van Hollebeke, MD

Opinions expressed by authors are their own and not necessarily those of San Diego Physician or SDCMS. San Diego Physician reserves the right to edit all contributions for clarity and length as well as to reject any material submitted. Not responsible for unsolicited manuscripts. Advertising rates and information sent upon request.

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San Diego Physician is published monthly on the first of the month. Subscription rates are $35.00 per year. For subscriptions, email Editor@SDCMS.org. [San Diego County Medical Society (SDCMS) Printed in the U.S.A.]

Features

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Waning Vaccine Effectiveness During a COVID-19 Delta Variant Surge in a San Diego County Health System

By Francesca Torriani, MD, FIDSA

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Post-COVID Conditions in Adults

By Jessica Merchant, DNP, ANP and Michael Butera, MD, FIDSA

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COVID-19 Impact on Sexually Transmitted Infections

By Winston Tilghman, MD

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Candida auris, an Emerging Pathogen of Concern: Epidemiology, Clinical Spectrum, Diagnosis, Treatment, and Mitigation Strategies

By Grace Kang, RN, PHN and Raymond Chinn, MD

Departments

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Briefly Noted: Public Health * Professional Development and Education

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I Survived Cancer, I Survived the Pandemic

By Adama Dyoniziak

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Classifieds SanDiegoPhysician.org 1

BRIEFLY NOTED 2

October 2021

PUBLIC HEALTH

Report Finds Sharp Decreases in Opioid Prescribing, and Increases in Drug-Related Overdose and Death By California Medical Association OVER THE PAST DECADE, THERE HAS been a 44.4% decrease in opioid prescribing nationwide, according to a new report from the American Medical Association (AMA). At the same time, the country is facing a worsening drug-related epidemic of overdose and death. To address this continuing epidemic, AMA is urging policymakers to join physicians to reduce mortality and improve patient outcomes by removing barriers to evidence-based care.

The report shows that overdose and deaths are spiking even as physicians have greatly increased the use of prescription drug monitoring programs such as California’s CURES, which are electronic databases that track controlled-substance prescriptions and help identify patients who may be receiving multiple prescriptions from multiple prescribers. The report shows that physicians and others used state PDMPs more than 910 million times in 2020, up from 750 million times in 2019.

Yet the nation continues to see increases in overdose mainly due to illicit fentanyl, fentanyl analogs, methamphetamine, and cocaine, according to the U.S. Centers for Disease Control and Prevention. Research and data from the National Institutes of Health, U.S. Substance Abuse and Mental Health Services Administration, and Indian Health Service underscore the continued challenges and inequities for Black, Latinx and American Indian/Native Alaskan populations.

The report also highlights that more than 104,000 physicians and other healthcare professionals have an “X-waiver” to allow them to prescribe buprenorphine for the treatment of opioid use disorder. This is an increase of 70,000 providers since 2017, yet 80% to 90% of people with a substance use disorder receive no treatment.

“The nation’s drug overdose and death epidemic has never just been about prescription opioids,” says AMA president Gerald E. Harmon, MD. “Physicians have become more cautious about prescribing opioids, are trained to treat opioid use disorder, and support evidence-based harm reduction strategies. We use PDMPs as a tool, but they are not a panacea. Patients need policymakers, health

insurance plans, national pharmacy chains, and other stakeholders to change their focus and help us remove barriers to evidence-based care.”

AMA is urging policymakers to act now: • Stop prior authorization for medications to treat opioid use disorder. Prior authorization is a cost-control process that health insurance companies and other payers use that requires providers to obtain prior approval from the insurer or payer before performing a service or obtaining a prescription. It is used to deny and delay services — including life-saving ones — as physicians are required to fill out burdensome forms and patients are forced to wait for approval.

• Ensure access to affordable, evidencebased care for patients with pain, including opioid therapy when indicated. While opioid prescriptions have decreased, the AMA is greatly concerned by widespread reports of patients with pain being denied care because of arbitrary restrictions on opioid therapy or a lack of access to affordable nonopioid pain care.

• Take action to better support harm reduction services such as naloxone and needle and syringe exchange services. These proven harm reduction strategies save lives but are often stigmatized.

• Improve the data by collecting adequate, standardized data to identify and treat atrisk populations and better understand the issues facing communities. Effective public health interventions require robust data, and there are too many gaps to implement widespread interventions that work.

“With record-breaking numbers of overdose deaths across the country, these are actions policymakers and other stakeholders must take,” Dr. Harmon says. “The medical community will continue to play its part, and overall, the focus of our national efforts must shift. Until further action is taken, we are doing a great injustice to our patients with pain, those with a mental illness, and those with a substance use disorder.”

PROFESSIONAL DEVELOPMENT AND EDUCATION

Spreading COVID-19 Vaccine Misinformation May Put Medical License at Risk

that such unethical or unprofessional conduct may prompt their respective board to take action that could put their certification at risk. Expertise matters, and board-certified physicians have demonstrated that they have stayed current in their field.

Spreading misinformation or falsehoods to the public during a time of a public health emergency goes against everything our boards and our community of board-certified physicians stand for,” said Dr. Warren Newton, president and CEO of the American Board of Family Medicine, Dr. Richard J. Baron, president and CEO of the American Board of Internal Medicine, and Dr. David G. Nichols, president and CEO of the American Board of Pediatrics, in the joint statement.

“The evidence that we have safe, effective, and widely available vaccines against COVID-19 is overwhelming. We are particularly concerned about physicians who use their authority to denigrate vaccination at a time when vaccines continue to demonstrate excellent effectiveness against severe illness, hospitalization, and death. We all look to board-certified physicians to provide outstanding care and guidance; providing misinformation about a lethal disease is unethical, unprofessional, and dangerous. In times of medical emergency, the community of expert physicians committed to science and evidence collectively shares a responsibility for giving the public the most accurate and timely health information available, so they can make decisions that work best for themselves and their families.”

By California Medical Association The Federation of State Medical Boards (FSMB) recently released a statement in response to a dramatic increase in the dissemination of COVID-19 vaccine misinformation and disinformation by physicians and other healthcare professionals on social media platforms, online and in the media. According to the statement, providing misinformation about the COVID-19 vaccine contradicts physicians’ ethical and professional responsibilities, and therefore may subject a physician to disciplinary actions, including suspension or revocation of their medical license.

“Physicians who generate and spread COVID-19 vaccine misinformation or disinformation are risking disciplinary action by state medical boards, including the suspension or revocation of their medical license. Due to their specialized knowledge and training, licensed physicians possess a high degree of public trust and therefore have a powerful platform in society, whether they recognize it or not,” the statement says. “They also have an ethical and professional responsibility to practice medicine in the best interests of their patients and must share information that is factual, scientifically grounded, and consensus-driven for the betterment of public health. Spreading inaccurate COVID-19 vaccine information contradicts that responsibility, threatens to further erode public trust in the medical profession, and puts all patients at risk.”

The American Board of Family Medicine (ABFM), the American Board of Internal Medicine (ABIM), and the American Board of Pediatrics (ABP) also issued a joint statement in support FSMB’s position.

“We also want all physicians certified by our boards to know

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SanDiegoPhysician.org 3

INFEC T I O US D I S E A S E

Waning Vaccine Effectiveness During a COVID-19 Delta Variant Surge in a San Diego County Health System

By Francesca Torriani, MD, FIDSA

➻

IN THE WINTER OF 2020, THE SAN DIEGO REGION

experienced a dramatic surge in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections. At UC San Diego Health, vaccination with mRNA vaccines began in mid-December 2020. By March, 76% and by July, 87% of the UC San Diego Health’s workforce had been fully vaccinated.

In mid-January, vaccination superstations were set up in SD County and infections decreased dramatically by early February 2021 (Figure 1). At UC San Diego health, two-thirds of SARS-CoV-2 positives were observed among unvaccinated healthcare workers and fewer than 30 healthcare workers tested positive each month until June 2021. In mid-April, we had our first healthcare worker infected with the delta variant, but the variant did not take over until July 2021.

Everything was looking great until the masking mandate was ended in California on June 15. The economy opened up, people stopped masking and enjoyed the summer by congregating, traveling, and sending their children to summer camps, and tuned the COVID-19 pandemic out.

Starting in July 2021, San Diego experienced a fourth surge in the region that is tightly associated to the dominance of the delta variant, which now accounts for 99% of isolates

(Figure 2). The surge is disproportionally represented by unvaccinated individuals of all age groups, though some vaccine breakthrough cases are occurring.

In parallel to the surge in San Diego County, we noticed vaccine breakthrough cases among our Health System’s workers. UC San Diego Health has a mandatory daily symptom screen with a low threshold for SARS-CoV-2 testing. A test is triggered by the presence of at least one symptom or by an identified exposure irrespective of vaccination status.

From March 1 to Aug. 31, 2021, a total of 386 UCSDH health workers tested positive for SARS-CoV-2 by reverse transcriptase quantitative polymerase chain reaction (RT-qPCR) assay of nasal swabs. Of those, 268 positive individuals (69.4%) were fully vaccinated and 118 were unvaccinated. Symptoms were present in more than 80% of all health workers.

Virtually all the infections were found to be acquired in the community, and many of these were acquired in the household. Disease presentations were mild to moderate overall with only one unvaccinated person needing hospitalization for SARS-CoV-2-related symptoms, and no deaths in either group during the study period.

We calculated vaccine effectiveness for each month from

Figure 1: From Keehner et al. More on SARS-CoV-2 Infection after Vaccination in Health Care Workers. Reply. N Engl J Med. 2021 Jul 8;385(2):e8. doi: 10.1056/NEJMc2106004. Epub 2021 May 12. PMID: 33979508.

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October 2021

Right, Figure 2: From County of San Diego’s COVID-9 Vaccinations Report, September 1, 2021 Below, Table 1: From Keehner et al.

Resurgence of SARS-CoV-2 Infection in a Highly Vaccinated Health System Workforce. N Engl J Med. 2021 Sep 1. doi: 10.1056/NEJMc2112981. Epub ahead of print. PMID: 34469645.

March through July. The case definition was a positive PCR test and one or more symptoms among persons with no previous COVID-19 infection. Vaccine effectiveness exceeded 90% from March through June but fell to 65.5% (95% confidence interval [CI], 48.9 to 76.9) in July and to 57% (95% CI, 46 to 73) in August (Table 1).

July and August case rates were analyzed according to the month in which the vaccination series was completed; in workers completing vaccination in January or February, the attack rate was 6.7 per 1000 vaccinated persons (95% CI, 5.9 to 7.8), compared to 3.7 per 1000 vaccinated persons getting their second dose from March through (95% CI, 2.5 to 5.7) and to 16.4 per 1000 unvaccinated persons (95% CI, 11.8 to 22.9).

Our data suggest that vaccine effectiveness against symptomatic disease is not as strong with the more infectious delta variant and that the immune response generated by the vaccines is waning over time.

The CDC and the FDA are evaluating the need for boosters 6–8 months after completing initial vaccination, but there is no doubt that COVID-19 vaccines are working very well.

SD County data shows that case rate for not fully vaccinated residents is four times higher than that of fully vaccinated persons and that the hospitalization rate in not fully vaccinated persons is 86 times higher than that of fully vaccinated individuals.

San Diego County is experiencing a high level of community transmission that has been sustained since mid-July since the relaxation of the non-pharmaceutical measures.

Environments that have continued enforcing universal

masking, rigorous screening and testing, and have achieved high vaccination levels have seen few transmissions and breakthrough cases.

In our opinion, San Diego County’s vaccination goal should reflect the total population of San Diego, because ultimately every person is at risk of infection — not just the segment eligible to receive the COVID-19 vaccine. At this time, only 64% of the 3,298,634 residents of San Diego County are fully vaccinated — 25% below that is needed to achieve vaccineinduced herd immunity.

In conclusion, to prevent continued illnesses and deaths, to ensure that businesses and schools remain open and safe for all individuals, we urge reinstating masking mandates indoors and in crowded outdoor venues, continued improvement in indoor ventilation, attempts to decrease density and incorporate social distancing, and continue symptom screening and sustainable testing strategies, including asymptomatic and symptomatic testing. Lastly, efforts to increase vaccination coverage in San Diego County should be continued so that vulnerable populations such as children below the age of 12, the elderly, and immunocompromised individuals continue to be protected.

Dr. Torriani is a professor of clinical medicine in the division of ID And Global Health, Department of Medicine at UC San Diego, program director of Infection Prevention and Clinical Epidemiology and Tuberculosis Control at UC San Diego Health, and vice-chair of the San Diego County Medical Society GERM committee.

SanDiegoPhysician.org 5

INFEC T I O US D I S E A S E

PostCOVID-19 Conditions in Adults

By Jessica Merchant, DNP, ANP and Michael Butera, MD, FIDSA

➻

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SINCE THE EMERGENCE OF THE SARS-2 CORONAVIRUS/

COVID-19 pandemic, the World Health Organization (WHO) (8/27/2021), reports 214,468,601 confirmed cases with 4,470,969 deaths. The United States of America (USA) accounts for 33,527,411 cases with more than 632,000 deaths as of Aug. 27, 2021 (CDC, 2021). Symptoms of acute illness include fever, chills, cough, sore throat, shortness of breath, fatigue, muscle/ body aches, headache, loss of taste and smell, congestion, runny nose, and gastrointestinal symptoms including nausea, vomiting, and diarrhea. Older adults and people with underlying medical conditions, especially diabetes, morbid obesity, immunosuppressive conditions, and hypertension, are at risk for more severe disease. They are also more likely to require hospitalization than those who are younger and healthy (CDC, 2020b).

Early data from the United Kingdom COVID-19 symptom study suggested but around 10% of patients who tested positive for the virus remain unwell beyond three weeks, with an even smaller subset having lasting symptoms for months (COVID symptom study, 2020). While there are no uniformly agreed upon definitions, the Centers for Disease

October 2021

Control and Prevention (CDC) defines post-COVID conditions as the constellation of physical and mental health consequences experienced by some patients that persist beyond four weeks after onset of illness, when replication competent SARS-2-Cov is usually no longer detectable. (CDC, 2021). Recent literature further separates patients into two subgroups including subacute manifestations developing four to 12 weeks after illness, and chronic post-acute/longCOVID manifestations defined as those persisting beyond 12 weeks. Consequences of cellular damage, robust immune and cytokine response, hypercoagulable state, and dysautonomia may contribute to these sequelae.

There is more robust data on the post-acute manifestations for hospitalized patients who had experienced severe illness than in non-hospitalized persons for whom many had no access to PCR, antigen or antibody testing and confirmation of illness in the early months and initial waves of pandemic illness. Furthermore almost all published data on complications and sequelae were before the emergence of the current delta variant surge which, in addition to being more transmissible, may be more virulent as well.

Italian researchers investigating the clinical course among hospitalized patients noted that 125 of 143 patients aged 19 to 84, 20% of whom were ventilated, still experienced physician-confirmed COVID-19-related symptoms up to two months after initial symptoms. The most commonly noted long-term symptoms include fatigue (up to 50% of patients), dyspnea, joint pain, and chest discomfort.

A smaller proportion of patients had a more prolonged loss of smell, dry eyes, sinus congestion, myalgia, headache, and diarrhea. A worse quality of life was reported by 44% of patients (Renaud et al., 2021).

Researchers from China reported that 1,733 hospitalized patients were followed post-discharge with 63% experiencing prolonged fatigue, myalgias (26%), dyspnea (26%), anxiety (20%), and sleep disorders (Huang et al., 2021). A smaller proportion of patients have a more prolonged loss of smell, dry eyes, sinus congestion, myalgia, headache, and diarrhea.

Prolonged symptom duration and disabilities are common in adults hospitalized with severe coronavirus. This is especially true for older patients, and patients who require intensive care unit (ICU) stays requiring mechanical ventilation. A comprehensive review of ongoing clinical trials and organ system focused literature review of post-COVID complications and diagnostic and treatment implications was published in Nature Medicine in April, 2021 (Nalbandian et al, 2021). Complications due to COVID-19 in hospitalized patients include: severe interstitial pneumonia, acute respiratory failure, ARDS, dysautonomia with postural hypotension tachycardia, risk for venous thrombosis and pulmonary emboli, pulmonary microvascular thrombi, hypoxemia-related multi-organ injury, ischemic strokes, seizures, encephalitis, acute inflammatory polyneuropathies, cranial neuropathies, renal impairment, injury to lung tissue with scarring and post-viral reactive airways, post-ICU related and post-traumatic stress related psychological manifestations including brain fog, anxiety, and depression (Nalbandian et al, 2021).

Pulmonary complications in hospitalized patients with severe respiratory illness not requiring mechanical ventilation studied in a cohort from China were followed over 12 months and showed persisting decline on diffusion capacity 76% of predicted and 88% of predicted respectively at six and 12 months post-discharge (Wu et al., 2021).

Myocarditis with abnormalities noted on cardiac MRI was reported in 15–20% at two months post-COVID in two small studies and myocardial fibrosis can occur.

Hematologic sequelae include post acute thrombotic events. Data from a retrospective study with a small sample size suggests less than 5% risk. A single center report following 163 patients post-discharge without anticoagulation found 2.5% incidence of thrombotic events by 30 days with cumulative incidence of bleeding occurring in 3.7% mostly from mechanical falls. There are not currently any clear guidelines for patient selection and duration of

post-discharge anticoagulation prophylaxis. Risk vs. benefit suggests LMW heparin or direct-acting anticoagulants might be considered in patients with persistently elevated D-Dimers of two times the normal value and comorbid high risk factors, i.e. immobility, cancer, etc. (Patell et al., 2020).

Increased frequency of first-time diagnosis of psychiatric illness has been noted after COVID-19 illness. Neuropsychiatric sequelae also occur more commonly in patients with pre-existing depression and other psychiatric disorders.

Prolonged anosmia was reported with 85.9% of the patients objectively recovering their sense of smell at six months and 96.1% of patients objectively recovering after 12 months. Renaud et al. (2021).

Understanding the full spectrum of disease manifestations and duration of long-COVID among individuals with less severe disease that did not require hospitalization is the subject of ongoing research, including activities of patient led advocacy groups including: COVID Advocacy Exchange (https://www.covidadvocacyexchange.com), the National Patient Advocate Foundation COVID Care Resource Center (https://www.patientadvocate.org/covidcare), long-haul COVID fighters Facebook groups, the Body Politic COVID-19 Support Group (https://www.wearebodypolitic.com/covid19), Survivor Corps (https://www.survivorcorps.com/), and Patient-Led Research for COVID-19 (https://www. patientresearchcovid19.com).

A study of non-hospitalized patients was reported in MMWR by the IVY Network Investigators of the (CDC) COVID-19 response team. Among 292 respondents, 35% of those who were symptomatic reported not having return of their usual state of health two to three weeks after the initial diagnosis (Tenforde et al., 2020). This included 25% of patients under 50 and 43% of those aged 50 or older (Tenforde et al., 2020). Patients with underlying chronic medical conditions and preexisting psychiatric diagnosis including depression are more likely to experience prolonged symptoms.

The most common persistent or unresolved symptoms in order of prevalence include the following: fatigue, cough, headache, body aches, loss of taste and smell, congestion, dyspnea, chest pain, and confusion or brain fog (Tenforde et al., 2020). A smaller number of patients experiences gastrointestinal symptoms such as abdominal pain (CDC, 2020a).

The Body Politic COVID-19 support group and its international Patient–Led Research for COVID-19 are conducting ongoing surveys among long haulers. In an initial survey, 91% of 640 respondents with long-COVID symptoms reported ongoing symptoms 40 days out from onset of illness.

Symptoms included; fatigue, chills, sweats, body aches, headaches, brain fog, and gastrointestinal issues. A subset of these patients reported that the intensity of symptoms wax and wane. In this initial study only a quarter of The Body Politic survey respondents had tested positive for COVID-19 while nearly half were never tested.

In a follow-up study, participants (91% of whom had not

SanDiegoPhysician.org 7

been hospitalized) had confirmed (diagnostic/antibody positive; 1020) or suspected (diagnostic/antibody negative or untested; 2742) COVID-19, from 56 countries, with illness lasting over 28 days and onset prior to June 2020. A survey traced 66 symptoms over seven months (Davis et al., 2020).

The time to recovery exceeded 35 weeks for the majority of respondents (>91%). During their illness, participants experienced an average of 55.9+/- 25.5 (mean+/-STD) symptoms, across an average of 9.1 organ systems. The most frequent symptoms after six months were fatigue, postexertional malaise, cognitive dysfunction, sensory neural dysfunction, headaches, and brain fog. Symptoms varied in their prevalence over time, with three symptom clusters, each with a characteristic temporal profile. 85.9% of participants (95% CI, 84.8% to 87.0%) experienced relapses, primarily triggered by exercise, physical or mental activity, and stress. In addition, 1,700 respondents (45.2%) required a reduced work schedule compared to pre-illness, and an additional 839 (22.3%) were not working at the time of survey due to illness. Cognitive dysfunction or memory issues were common across all age groups (~88%) (Davis et al., 2020).

Outpatient post-COVID clinics are evolving in many medical facilities to study and provide treatment for the increasing number of patients experiencing post COVID-19 long-term complications. Many of these programs started as post hospitalization pulmonary rehabilitation programs, but are expanding to address the multitude of signs and symptoms of patients presenting with long-COVID. This encompasses medical disciplines including but not limited to neurology, neuropsychiatry, and physical and occupational rehabilitation medicine.

A longitudinal prospective cohort study from University of Cologne Germany outpatient post-COVID clinic followed 353 test-confirmed COVID-19 patients over seven months, with 27% experiencing one or more symptoms at four months including anosmia, fatigue, shortness of breath, and ageusia. At seven months, 14.7% experienced anosmia and fatigue, 11% ageusia, and 3.7% experienced a headache (Augustin et. al., 2021).

Havervall et al. (2021), reported on symptoms and functional impairment among 323 seropositive healthcare workers in Sweden. They found that 26%, consistent with 9% of the negative control group, reported at least one severe symptom lasting greater than two months, with 15% with symptoms lasting at least 8 months. Symptoms included anosmia, fatigue, aguisia, dyspnea, sleep disorder, headache, palpitations, concentration impairment, muscle and joint pain, and memory impairment in order of prevalence. Eight percent reported significant disruption in work social and home life activities (Havervall et al., 2021).

The symptoms experienced by long-COVID patients have considerable overlap with the myalgic encephalomyelitis/ chronic fatigue syndrome illness (Solve ME/CFS initiative, 2021). Dysregulation of the autonomic nervous system

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and the renin angiotensin aldosterone system can have multi-organ manifestations and may explain some of the symptom manifestations of COVID-19 long-haulers and the overlap with the ME/CFS illness (Solve ME/CFS initiative, 2021). In a webinar presented on Jan. 16, 2021 at the joint ID SA/CDC weekly seminar, Mitchell Miglis, MD, presented his published case report of a young woman, COVID-19 survivor with long-term symptoms, now diagnosed with postural tachycardia syndrome (POTS). This autonomic syndrome is characterized by tachycardia, gastrointestinal upset, vasomotor instability, headache, brain fog, anxiety, and sleep disorder, and is thought to be related to a small fiber neuropathy (Miglis et al., 2020). Infection has been a documented precursor to POTS as well as other autonomic syndromes, and there were documented cases of autonomic dysfunction in patients following the 2002 SARS outbreak (Miglis et al., 2020). Miglis et al. (2020), describes that this pandemic offers an opportunity to further study autonomic dysfunction as a result of infectious processes.

Multidisciplinary approaches in assisting patients with long-term post-COVID symptoms are being developed in many major medical institutions, given the increasing number of patients experiencing these symptoms and increased recognition of the need for study response. It is clear that the symptoms perceived by the majority of these patients are real and shouldn’t be dismissed by the medical community.

A valuable resource published in the British Medical Journal outlines practical pointers for management of post-acute COVID-19 for primary care physicians.

Jessica Merchant is a nurse practitioner working in infectious diseases at Sharp Coronado Hospital. Dr. Butera is a fellow of the Infectious Disease Society of America, past president of Infectious Disease Association in California, an epidemiologist at Sharp Coronado Hospital, and co-chair of the San Diego County Medical Society’s GERM committee.

References Augustin, M. Schommers, P. Stecher, M. Dewald, F. Gieselmann, L. Gruell, H. Horn, C. Vanshylla, K. Cristanziano, V. D. Osebold, L. Roventa, M. Riaz, T. Tschernoster, N. Altmueller, J. Rose, L. Salomon, S. Priesner, V., Luers, J. C. Albus, C. Rosenkranz, S. Gathof, B. Fätkenheuer, G. Hallek, M. Klein, F. Suá. (2021). Post-COVID syndrome In non-hospitalised patients with covid-19: A LONGITUDINAL prospective cohort study. The Lancet regional health. Europe. https:// pubmed.ncbi.nlm.nih.gov/34027514/.

British Medical Journal (BMJ). (2020). Management of post-acute covid-19 in primary care. Retrieved from http:// dx.doi.org/10.1136/bmj.m3026 Centers for Disease Control and Prevention. (2020a). Symptom duration and risk factors for delayed return to usual health among outpatients with COVID-19 in a multistate health care systems network — United States, March–June 2020. 69(30);993-998. Retrieved from https://www.cdc.gov/ mmwr/volumes/69/wr/mm6930e1.htm Centers for Disease Control and Prevention. (2020b). Symptoms of coronavirus. Retrieved from https://www.cdc. gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc. gov%2Fcoronavirus%2F2019-ncov%2Fabout%2Fsymptoms.html Centers for Disease Control and Prevention. (2021). COVID-19 and Your Health. Retrieved from https://www.cdc. gov/coronavirus/2019-ncov/long-term-effects.html Davis, H. E., Assaf, G. S., McCorkell, L., Wei, H., Low, R. J., Re’em, Y., Redfield, S., Austin, J. P., & Akrami, A. (2020).

Characterizing long COVID in an International COHORT: 7 months of symptoms and their impact. https://doi.org/10.11 01/2020.12.24.20248802 Havervall S, Rosell A, Phillipson M, Mangsbo SM, Nilsson P, Hober S, Thålin C. Symptoms and Functional Impairment Assessed 8 Months After Mild COVID-19 Among Health Care Workers. JAMA. 2021 May 18;325(19):2015-2016. doi: 10.1001/jama.2021.5612. PMID: 33825846; PMCID: PMC8027932.

How long does COVID last? (June, 6, 2020). COVID symptom study. Retrieved January 20, 2021, from https://covid. joinzoe.com/post/covid-long-term Huang, C., Huang, L., Wang, Y., Li, X., Ren, L., Gu, X., Kang, L., Guo, L., Liu, M., Zhou, X., Luo, J., Huang, Z., Tu, S., Zhao, Y., Chen, L., Xu, D., Li, Y., Li, C., Peng, L., . . . Cao, B. (2021).

6-month consequences of COVID-19 in patients discharged from hospital: a cohort study. Lancet 2021; 397: 220–32. Retrieved from https://doi.org/10.1016/S0140-6736(20)32656-8

Miglis, M. G., Prieto, T., Shaik, R., Muppidi, S., Sinn, D. I., & Jaradeh, S. (2020). A case report of postural tachycardia syndrome after COVID-19. Clinical autonomic research : official journal of the Clinical Autonomic Research Society, 30(5), 449–451. https://doi.org/10.1007/s10286-020-00727-9 Nalbandian, A. (2021). Post-acute COVID-19 syndrome. Nature Medicine. Retrieved from https://www.nature.com/ articles/s41591-021-01283 Renaud, M., Thibault, C., le Normand, F., Mcdonald, E. G., Gallix, B., Debry, C., Venkatasamy, A. (2021). Clinical Outcomes for Patients With Anosmia 1 Year After COVID-19 Diagnosis. Retrieved from JAMA Network Open, 4(6), e2115352. https://doi.org/10.1001/jamanetworkopen.2021.15352 Solve ME/CFS initiative. (2021, July 28). ME/CFS & Long Covid. https://solvecfs.org/me-cfs-long-covid/ Tenforde, M. W. (2020). Symptom Duration and Risk Factors for Delayed Return to Usual. . . Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/ mmwr/volumes/69/wr/mm6930e1.htm Patell, R., Bogue, T., Koshy, A., Bindal, P., Merrill, M., Aird, W. C., Bauer, K. A., & Zwicker, J. I. (2020). Postdischarge thrombosis and hemorrhage in patients With covid-19. Blood, 136(11), 1342–1346. https://doi.org/10.1182/ blood.2020007938 Wu, X., Liu, X., Zhou, Y., Yu, H., Li, R., Zhan, Q., Ni, F., Fang, S., Lu, Y., Ding, X., Liu, H., Ewing, R. M., Jones, M. G., Hu, Y., Nie, H., & Wang, Y. (2021). 3-Month, 6-month, 9-month, and 12-month Respiratory outcomes in patients following Covid-19-related hospitalisation: A prospective study. The Lancet Respiratory Medicine. https://doi.org/10.1016/s22132600(21)00174-0 CDC in collaboration with Kaiser Permanente Giorgis reported clinical characteristics of non hospitalized adults 28–180 days after covid 129dx. MMWR /April30,2021/ VOL.7/No17 Hernandez-Romieu,AC, et al . 69% of 3,171 had one or more outpatient visits. New dx included cough dyspnea chest and throat pain and fatigue likely related to COVID-19 more than 38% patients had subspecialty referrals related to post-COVID conditions including pulmonary cardiology neurology and behavioral health.

SanDiegoPhysician.org 9

INFEC T I O US D I S E A S E

COVID-19 Impact on Sexually Transmitted Infections

By Winston Tilghman, MD

➻

10

IN 2019, REPORTED CASES AND RATES OF SEXUALLY transmitted infections (STIs) in San Diego County were the highest that they had been in three decades and continuing to increase. In 2019, a total of 1,154 cases of early syphilis (including primary, secondary, and early latent syphilis) were reported in San Diego County, with a rate of 34.4 cases per 100,000 population, representing a 6.5% increase from 2018 and a 35.4% increase from 2015. A total of 6,395 cases of gonorrhea were reported, with a rate of 190.8 cases per 100,000 population, representing a 2.7% increase from 2018 and a 68.6% increase from 2015. Chlamydia continued to be the most common reportable communicable disease in 2019, and 23,007 cases were reported in San Diego County. The rate of chlamydia was 686.4 cases per 100,000 population, representing a 3.7% increase from 2018 and a 28.6% increase from 2015. Further, a total of 21 cases of congenital syphilis

October 2021

were reported, representing a threefold increase from 7 cases in 2015 and inclusive of three stillbirths [1].

Based on unpublished preliminary 2020 surveillance data, while reported cases of early syphilis, gonorrhea, and chlamydia were at or above baseline during the first two months of the year, there was a sharp decline in reported cases that began in March 2020 and reached a nadir in April 2020. The number of cases of early syphilis, gonorrhea, and chlamydia reported from January–June 2020 decreased by 8.3%, 12.2%, and 20.2%, respectively, compared to January– June 2019, before starting to rise again in May 2020. By the end of 2020, early syphilis and gonorrhea cases had returned to baseline, while chlamydia cases remained much lower than baseline. Reported cases of early syphilis and gonorrhea from July–December 2020 were 1.7% and 1.0% higher than July–December 2019, and the number of chlamydia

Figure 1: Chlamydia, Gonorrhea, and Early Syphilis Cases and Rates per 100,000 Population* by Month, San Diego County, CA 2019–2020**

cases reported during this timeframe was 21.8% lower than in 2019 (see Figure 1). [2].

The Coronavirus Disease 2019 (COVID-19) global pandemic has had multiple effects on the United States (U.S.) economy and society that impact STI incidence, prevention, and control. The introduction of public health measures to control the COVID-19 pandemic, such as masking, recommendations for social distancing, and stay-at-home orders, could have resulted in changes in sexual behavior that decrease STI incidence. The decline in reported STI cases, in March 2020, coincided with the issuance of a stay-at-home order for the state of California, which occurred on the 19th day of that month. However, studies have indicated that social distancing measures did not result in reductions in the number of sexual partners during the pandemic, and in one U.S.-based survey, of men who have sex with men (MSM), an increase in the mean number of anal sex partners (from 2.1 to 2.3) was reported [3].

Aside from a decrease in actual incidence, other explanations for the decline in reported STIs include effects of COVID-19 on the availability of sexual health services to persons who are vulnerable to STIs and the capacity of public health departments to maintain contact tracing and other disease intervention activities that reduce transmission.

Decreases in laboratory testing for STIs have been attributed to repurposing of supplies and services for COVID-19, as well as shortages in STI test kits (i.e., nucleic acid amplification testing kits for gonorrhea and chlamydia), personnel, and personal protective equipment. Further, due to social distancing measures, in-person patient care was reduced, thereby resulting in elimination of or significant reduction in routine STI screening among asymptomatic individuals and lengthening the amount of time that persons with asymptomatic STIs could transmit to others. In many regions, providers have used syndromic treatment (i.e., empiric treatment based on signs and symptoms without testing to confirm the diagnosis) and provided expedited partner therapy to known contacts to STIs without confirmatory testing. In fact, the Centers for Disease Control and Preven-

tion (CDC) issued interim guidance for management of STIrelated syndromes in settings in which in-person services and confirmatory testing were not available [4]. Although it is not clear how much syndromic and partner treatment has occurred without confirmatory testing in San Diego County, these cases are less likely to be reported to the local health department and may partially account for the decrease in reported cases, leading to underestimation of the true STI burden in 2020.

According to an analysis conducted by the California Department of Public Health (CDPH) of weekly gonorrhea and chlamydia testing volumes at California Family Planning, Access, Care, and Treatment (PACT) clinics served by a commercial laboratory between January 2019 and June 2020, testing for gonorrhea and chlamydia declined by 44% and 43%, respectively, in the January–June 2020 timeframe, compared to the same timeframe in 2019, and more so among women than among men [5]. This is likely due to the reduction in routine screening of sexually active women aged 24 years and younger for gonorrhea and chlamydia, which is recommended by CDC and the U.S. Preventive Services Task Force to reduce the risk of pelvic inflammatory disease (PID) and infertility [6-7]. While these observations may not be generalizable to all healthcare facilities and all regions of California, they indicate that routine STI testing was less available to asymptomatic individuals, including low-income populations and other groups that encounter barriers to accessing care.

Preliminary 2020 STI surveillance data support the hypothesis of decreased routine testing of asymptomatic individuals. Most chlamydia cases in San Diego County are diagnosed among young women aged 15 to 24 years, a population for whom routine screening is recommended [1,6-7]. Chlamydia has been associated with the largest and most sustained declines in reported cases through December 2020 compared to 2019. Gonorrhea was associated with a smaller decline in reported cases, which had returned to baseline by October 2020 (see Figure 1) [2]. The fact that patients with gonococcal urethritis are usually symptomatic and more likely to seek medical attention could account for this.

This is supported further by declines in extragenital (i.e., rectal and pharyngeal) gonorrhea and chlamydia cases that were disproportionate to the overall declines in gonorrhea and chlamydia cases. Extragenital gonorrhea and chlamydia infections are typically asymptomatic, in contrast to gonococcal urethritis, and are usually detected by screening. Cases of extragenital gonorrhea and chlamydia reported from January-June 2020 decreased by 37.0% and 39.1%, respectively, compared to January-June 2019, while total gonorrhea and chlamydia cases declined by 12.2% and 20.2%, respectively. While total gonorrhea cases had returned to baseline during July-December 2020, reported extrageni-

SanDiegoPhysician.org 11

Figure 2: Number of Positive Extragenital* Chlamydia (CT) and Gonorrhea (GC) Tests, San Diego County, CA, 2019–2020**

tal gonorrhea cases from July-December 2020 were 30.0% lower than from July-December 2019. Reported extragenital chlamydia cases from July-December 2020 were 45.5% lower than from July-December 2019, while the total number of reported chlamydia cases was 21.8% lower (see Figures 1&2) [2]. Since negative test results are not reported to the public health department, it is not possible to determine if there was a decline in extragenital testing for gonorrhea and chlamydia, versus an actual decrease in extragenital infections, although it is likely that decreased availability of routine testing or longer testing intervals for groups for whom three-site testing is typically performed (e.g., MSM on human immunodeficiency virus, or HIV, pre-exposure prophylaxis) played a role.

While many local health departments throughout the U.S. were unable to sustain STI case investigations, contact tracing, and clinical services due to redirection of staff and resources to the COVID-19 response, these factors are unlikely to have had a major impact on reported STIs in San Diego County. According to surveys of California local health jurisdictions conducted by CDPH, 13% of responding jurisdictions reported decreased capacity to perform disease investigation in April 2020, and 41% reported decreased capacity in June and September 2020. Up to 26% of jurisdictions had closures of some or all STI-related services, such as screening, testing, diagnosis, treatment, and partner services, at some point in 2020 [5]. However, despite redirection of multiple staff members to the COVID-19 response, the San Diego STI program continued to conduct disease investigation of priority cases and contract tracing, and the four categorical STI clinics operated by the County of San Diego continued to provide in-person care to patients without interruption (albeit with some restrictions in March and April 2020 that were lifted by May 2020).

Syphilis is the primary focus of STI disease investigation and contact tracing efforts due to the potential for severe complications (e.g., neurosyphilis) during early and late disease, and the resurgence of congenital syphilis in recent years. Investigative priorities include symptomatic cases (i.e., primary and secondary syphilis) and cases that could

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result in congenital syphilis (i.e., females of childbearing potential, pregnant women, and men with female sexual partners). The County’s categorical STI clinics play an important role in providing same-day evaluation for and/or treatment for syphilis. In 2019, 26% of primary and secondary syphilis cases were treated in County-operated STI clinics [1].

Although reported primary and secondary syphilis cases decreased by 5.5% from January–June 2019 to January–June 2020, cases increased by 5.4% from July–December 2019 to July–December 2020 (see Figure 3A). Further, early latent syphilis followed a similar pattern, with reported cases decreasing by 10.7% and 1.6% from January–June 2019 to January–June 2020 and from July–December 2019 to July– December 2020, respectively (see Figure 3B). These trends imply that the disease investigation, contact tracing, and STI clinical services continued to be effective at identifying and treating cases of early syphilis (i.e., cases of syphilis that occurred within the last 12 months); that patients with symptoms continued to seek healthcare (except, perhaps, during the initial weeks of the pandemic when the stay-athome order was in place); and testing for syphilis was less vulnerable to service disruptions, since it is mostly bloodbased (in contrast to extragenital gonorrhea and chlamydia testing, which require collection of specimens from the rectum and pharynx).

In conclusion, the COVID-19 pandemic resulted in a significant decline in reported STI cases in San Diego

Figures 3A and 3B: Primary and Secondary (A) and Early Latent (B) Syphilis Cases and Rates per 100,000 Population* by Month, San Diego County, CA 2019–2020** (A)

County that, with the exceptions of chlamydia and late latent syphilis/latent syphilis of unknown duration (data not shown), returned to or even exceeded baseline during the second half of 2020. These trends mirror national trends reported by CDC [8] and CDPH [5]. Masking, social distancing measures, and the stay-at-home order probably resulted in behavior changes that reduced STI transmission. However, decreased availability of services, particularly in-person evaluations and routine screening of asymptomatic persons, likely contributed to these observations.

It is vital to prevent exacerbation of one epidemic due to another epidemic: STI complications, such as neurosyphilis, congenital syphilis, antibiotic-resistant gonorrhea, and PID; and widening of existing health disparities. Continued availability of in-person evaluations for symptomatic patients and contacts to STIs is essential. Further, routine STI screening for vulnerable populations at recommended intervals is critical to decrease transmission from asymptomatic individuals. Finally, prevention of STI complications and gonococcal antibiotic resistance relies on treatment according to evidence-based national guidelines, the most recent of which were recently released [9].

Dr. Tilghman is senior physician/STD controller; HIV, STD, and Hepatitis Branch of Public Health Services at County of San Diego.

References:

County of San Diego, Health and Human Services Agency, Division of Public Health Services, HIV, STD, and Hepatitis Branch. April 2021. Sexually Transmitted Diseases in San Diego County, 2019 Data Slides. Accessed 08/09/21 from www.STDSanDiego.org.

2 County of San Diego, Health and Human Services Agency, Division of Public Health Services, HIV, STD, and Hepatitis Branch. Unpublished data.

3 Stephenson R, Chavanduka TMD, Rosso MT, et al. Sex in the time of COVID-19: results of an online survey of gay, bisexual and other men who have sex with men’s experience of sex and HIV prevention during the US COVID-19 epidemic. AIDS Behav 2020; 25:40-48.

4 Centers for Disease Control and Prevention. Dear colleague letter – STD treatment options – April 2020. Available at: https://www.cdc.gov/std/dstdp/DCLSTDTreatment-COVID19-04062020.pdf. Accessed 08/09/21.

5 Johnson KA, Burghardt NO, Tang EC, et al. Measuring the impact of the COVID-19 pandemic on sexually transmitted diseases public health surveillance and program operations in the state of California. Sex Transm Dis 2021; 48(8):606-613 6 Centers for Disease Control and Prevention. Sexually transmitted infections treatment guidelines – detection of STIs in special populations – adolescents.

Available at: https://www.cdc.gov/std/treatment-guidelines/adolescents. htm. Accessed on 08/09/21.

7 United States Preventive Services Task Force. Draft recommendation statement – screening for chlamydia and gonorrhea. Available at: https:// www.uspreventiveservicestaskforce.org/uspstf/draft-recommendation/ chlamydial-and-gonococcal-infections-screening#fullrecommendationsta rt. Accessed on 08/09/21.

8 Weinstock H, Grey J, Stenger M, Pagaoa M, Kreisel K. Impact of COVID-19 on STD surveillance. Presented at: 2020 STD Prevention Conference [oral presentation]; 2020; Virtual.

9 Centers for Disease Control and Prevention. Sexually transmitted infections treatment guidelines. Available at: https://www.cdc.gov/std/treatmentguidelines/toc.htm. Accessed on 08/09/21.

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INFEC T I O US D I S E A S E

Candida auris, an Emerging Pathogen of Concern: Epidemiology, Clinical Spectrum, Diagnosis, Treatment, and Mitigation Strategies

By Grace Kang, RN, PHN and Raymond Chinn, MD

➻

KEY POINTS

• Candida auris (C. auris) is an emerging multidrug-resistant yeast that has been associated with healthcare-facility outbreaks and results in significant morbidity and mortality in patients with multiple comorbidities • C. auris colonization and environmental contamination can persist for a long time, making the organism difficult to eradicate • C. auris can be misidentified when using traditional phenotypic methods for yeast identification. County of San Diego Epidemiology can assist with identification.

• C. auris is generally susceptible to the echinocandins; however, pan-resistance to all classes of antifungals has been reported.

• Strategies to control C. auris include: adherence to hand hygiene guidelines, use of standard and contact precautions, cleaning and disinfecting the environment with an Environmental Protective Agency (EPA) “List P” disinfectant, interfacility transfer communication of C. auris status, screening of contacts, laboratory surveillance, and a robust antimicrobial stewardship program.

• Both presumptive and confirmed C. auris should be reported to San Diego County Epidemiology within one working day.

INTRODUCTION

Since 2009, when C. auris was first identified as a pathogen in Japan, this multidrug-resistant yeast has emerged as a major public health concern, with reports of healthcareassociated outbreaks that have resulted in severe and fatal infections. Some strains are resistant to the three major antifungal classes, therefore limiting therapeutic options.

C. auris has a special predilection for the skin that results in a prolonged carrier state. Its ability to survive in harsh environmental conditions contributes to its persistence in the healthcare environment for weeks, and routine disinfectants used in healthcare settings are not effective against this organism. (1,2,3)

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October 2021

The recent COVID-19 pandemic with its challenges of inadequate personal protective equipment (PPE) supplies, cohorting only by COVID-19 status without consideration for multidrug-resistant organism (MDRO) status, and suboptimal environmental disinfection have likely contributed to the overall increase in the number of cases. (4) These observations are highlighted in an outbreak that occurred on a Florida COVID-19 unit. A point prevalence survey conducted after four C. auris clinical cases were reported showed that 35 out of 67 patients (52%) were colonized. Six (17%) of the colonized patients later grew C. auris from clinical cultures. (5) The CDC estimates that each case of candidemia results in an additional 3 to 13 days of hospitalization, and costs between $6,000 and $29,000, and likely higher when the infection is caused by a multidrug-resistant C. auris. (6) EPIDEMIOLOGY

As of 2020, Candida auris has been isolated in more than 40 countries across 6 continents and has led to several recent outbreaks in hospitals worldwide. (Figure 1) (5,7-9) Whole genome sequencing and epidemiologic analyses performed on samples obtained during 2012–2015 identified the simultaneous emergence of multidrug-resistant C. auris across 3 continents. (10) Since then, five distinct major clades of have been described and each confined to specific areas of the world, thereby suggesting independent evolution. (8) Figure 1 In the United States, most cases of C. auris result from local spread within healthcare. However, patients who received healthcare elsewhere in the United States or abroad in areas with C. auris transmission can also introduce the organism into healthcare facilities. 1,012 confirmed and probable clinical cases have been identified in the U.S. to date.

Targeted screening has identified 2,386 colonized patients.

(Figure 2) (2,11)

Figure 1 Countries With Reported Cases of C. auris Infection or Colonization, January 2009–June 2020 (6)

Figure 2 Reported Clinical Cases of C. auris, June 2020–May 2021 (5)

Figure 3 C. auris Cases Reported by Local Health Jurisdiction Through July 2021 (9)

Figure 4 C. auris and COVID-19 Cases in CA Through July 2021 (9)

Figure 2 California experienced its first C. auris outbreak in Orange County in February 2019. Although initially contained, a second surge was noted during the COVID-19 pandemic in May 2020 and spread to five other Southern California local health jurisdictions. (Figure 3) Figure 3 Between May 2020–May 2021, 1192 cases of C. auris were identified in 93 California healthcare facilities. During the peak of the COVID-19 pandemic in December 2020 when nearly 1.2 million cases were documented in California, there was a subsequent peak in the number of C. auris cases (184) in February 2021. After statewide mitigation efforts were implemented, the number of C. auris cases fell to 78 cases in July 2021. The majority is colonization related (85%) and 76% were identified in long term acute care hospitals and 10% were identified at acute care hospitals. (11) Figure 4 Seven cases of C. auris have been identified between March 2020–present. Positive C. auris status was known for three cases at the time of transfer. Two cases were reported by local providers, with epi-linkage to exposures outside of San Diego; no secondary transmission was identified. The two most recent cases, with no known exposures outside of San Diego, were reported by local providers from acute care facilities.

Recent reports of healthcare transmission of pan- or echinocandin-resistant C. auris in two healthcare settings without an epidemiologic link signal a disturbing trend.

Independent surveillance activities conducted in Washington, DC, and Florida this year detected pan-resistance in 3 out of 101 samples (traced to a single skilled nursing facility) in the former and 2 samples (plus 5 echinocandins and azoles resistant strains) out of 22 (identified from 2 facilities that shared patients) in the latter. There are sporadic reports of pan-resistant isolates where the pan-resistance evolved during treatment and was attributed to antimicrobial pressure; however, these current clusters had no exposure to prior antifungal therapy. (12) Given the ease of transmission, this observation is especially disconcerting from a therapeutic standpoint.

CLINICAL PRESENTATION

As with other multi-drug resistant organisms (MDRO), risk factors that predispose patients to C. auris infection and colonization include: multiple medical problems (such as immunosuppressive states, diabetes mellitus, chronic kidney disease, hemodialysis, recent surgery); presence of indwelling medical devices (e.g., central venous catheters, urinary catheters, feeding tubes, tracheostomies); prolonged exposure to healthcare facilities (particularly long-term care facilities); and extensive exposure to antimicrobial agents. Most patients with C. auris are asymptomatically colonized; these individuals often remain colonized

SanDiegoPhysician.org 15

with C. auris for many months, perhaps indefinitely, even after the acute infection has resolved. (13) Invasive infections, such as bloodstream, wound, and ear infections develop in 5–10% of cases. (1,8,9) Persistent fungemia, when associated with a central line that cannot be removed, is likely related to a biofilm or to hematogenous dissemination to other sites. Eradication of soft-tissue infection can be difficult, even with appropriate antimicrobial therapy, unless the bioburden is reduced. (8,9,14) Based on a limited number of cases with C. auris infections, the Centers for Disease Control and Prevention (CDC) estimates the overall mortality to be 30–60%. (1) DIAGNOSIS AND TREATMENT

The accurate diagnosis of C. auris is dependent on the laboratory methods used; therefore, knowing the laboratory methodology is critical. Matrix-assisted laser desorption/ ionization time-of-flight mass spectrometry (MALDI-TOF MS) is the most reliable method to detecting C. auris, but C. auris must be included in the database. The identification of Candida haemulonii should be an alert that C. auris is a possibility. Other Candida species may be misidentified and are dependent on the phenotypic method that is used for yeast identification (Table 1). Although not yet widely available, molecular methods can correctly identify C. auris.

(9,15) Table 1 Laboratory Identification Methods and Potential Misidentification Results for C. auris (13)

Identification Method

Organism C. auris can be misidentified as

Vitek 2 YST

C. haemulonii, C duobushaemulonii, C. lusitaniae, C. famata

API 20C

Rhodotorula glutinis, C. sake

API ID 32C

C. intermedia, C. sake, Saccharomyces kluyveri

BD Phoenix yeast identification system

C. haemulonii, C. catenulate

MicroScan

C. famata, C. guilliermondii, C. lusitaniae, C. parapsilosis

RapID Yeast Plus

C. parapsilosis

Prompt and correct diagnosis of C. auris will allow the clinician to initiate appropriate empiric therapy. With increasing reports of multidrug resistance, susceptibility testing should be performed on any clinical isolate, especially when associated with invasive disease. In the absence of established C. auris breakpoints, published breakpoints are based on closely related Candida species and on expert opinion. Initial antifungal treatment should consist of an echinocandin (caspofungin, micafungin, or anidulafungin); azoles, amphotericin B, and other antifungal agents may be useful, depending on the clinical setting and patient profile. The site of the infection should be considered in the choice of therapy. For example, the echi-

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October 2021

nocandins have limited penetration into the cerebrospinal fluid and minimal amounts of drug is recovered from the urine. In breakthrough infections, the finding of an elevated minimum inhibitory concentration (MIC) does not necessarily preclude its use. (9,16-18) The AR Lab Network reports the following resistance rates on isolates submitted from 2016–2019 in the US: 85% to azoles, 33% to amphotericin B, and 1% to echinocandins. (19) Switching therapy from an echinocandin to liposomal amphotericin B is an option if the patient is unresponsive to therapy or has evidence of sustained fungemia. Recalcitrant fungemia when catheter-related is especially difficult to treat since in vitro studies suggest that the biofilm is not susceptible to the azoles, echinocandins, or liposomal amphotericin, but is susceptible to the deoxycholate formulation of amphotericin B. These observations contrast the planktonic susceptibility patterns. (19) In vitro evaluation of antifungal drug combinations against multidrug-resistant C. auris using flucytosine might represent a therapeutic option; however, clinical studies are needed to validate these observations. (21) The duration of therapy is dependent on the site of infection and response to antifungal therapy. Guidelines issued by the Infectious Disease Society of America on the management of Candida infections are appropriate. For candidemia, the recommended duration of therapy is two weeks upon clearance of the fungemia, resolution of the signs and symptoms of infection, and absence of metastatic foci, and recovery from neutropenia if applicable. Other invasive forms of candidiasis may require a longer duration of therapy. (18) Isolation of C. auris from the respiratory and urinary tracts likely represent colonization and therefore, treatment is not indicated unless the risk of disseminated infection is high. Patients who are neutropenic, infants with very low birth weight (<1500 g), or patients who are to undergo urologic manipulation comprise this high-risk group. (17,18) A bundle approach has been used to decrease the risk of invasive infection in those patients who are colonized with C. auris. Components of this bundle include: chlorhexidine (CHG) baths, placement of a CHG-impregnated disc around central lines, and the use of CHG for oral hygiene. (22) One in vitro study demonstrated inhibition of C. auris with CHG at concentrations of 0.125%–1.5% and iodinated povidone of 0.07%–1.25%. (23) ANTIMICROBIAL STEWARDSHIP

A study of ventilators in skilled nursing facilities identified receipt of a carbapenem and fluconazole in the prior 90 days as risk factors for acquisition of C. auris. Antimicrobial stewardship is promoted as a strategy to discourage emergence of all MDRO. (24) INFECTION PREVENTION AND CONTROL CONSIDERATIONS AND RECOMMENDATIONS

Because it is more challenging to mitigate after transmission

Table 2 Infection Prevention and Control Considerations and Recommendations

Topic

Action Items

Laboratory

Confirm that your laboratory is able to detect C. auris or suspect C. auris, including a PCR screening method. Some commercial labs have screen testing capability. (25)

Admission Screening

Conduct admission screening testing for the following patient population at high risk (2) for C. auris on admission: • Persons admitted from a facility with known transmission of C. auris.

• Persons identified as high-risk contacts of confirmed C. auris cases (e.g. roommates).

• Persons admitted from any high-risk facility (e.g. long-term acute care hospital or subacute unit of a skilled nursing facility).

• Persons with tracheostomy or mechanically ventilated.

• Those who had an overnight stay in a healthcare facility in the last 12 months in a region or state with transmission of C. auris.

• Those who received healthcare outside the U.S. in the last 12 months.

• Those colonized carbapenemase-producing (CP) organisms, prioritizing rare (non-KPC) mechanisms.

Precautions

Disinfection and Cleaning

• • • • • •

Place patients with suspected or confirmed C. auris in a private room, and minimize room transfers.

Implement strict Contact Isolation, do not reuse or extended use PPE. Reinforce hand hygiene practices for staff and visitors.

Use dedicated medical equipment as much as possible.

Minimize the number of healthcare staff caring for the patient by consolidating duties.

Continue transmission-based precautions in all subsequent admissions. Clearance testing is not recommended at this time.

Perform daily/terminal cleaning with an EPA List P registered disinfectant. (26)

Education

• Educate patients/families, including importance of disclosing C. auris history in subsequent healthcare encounters.

• Educate healthcare staff to promote awareness and name recognition.

• Review interfacility transfer processes to ensure C. auris status is requested/communicated.

Communication/ Notification

• Notify County Healthcare-Associated Infections (HAI) Program of C. auris suspected/confirmed persons.

• Ensure Infection Preventionist (IP) to IP communication during interfacility transfers.

• Notify the County HAI Program of all patient transport/transfers/discharges.

Obtain More Information

• CDPH Candida auris page https://www.cdph.ca.gov/Programs/CHCQ/HAI/Pages/Candida-auris.aspx • CDC Candida auris page https://www.cdc.gov/fungal/candida-auris/index.html • County of San Diego Healthcare-Associated Infections (HAI) Program (619) 692-8499

has occurred, early detection, aggressive infection control, and coordinated response between public health and the healthcare facility are critical to proactively contain spread.

Infection prevention and control recommendations are outlined in Table 2.

miology within one working day by calling (619) 692-8499.

Isolates of Candida should be identified to the species level, in both sterile and non-sterile sites, in patients at high risk for C. auris. If assistance is needed for identification, County Public Health Lab has the capacity to identify isolates.

REPORTING: NATIONALLY NOTIFIABLE, LOCALLY REPORTABLE

SUMMARY

C. auris became nationally notifiable in 2018 due to its status as an emerging multidrug-resistant pathogen.

San Diego made C. auris locally reportable in June 2019 in response to increasing numbers of cases identified in healthcare facilities in Southern California. Because of the increasing threat in California, it is anticipated to become a reportable condition statewide very soon, with both a provider and laboratory reporting component.

WHAT TO DO IF C. AURIS IS SUSPECTED/IDENTIFIED

If a patient is suspected or confirmed to be a C. auris case (whether a clinical infection or colonized), promptly ensure that they are placed on contact isolation in a private room with dedicated equipment. Report the case to County Epide-

The increasing reports of outbreaks related to multidrugresistant (and now, pan-resistant) C. auris in highly vulnerable populations is of global concern. The difficulty in identifying the organism, persistence in the environment, and its predilection to colonize the skin facilitates transmission. The high mortality and significant financial burden associated with invasive infection can erode the healthcare infrastructure. Therefore, it is incumbent on healthcare systems to be proactive and mitigate further transmission.

Grace Kang and Dr. Chinn work for the Healthcare-Associated Infections Program, Epidemiology and Immunizations Services Branch, County of San Diego Health & Human Services Agency.

SanDiegoPhysician.org 17

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October 2021

BIBLIOGRAPHY 1. CDC https://www.cdc.gov/fungal/candida-auris/candida-auris-qanda.html 2. CDPH https://www.cdph.ca.gov/Programs/CHCQ/HAI/Pages/Candida-auris.aspx 3. Sexton DJ, Bentz ML, Welsh RM, et al. Positive Correlation between Candida auris SkinColonization Burden and Environmental Contamination at a Ventilator-Capable Skilled Nursing Facility in Chicago. Clin Infect Dis. 2021 May 12:ciab327. doi: 10.1093/cid/ciab327.

Epub ahead of print. PMID: 33978150.

4. Magnasco L, Mikulska M, Giacobbe DR, et al. Spread of Carbapenem-Resistant GramNegatives and Candida auris during the COVID-19 Pandemic in Critically Ill Patients: One Step Back in Antimicrobial Stewardship? Microorganisms 2021;9(1):95. doi: 10.3390/ microorganisms9010095. PMID: 33401591; PMCID: PMC7823370.

5. Prestel C, Anderson E, Forsberg K, et al. Candida auris Outbreak in a COVID-19 Specialty Care Unite – Florida, July-August 2020. MMWR Morb Mortal Wkly Rep 2021;70:56-57.

6. CDC https://www.cdc.gov/fungal/diseases/candidiasis/invasive/statistics.html 7. CDC https://www.cdc.gov/fungal/candida-auris/tracking-c-auris.html 8. Du H, Bing J, Hu T, Ennis CL, Nobile CJ, Huang G. Candida auris: Epidemiology, Biology, Antifungal Resistance, and Virulence. PLoS Pathog. 2020;16(10):e1008921.

9. Jeffery-Smith A, Taori SK, Schelenz S, Jeffery K, Johnson EM, Borman A, Candida auris Incident Management Team, Manuel R, Brown CS. 2018. Candida auris: a Review of the Literature. Clin Microbiol Rev 31:e00029-17. https://doi.org/10.1128/CMR.00029-17.

10. Lockhart SR, Etienne KA, Vallabhaneni S, et al. Simultaneous Emergence of Multidrugresistant Candida auris on 3 Continents Confirmed by Whole-Genome Sequencing and Epidemiological Analyses. Clin Infect Dis 2017; 64:134–140.

11. CDPH Healthcare Associated Infections Program, Epson, E. Preventing Multidrug-resistant Organism (MDRO) Transmission in the Setting of COVID-19. Webinar August 18, 2021. https://www.hsag.com/globalassets/covid-19/mdro_covid_surge508.pdf 12. Lyman M, Fosberg K, Reuben J, et al. Notes from the Field: Transmission of Pan-Resistant and Echinocandin-Resistant Candida auris in Health Care Facilities – Texas and District of Columbia, January-April 2021. MMWR Morb Mort Wkly Rep 2021;70:1022-1023 13. https://www.cdc.gov/fungal/candida-auris/c-auris-infection-control.html 14. Sherry L, Ramage G, Kean R, et al. Biofilm-Forming Capability of Highly Virulent Multidrug-Resistant Candida auris. Emerg Infect Dis 2017;23:328–331 15. CDC http://www.cdc.gov/fungal/cadida-auris/identification.html 16. CDC https://www.cdc.gov/fungal/candida-auris/c-auris-antifungal.html.

17. CDC https://www.cdc.gov/fungal/candida-auris/c-auris-treatment.html 18. Pappas PG, Kauffman CA, Andes DR, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2016 Feb 15;62(4):e1-50. doi: 10.1093/cid/civ933. Epub 2015 Dec 16. PMID: 26679628; PMCID: PMC4725385.

19. Forsberg K, Lyman M, Chaturvedi S, et al. Public Health Action-Based System for Tracking and Responding to U.S. Candida Drug Resistance: AR Lab Network, 2016–2019. Open Forum Infect Dis 2020;7(Suppl 1):S206–7. https://doi.org/10.1093/ofid/ofaa439.465external icon 20. Chatzimoschou A, Giampani A, Meis JF, Roilides E. Activities of Nine Antifungal Agents against Candida auris Biofilms. Mycoses. 2021 Apr;64(4):381-384. doi: 10.1111/myc.13223.

Epub 2020 Dec 13. PMID: 33270284.

21. O’Brien B, Chaturvedi S, Chaturvedi V. In Vitro Evaluation of Antifungal Drug Combinations against Multidrug-Resistant Candida auris Isolates from New York Outbreak. Antimicrob Agents Chemother. 2020;64(4):e02195-19. Published 2020 Mar 24. doi:10.1128/AAC.02195-19.

22. Schelenz, S., Hagen, F., Rhodes, J.L. et al. First Hospital Outbreak of the Globally Emerging Candida auris in a European Hospital. Antimicrob Resist Infect Control 2016;5:35https://doi.org/10.1186/s13756-016-0132-5 23. Abdolrasouli A, Armstrong-James D, Ryan L, et al. In Vitro Efficacy of Disinfectants Utilised for Skin Decolonisation and Environmental Decontamination during a Hospital Outbreak with Candida auris. Mycoses 2017; 60:758-763. DOI: 10.1111/myc.12699.

24. Rossow J, Ostrowsky B, Adams E, et al. Factors Associated with Candida auris Colonization and Transmission in Skilled Nursing Facilities With Ventilator Units, New York, 2016-2018. Clin Infect Dis 2021;72:e753-e760. doi: 10.1093/cid/ciaa1462. PMID: 32984882; PMCID: PMC8155826.

25. LA County List of Laboratories with C. auris Testing Capacity http://publichealth. lacounty.gov/acd/docs/List_C.aurisLabs.pdf 26. EPA List P, Antimicrobial Products with Claims Against C. auris https://www.epa.gov/ pesticide-registration/list-p-antimicrobial-products-registered-epa-claims-againstcandida-auris

CHAMPIONS FOR HEALTH

I Survived Cancer, I Survived the Pandemic

by Adama Dyoniziak

I

t started in mid-2018 for Lilia: the pain in her back, constant ringing in her ears, frequent headaches, and phlegm. Without health insurance, and with financial issues, it was difficult to see a doctor. When she did save some money for a visit, doctors couldn’t identify what was wrong. Lilia was taking medicine for pain daily, she couldn’t sleep, and her arms were getting numb. She attributed it to the hard work of cleaning houses. After a year, her headaches were frequent and her pain was affecting her ability to work, spend time with her family, and dance with her husband. “I just wanted to sleep or take the medicine,” Lilia says.

On New Year’s Day in 2020, Lilia’s husband saw a large bump on Lilia’s neck and immediately said, “I need to take you to the hospital!” In May 2020, at the beginning of the COVID pandemic, Project Access client Lilia Reyes entered Tri City Hospital to receive surgery for her thyroid cancer. Dr. Bruce K. Reisman, a volunteer Project Access ENT surgeon with ENT Associates, and the team at the hospital provided pro bono surgery. “I was greeted by angels at the hospital — I knew that they had been guided there,” Lilia says. “It felt magical.”

It was the beginning of healing for Lilia and her family.

When Lilia first found out she had thyroid cancer, she cried. “What is going to happen?” she wondered. “My family can’t afford this (medical treatment) especially with the pandemic. How can this be happening to me?” Lilia could feel the world closing in, and recalls saying to her mother, “It looks like you are going to be left without a daughter.”

“Ms. Reyes represents the ideal patient for utilizing a program such as Project Access San Diego,” says Dr. Reisman. “She

Left: Lilia and her daughter Below: Dr. Bruce Reisman

is a young woman in the prime of her life, with a potentially life-altering and/ or life-threatening disease. She has no insurance and no means to acquire any.

She would easily ‘fall through the cracks’ of our current healthcare system.”

Dr. Reisman explained the surgery process, what part of her neck they would be performing surgery on, and giving her an idea of the size of the incision. When Dr. Reisman also shared that he would be performing the surgery as a volunteer with Project Access, Lilia hugged the doctor. “In a pandemic and with cancer — it was all a blessing,” she says. Lilia felt a sudden peace knowing Dr. Reisman would be her surgeon.

Lilia adds, “I am blessed — I am alive.

Each time I see my scar I thank God that you all gave me a long staircase to keep climbing. There is nothing I can do to pay Dr. Reisman back. Thank you to everyone who is on this marvelous team that helps people without hope.”

Dr. Reisman was honored to be able to provide her the surgical care necessary to offer her a potential cure of her condition. “I have enjoyed participating

in Project Access and am grateful that the other facilities and specialists that I depend on to provide my patients comprehensive care participate also,” adds Dr. Reisman.

Since 2008, Project Access has facilitated $21 million in care for more than 6,500 uninsured patients just like Lilia by providing free consultations and surgeries — all thanks to the dedication, time, and talent of our volunteer specialty healthcare physicians. For every $1 spent on program expenses, we provide $10 in contributed healthcare services — a return on investment of 1,000 percent! To help Project Access patients by donating to Champions for Health, please visit www.championsforhealth.org/donate.

Adama Dyoniziak is executive director of Champions for Health.

SanDiegoPhysician.org 19

CLASSIFIEDS VOLUNTEER OPPORTUNITIES

PHYSICIANS: HELP US HELP IMPROVE THE HEALTH LITERACY OF OUR SAN DIEGO COUNTY COMMUNITIES by giving a brief presentation (30–45 minutes) to area children, adults, seniors, or employees on a topic that impassions you. Be a part of Champions for Health’s Live Well San Diego Speakers Bureau and help improve the health literacy of those with limited access to care. For further details on how you can get involved, please email Andrew.

Gonzalez@ChampionsFH.org.

CHAMPIONS FOR HEALTH PROJECT ACCESS: Volunteer physicians are needed for the following specialties: endocrinology, ENT or head and neck, general surgery, GI, gynecology, neurology, ophthalmology, orthopedics, pulmonology, rheumatology, and urology. We are seeking these specialists throughout all regions of San Diego to support those that are uninsured and not eligible for Medi-Cal receive short term specialty care. Commitment can vary by practice. The mission of the Champions for Health’s Project Access is to improve community health, access to care for all, and wellness for patients and physicians through engaged volunteerism.

Will you be a health CHAMPION today? For more information, contact Andrew Gonzalez at (858) 300-2787 or at Andrew.Gonzalez@ChampionsFH.org, or visit www.ChampionsforHealth.org.

PHYSICIAN OPPORTUNITIES

RADY CHILDREN’S HOSPITAL – PEDIATRICIANS POSITION: Rady Children’s Hospital of San Diego seeking board-certified/eligible pediatricians or family practice physicians to join the Division of Emergency Medicine in the Department of Urgent Care (UC). Candidate will work at any of our six UC sites in San Diego and Riverside Counties. The position can be any amount of FTE (full-time equivalent) equal to or above 0.51 FTE. Must have an MD/DO or equivalent and must be board certified/eligible, have a California medical license or equivalent, PALS certification, and have a current DEA license.

Contact Dr. Langley glangley@rchsd.org and Dr. Mishra smishra@rchsd.org.

TUBERCULOSIS CONTROL & REFUGEE HEALTH CHIEF AND MEDICAL DIRECTOR: recruitment is attached and linked here - https:// www.governmentjobs.com/careers/sdcounty/ jobs/3223044/chief-tb-control-refugee-healthpublic-health-medical-officer-21412809uth PUBLIC HEALTH SERVICES MEDICAL CONSULTANT M.D., D.O: Medical Consultant-21416207 | Job Details tab | Career Pages (governmentjobs.com)<https://www. governmentjobs.com/careers/sdcounty/ jobs/3148610/m-d-d-o-medical-consultant21416207?keywords=medical%20consultant&pa getype=jobOpportunitiesJobs PER DIEM OBGYN LABORIST POSITION AVAILABLE: IGO Medical Group is seeking a per diem laborist to cover Labor and Delivery and emergency calls at Scripps Memorial Hospital in La Jolla. 70 deliveries/month. 24-hour shifts preferred but negotiable. Please send inquiries by email to IGO@IGOMED.com.

20

October 2021

MEDICAL CONSULTANT – SAN DIEGO COUNTY: The County of San Diego, Health and Human Services Agency’s Public Health Services is looking for a Board Certified Family Practice or Internal Medicine physician for the Epidemiology and Communicable Disease Division. Under general direction, incumbents perform a variety of duties necessary for the identification, diagnosis, and control of communicable diseases within the population. This position works closely with the medical and laboratory community, institutional settings, or hospital control practitioners. Learn more here: https://www.governmentjobs.com/ careers/sdcounty?keywords=21416207 KAISER PERMANENTE SAN DIEGO - PER DIEM PHYSIATRIST: Southern California Permanente Medical Group is an organization with strong values, which provides our physicians with the resources and support systems to ensure they can focus on practicing medicine, connecting with one another, and providing the best possible care to their patients.

For consideration or to apply, visit https:// scpmgphysiciancareers.com/specialty/physicalmedicine-rehabilitation. For questions or additional information, please contact Michelle Johnson at 866-503-1860 or Michelle.S1.Johnson@ kp.org. We are an AAP/EEO employer.

CHULA VISTA VETERANS HOME SEEKS A STAFF PSYCHIATRIST: The Veterans Home of California - Chula Vista seeks a 30 hour/week Staff Psychiatrist. This facility contains three level of care for our 300 resident veterans: independent living, assisted living and skilled nursing. A Geropsychiatry background is recommended but not mandatory. More information may be reviewed at the following URL https:// www.jobs.ca.gov/CalHrPublic/Jobs/JobPosting. aspx?JobControlId=221636 or you may email Paul D. Wagner, MD, FACP, Chief Medical Officer at paul.wagner@calvet.ca.gov.

PRIMARY CARE PHYSICIAN POSITION: San Diego Family Care is seeking a Primary Care Physician (MD/DO) at its Linda Vista location to provide direct outpatient care for acute and chronic conditions to a diverse adult population.

San Diego Family Care is a federally qualified, culturally competent and affordable health center in San Diego, CA. Job duties include providing complete, high quality primary care, and participation in supporting quality assurance programs. Benefits include flexible schedules, no call requirements, a robust benefits package, and competitive salary. If interested, please email CV to sdfcinfo@sdfamilycare.org or call us at (858) 810- 8700.

FAMILY MEDICINE OR INTERNAL MEDICINE PHYSICIAN: TrueCare is more than just a place to work; it feels like home. Sound like a fit?

We’d love to hear from you! Visit our website at www.truecare.org. Under the direction of the Chief Medical Officer and the Lead Physician, ensure the provision of effective quality medical service to the patients of the Health center. The physician is responsible for assuring clinical procedures are continually and systematically followed, patient flow is enhanced, and customer service is extended to all patients at all times.

PUBLIC HEALTH LABORATORY DIRECTOR: The County of San Diego is seeking a dynamic

leader with a passion for building healthy communities. This is a unique opportunity for a qualified individual to work for a Level 3 Public Health Laboratory. The Public Health Services department, part of the County’s Health and Human Services Agency, is a local health department nationally accredited by the Public Health Accreditation Board and first of the urban health departments to be accredited. Public Health Laboratory Director-21226701UPH NEIGHBORHOOD HEALTHCARE MD, FAMILY PRACTICE AND INTERNISTS/HOSPITALISTS: Physicians wanted, beautiful Riverside County and San Diego County- High Quality Family Practice for a private-nonprofit outpatient clinic serving the communities of Riverside County and San Diego County. Work Full time schedule and receive paid family medical benefits.

Malpractice coverage provided. Be part of a dynamic team voted ‘San Diego Top Docs’ by their peers. Please click the link to be directed to our website to learn more about our organization and view our careers page at www.Nhcare.org.

PHYSICIAN WANTED: Samahan Health Centers is seeking a physician for their federally qualified community health centers that emerged over forty years ago. The agency serves lowincome families and individuals in the County of San Diego in two (2) strategic areas with a high density population of Filipinos/Asian and other low-income, uninsured individuals — National City (Southern San Diego County) and Mira Mesa (North Central San Diego). The physician will report to the Medical Director and provide the full scope of primary care services, including but not limited to diagnosis, treatment, coordination of care, preventive care and health maintenance to patients. For more information and to apply, please contact Clara Rubio at (844) 200-2426 EXT 1046 or at crubio@samahanhealth.org.

FULL-TIME CARDIOLOGIST POSITION AVAILABLE: Seeking full time cardiologist in North County San Diego in busy established general cardiology practice. EP or Interventional also welcome if willing to hold general cardiology outpatient clinic also at least 50% of time while building practice. Please email resume to jhelmuth1220@gmail.com. Immediate opening.

INTERVENTIONAL PHYSIATRY/PHYSICAL MEDICINE SPECIALIST POSITION AVAILABLE: Practice opportunity for part time interventional physiatry/physical medicine specialist with well-established orthopaedic practice.

Position includes providing direct patient evaluation/care of spine and musculoskeletal cases, coordinating PMR services with all referring providers. Must have excellent interpersonal and communication skills. Office located near Alvarado Hospital. Onsite digital x-ray and EMR. Interested parties, please email lisas@sdsm.net.

CARDIOLOGIST WANTED: San Marcos cardiology office looking for a part-time cardiologist. If interested, send CV to evelynochoa2013@yahoo. com or via fax to (760) 510-1811.

GENERAL FAMILY MEDICINE PHYSICIAN: to provide quality patient care to all ages of patient in a full-time traditional practice. The Physician will conduct medical diagnosis and treatment of patients using medical office procedures consis-

tent with training including surgical assist, flexible sigmoidoscopy, and basic dermatology. The incumbent must hold a current California license and be board eligible. Bilingual Spanish/English preferred. Founded as a small family practice in Escondido 1932 by Dr. Martin B. Graybill, today we’re the region’s largest Independent Multispecialty Medical Group. Our location is 277 Rancheros Dr., Suite 100, San Marcos, CA 92069.

We are an equal opportunity employer and value diversity. Please contact Natalie Shields at (760) 291-6637/nshields@graybill.org. You may view our open positions at: https://jobs.graybill.org/.

BOARD CERTIFIED OR BOARD-ELIGIBLE PHYSICIAN DERMATOLOGIST: Needed for busy, well-established East County San Diego (La Mesa) private Practice. We currently have an immediate part-time opening for a CA licensed Dermatologist to work 2-3 days per week with the potential for full-time covering for existing physicians, whenever needed. We are a fullservice Dermatology office providing general, cosmetic and surgical services, including Mohs surgery and are seeking a candidate with a desire to provide general dermatology care to our patients, but willing to learn laser and cosmetics as well. If interested, please forward CV with salary expectation to patricia@grossmontdermatology.com.

PHYSICIAN POSITIONS WANTED

SEMI-RETIRED MD AVAILABLE: Semi-retired MD- past San Diego County Medical Society Member with 10 years post retirement experience as part time, independent contract, medical director for Methadone/Opiate Addiction Clinics. Would like to continue work. Recent clinic was sold in pristine condition, unrestricted.

CA MD Lice and same for DEA. DEA has suboxone rider, please email at mb9828@gmail.com or call 858-382-0552.

PRACTICE FOR SALE

Mercy Medical Building, one large consultation room facing eastern mountains, large windows, recently remodeled. Includes waiting room, plenty of storage, BR, parking for patients. Walking distance to UCSD medical center and Mercy Hospital and lots of restaurants. Freeway close.

Contact Randall Hicks MD, at 619-298-7135.

TURNKEY MEDICAL OFFICE FOR LEASE IN BRAWLEY, CA: 6,504 SF medical office space available at 283 Main Street Brawley, CA. Office includes a large reception area, 10 exams rooms, 5 offices, 5 restrooms, X-ray room, lounge, lab space and nurses station.

Located on the main road with easy access and abundant parking. Available for a short or long term lease. Please call Melissa at 310-471-2700 for more information.

TURNKEY OFFICE SPACE FOR RENT NEAR ALVARADO HOSPITAL: Turnkey office space for rent. Modern, remodeled and clean. We have a little space available or a lot, depending on your needs. We are located near Alvarado hospital. Conference room, nurses station and many exam rooms, along with Doctors and Admin spaces. To inquire or to schedule a showing, please contact Jo Turner (619) 733-4068.

OFFICE SPACE IN POWAY: Office in Poway.

Centrally located. Close to Pomerado Hospital.

Radiology, pharmacy next door. Fully furnished, WiFi included. Three exam rooms, reception area, waiting room. Half days to full time available. Ideal for specialist who wants to expand.

Call Dr. Luna if interested: (619) 472-1914.

KEARNY MESA OFFICE FOR SUBLEASE: Kearny Mesa area sublease in our orthopedic office which includes: onsite x-ray available, storage space, space for 1-2 employees and free parking.

Can discuss internet, phones, fax line, access to printer/copier, and more. Please contact Kaye Spotz at kspotz@synergysmg.com for more information.

OTOLARYNGOLOGY HEAD & NECK SURGERY SOLO PRACTICE FOR SALE: Otolaryngology Head & Neck Surgery solo practice located in the Ximed building on the Scripps Memorial Hospital La Jolla campus is for sale. The office is approximately 3,000 SF with 1 or 2 Physician Offices. It has 4 fully equipped exam rooms, an audio room, one procedure room, one conference room, one office manager room as well as in-house billing section, staff room and a bathroom. There is ample parking for staff and patients with close access to radiology and laboratory facilities. For further information please contact Christine Van Such at 858-354-1895 or email: mahdavim3@gmail.com

SAN DIEGO OFFICE NEAR SHARP FOR SUBLEASE OR TO SHARE: Rady Children’s Hospital medical office building at 7910 Frost Street.

Central location near to both Rady Children’s Hospital and Sharp Memorial Hospital, between HWY 163 and I-805. Available to any specialty.

The space available includes access to one office, two exam rooms and a nurse’s station / common area desk. Be close to excellent referral sources in the building and from the hospital campus. If you have an interest or would like more information, please call (858) 278-8300 x.

2210 or email nhughes@synergysmg.com

OFFICE SPACE / REAL ESTATE AVAILABLE

MEDICAL OFFICE SUBLET DESIRED: Solo endocrinologist looking for updated bright office space in Encinitas or Carlsbad to share with another solo practitioner. Primary care, ENT, ob/ gyn would be compatible fields. I would ideally have one consultation room and one small exam room but I am flexible. If the consultation room was large enough I could have an exam table in the same room and forgo the separate exam room. I have two staff members that will need a small space to answer phones and complete tasks. Please contact (858) 633-6959.

UTC AREA MEDICAL OFFICE SPACE: 2,000 sq. ft. Recently renovated corner office space in La Jolla Medical & Surgical Center. 8929 University Center Lane. Beautiful building with ample free parking. One mile from UCSD Jacobs Health Center and Scripps Memorial Hospital.

Prime location. Competitive rent. Contact (858) 337-3768. Email Marcekramer@me.com OFFICE SPACE FOR MENTAL HEALTH PRACTITIONER: Available June 1st, 2021,

OFFICE SPACE / REAL ESTATE WANTED

MEDICAL EQUIPMENT / FURNITURE FOR SALE

MEDICAL EXAM TABLES FOR SALE: Unfortunately for us, we are unable to utilize our medical exam tables which are in great condition. Our practice is going in a different direction, thus the need for us to provide these tables, which were barely used. The tables are approximately 70 x 30 inches and have black padding on top of a natural pine wood frame. Each table adjusts up and has a headrest with a pillow included. We are interested in moving these out of our office as soon as possible, since we are remodeling and need the space to complete the project. We can provide a picture and schedule time to see the tables between 9am - 5pm M-Th, or 9am-2:00pm Friday. Price is negotiable and we are just looking for a reasonable donation for the tables. We can sell individually as well, but will provide a greater incentive for taking both. Please contact Rick at 619-795-6700 or email rick@manageyourage.com.

OBGYN RETIRING WITH OFFICE EQUIPMENT FOR DONATION: Retiring from practice and have the following office equipment for donation: speculums, biopsy equipment, lights, exam tables with electric outlets, etc. Please contact kristi. eisenhauermd@yahoo.com or (760) 753-8413.

MEDICAL EQUIPMENT FOR SALE: 2 Electric tables one midmark, 3 Ultrasounds including high resolution Samsung UG-HE60 with endovag and linear probes, STORTZ hysteroscopy equipment, 2 NOVASURE GENERATORS ,ENDOSEE OFFICE HYSTEROSCOPY EQUIPMENT : NEW MODEL, OLDER MODEL, Cynosure laser equipment:MONALISATOUCH (menopausal atrophy), TEMPSURE Vitalia RF (300 watts!) for incontinence, ENVI for face, Cynosure SculpSure with neck attachment for body contouring by warm sculpting. Please contact kristi.eisenhauermd@yahoo.com or 760-753-8413.

FOR SALE: Nuclear medicine equipment including Ge Millennium MG system, hot lab, and sources Cs-137. Rod Std 2. Cs-137. DCRS 3. Cs-137.

Spot 4. Co-57. Flood sheet. Please contact us at (760) 730-3536 if interested in purchasing, pricing or have any questions. Thank you.

NON-PHYSICIAN POSITIONS WANTED

MEDICAL OFFICE MANAGER/CONTRACTS/ BILLING PERSON: MD specialist leaving group practice, looking to reestablish solo private practice. Need assistance reactivating payer contracts, including Medicare. If you have that skill, contact ljmedoffice@yahoo.com. I’m looking for a project bid. Be prepared to discuss prior experience, your hourly charge, estimated hours involved. May lead to additional work.

SanDiegoPhysician.org 21

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