Educational Webinar: Magnitude of the Source: Pathogens from the Gut in the Fight Against Infections

Hello and welcome. This is Mary Beth Deneen from mckesson Medical Surgical. Today's webinar magnitude of the source pathogens from the gut in the fight against infections is being recorded to submit questions for our speaker. Please locate the Q and A panel in the lower left corner of your console. We are excited to welcome today's presenter, Marty Moore. Marty Moore is an award-winning health care executive with outstanding knowledge and skills in advancing research, implementation, science, cultural transformation and patient safety. She is a global presenter and author in addition to holding patents and trademarks for health care innovation and leadership models. Invite you to view our disclaimer here and with that, Marty, I'll turn it over to you. Thank you so much. So today we're gonna talk about magnitude of the source um and how pathogens from the gut are really the center stage in this fight against infections. Now, I'm your presenter and, and what wasn't shared with you is is that I've been a Chief Nursing Officer at a corporate uh system and a magnet facility level um for numerous years. And part of my work was really looking at reduction of catheter associated tract infections and copsy and surgical site infections and ventilator associated infections and, and all of those things that we have all been working on as part of our health care acquired infection calling to reduce. But one of the things is is that I had to start thinking about and looking at pathogens in a whole new way, which is what we're gonna be talking about here. So we're going to talk about the role the pathogens have in the gut and how they play into infectious diseases, including health care, acquired infections. And we're gonna look at how gut bacteria is really become the much more resistant and virulent. Additionally, we're gonna look at new strategies that have to be utilized to manage gut bacteria. And lastly, we're gonna talk about the role that P H plays and, and lipid production. You know, we say all the time that skin is the first line of defense and yet we do everything we can to strip that defense away. So we're gonna walk into that conversation and look at it a little bit more. Now, when you think of, of my microbes and, and bacteria and balance, we really have lived together for a very, very long time. It is only when one of those becomes opportunistic. So if you look at estimates there are between 30 trillion and 400 trillion microorganisms in the human gut, let's just kind of have that moment there between 30 trillion and 400 trillion micro organisms are in the human gut and from 3 to 100 times more bacteria in the gut than there are in any other cells in the human body. Now, why is there such a large distance between uh the uh between 30 and 400 trillion? Well, part of that is, is that we have really worked hard on understanding uh reflux and, and, and when we look at what we're doing with proton inhibitors or acid reducers, acid is an important part of the gut. And because of that, the changes that have happened within the acid environment has actually then led to kind of this change that we're seeing and this spread that we're seeing within the human gut. Now, we know that imbalances in the gut have been linked to a number of things. As a matter of fact, we know that the gut is seen now as the second brain of the body that if you don't have a healthy intestinal tract, you will have an immune system that is not as healthy as it can be. Um And that the gut really plays such a larger component into health and well-being than I think what we really had understood for a very long time. We know that imbalances in the gut have been linked to a number of health problems from obesity to even behavioral health and mental health issues with mood disorders. And, and as I've already talked about this altered immune response. One of the things is, is you've got to kind of step back and think about the immune system in many ways, is also the defense that the body has. And, and if it is restricted or, or has the inability to be as responsive as it possibly could be, then that actually then is setting um, somebody up for more introduction or, or possibly more severity of disease. And so it's just that, that critical connectiveness that has to happen around gut health and immune and the body's capabilities. So, you know, I I think of this as the quad and you know, the quad, when you, when you look at my microbial fitness, it is the ability of germs to survive and thrive. And what we know is is that uh microbial are becoming much more fit because they're becoming much more resistant. Additionally, that virulency that increased ability to infect and multiply is causing severity of illness and spread. And, and I'll talk about that in just a few seconds. When we look at this environmental persistence, the ability to withstand pressure that allows germs to thrive and survive in an environment or a host or a setting. And boy can is one that I that I'm gonna be talking about and it is just alarming. It's its capability to survive and thrive. And lastly, we is the in the, in the other part of the quad is, is the spread and we're seeing this increase ability to spread from person to person. As a matter of fact, one of the things that we're we're finding is is that this virulency and with some of the of these pathogens or capability of surviving outside of the intestinal tract on inanimate objects is very alarming. So, infections by the numbers. And I'm just gonna talk about urinary tract infections and catheter associated urinary tract infections. Um Today understand though that clay so uh central line associated blood stream infections um are very much, very much associated uh with gut back pathogens as as also surgical site. But I'm going to focus in and I want to hone in on urinary tract infections. And why is that because it is such a contributor uh to our health care costs? As a matter of fact, I think the statistics is, is $1.6 billion a year is attributed to urinary tract infections. We know it's the number one infection in health care. I think this data is incredibly conservative. Um But what we know about is is that it's estimated to cost an additional $13,500 plus. Uh if somebody contracts in a health care setting and then has been estimated to uh cost uh 34,600 plus dollars associated with the extension and care that's in the treatment that's there. I again, I think this is incredibly conservative and here's why because we're not able to capture what I call this upstream downstream kind of care that's needed after somebody contracts, um a catheter associated urinary tract infection or a central line associated bloodstream infection. And so, um when you look at kind of the, what the predictive modeling could be that 1.6 billion just associated with urinary tract infections multiplies substantially. Now, what we also know is is that 50% of all organisms infecting catheters and central lines are kind are gut related as a matter of, we're gonna dive deeper into that and that we found that most hospitals are using and, and by the way, hospitals and additionally, other health care settings such as long term care have now started to be using or are using C H G chloro heid and glutamate, but they cannot address it is contraindicated on the permiam. And so they're not able to decolonize the area of bacteria that causes urinary tract infections or cat uh catheter associated urinary tract infections. As a matter of fact, collapsing is one of the most definitely types of health care required infections with a high mortality rate of anywhere between 12 to 25%. If any of you have ever had a urinary tract infection, you will know that it is debilitating and it is painful. It is also the sixth most common cause of re admissions and admissions. We know that it's associated especially in the elderly with balls and other secondary issues. Um And we also know that it accounts for 30 to 60% of all antibiotics prescribed. We're in this struggle right now around antibiotic stewardship and yet we're having this battle around urinary tract infections. So, when we think about bacterial gut related infections, I really wanna dive a little bit deeper into this. We know the CV C has implicated 15 pathogens that account for 86% of healthcare associated infections. Let's, let's just hang with that for a minute. 15 pathogens that account for 86% of healthcare associated infections and out of that, what is considered opportunistic 11 are considered gut related. Well, when you break it up and you can look at the gut related pathogens. Almost 88% are the causation, gut related pathogens or the causation of Cody just under 50% of claps and just right at 50% for surgical site infections. But what are those pathogens? You know, I have this mental picture in my head of E coli holding up this sign saying I'm number one, I'm number one. And overall E coli is uh is the number one pathogen that causes infections, certainly associated with urinary tract infections and Cody. It's secondary uh it with surgical side infections and additionally, it's fifth with claps. Now, what's interesting is is that when you look at what is number one, it's staff, right? We, we know that and, and uh different strains, different species are number one and two associated uh with causation of central line associated bloodstream infections. But the number three is clea and we're gonna kind of dive a little bit deeper into that. Now, a long time ago, there was a uh talk show host, a late night talk show host that had his top 10. And so this is Marty Moore's top five most opportunistic gut pathogens. So we know that is number one, but not wanting to be left out is cilia and cilia is becoming much more of a foe when you're looking at urinary tract infections and Cody um because it's becoming much more resistant and virulent. So P A is uh number three endo coccus and pro is number four and five. When you look at causation of pathogens under uh Copsy Clay, as IRA indicated is number one, inter coccus is number two A or E coli is number three, but there's a, a fourth one that pops up and that is Candida al. Um And fungal infections are really becoming such a uh a focal point for us with Candida or, and I'm gonna touch on that because it is worrisome folks. It is incredibly worrisome and then number five for copy is end. So when you think about and, and you're starting to develop your kind of strategies on prevention, we have a tendency to assume that it's E coli um but don't do that. Um What I recommend is, is if, if you're battling an infection with, with somebody that you're caring for, do the culture in sens to identify what the causation is of the pathogen. What's its sensitivity? Because what we're seeing with clea is, is that it is resistance. And again, we're going to dive into that. All right. So, understanding opportunistic gut pathogens. Now, I, I'm sharing something with you about myself and that I love British Mysteries. Um And part of the reason that I love British Mysteries is, is because they write it in such a way that you, you look at and understand who your foe is and, and you study them. And so I started to ask the question, do I really know what I uh need to know about these pathogens? So we're gonna go kinda into this fun trip down pathogen lane if that's uh OK with you, and we're gonna explore what these pathogens are about what their contributions have been. But additionally, why you need to be aware of them. So we're gonna start with my friend E Coli. So, well, I don't think it's my friend, but uh I've known E Coli for a long time and I have uh taken care of, of individuals that have contracted um e coli and some of them incredibly sick. And so it is a foe to be aware of. It's a grand negative anaerobic rod shape spectrum. It's normally found in the intestines of humans and animals. One of the most um horrific cases of um septicaemia and, and toxicity that I ever saw uh was ingestion of, of some sort of, of food uh that was contaminated from probably fecal material of some uh manure that was used for fertilization. Um and was had not been properly cleansed or processed and this individual was incredibly sick. So, you know, most strains are harmless. Uh it is part of our healthy intestinal tract, but it also can become incredibly opportunistic. So some fun facts, something to share, you know, on a Friday night with your friends is is that this bacteria is the best or most studied free living organism. And I don't know if you knew this. I did not. It has a record of 11 prestigious nobel prizes associated with it. Now, there are 700 stereotypes of E coli that have been identified. Um It can grow with or without oxygen. That's the anaerobic that I just talked about. It causes infections by producing these toxins and how severe you are are sick or the individuals that you're caring uh for depends upon the type of E coli. Remember there's 700 stereotypes of E coli what makes E coli remarkably dangerous is, is it takes very low amount of it of the uh bacteria, this infectious bacteria uh to cause severity of illness and it is difficult to kill. Now, it has a use though. And the use is is that it can be used to make um human insulin, human growth factor Taxol and epidermal growth factor. Our most notorious, uh, strain or type is E coli oh 157 point H seven. Now, I don't know if I've ever looked at a lab, uh, value and it said, oh, this is E coli oh 157 H seven. Um, but it is important to know that there is more virulent strains than others when it comes to E coli, it is opportunistic and, and I know I've shared that with you so many times. But uh what we know is is that um it is responsible for 80% of urinary tract infections. When you look at septic cases, 47% of those are e coli you know, when you look at total septicaemia cases, 25% of septicaemia cases uh are euro sepsis and out of that 25% 47% the causation of the pathogen that caused the the illness is e coli we know it's associated with bloodstream infections. As a matter of fact, when E coli gets into the bloodstream, it is incredibly difficult to treat. It's becoming much more resistant to antibiotics. And there's now studies, emerging studies that are showing uh C H D resistance as well. So it is a foe to know it is a foe to understand. So, clea is another um and we have clea pneumonia which is a grand negative encapsulated kind of this lactose fermenting can an anaerobic rod shape, right? Um And we also know that it has two different uh strains or species. And Soleil oxy toca is a grand negative anaerobic tru that is closely related to I call it its cousin clea pneumonia. Multiple strains are associated with clay oxy. So what we're also seeing this is that um clea is becoming carbon pen and resistant or C R E and that it's actually the most common type of C R E in the United States. So what does that mean? It means that it's totally resistant to certain types of antibiotics? You know, we have used antibiotics as such a weapon against infectious disease. And now we're starting to run out of tools in our tool box box to be able to care for and properly treat. And cloy is one of them that's incredibly wor worrisome, by the way, E coli is also becoming C R E. There's some strains that are carbo resistant, which that also is worrisome. So interesting facts about SIA is, is that it first uh it was first named after Edwin Klebs. Uh He was a German microbiologist who was renowned for his extensive studies on infectious disease. It has a tendency to hang out in soil and water and can be on plants and some strains are considered to be part of the normal flora of the human G I track. Now, this fun fact is why you have to use your hand sanitizers when you take public transportation or you touch anything. So, uh, a study that was done in 2017 in London's Underground Victoria Line which uh if you, you know, if you've ever been there, it's called the tube. Um It found the following pneumonia. E Coli staph, uh Staphylococcus aus and pseudomonas. Those happy little pathogens, those wonderful opportunistic pathogens were just hanging out for others to touch and for them then to travel along on hands or other parts of the bodies. Um And so, it's just fascinating to think about the fact that these pathogens can survive in an adamant areas. Um and, and be willing to get to ride, as I like to say on other people's hands or part or parts of the body. Now, what we know about opportunistic is is that the term uh C R E that I talked about is associated with it. But here's what's really interesting. It is the most common type. Uh And at what's known as K PC in the United States. As a matter of fact, this invasive infection caused by C R E has been associated with this high mortality rate up to 50% in some studies. Um And so, when you're seeing this cilia that is, is C R E, uh you really do have limited capabilities to be able to treat. Um And that within itself has made up uh clea this opportunistic pathogen um that we have to have consciousness about. Now. Pseudomonas uh Argen is, is another one. And um you know, there was a point in my, a career that I was uh the uh director for Children's Services. And so I oversaw the pediatric intensive care units and the pediatric floors and we had a fibrosis uh unit and many times um those kiddos would come in with pseudomonas in their lungs. And, and what people don't know is is that pseudomonas, um AOA likes to live in water, soil and vegetation and that it's this common kind of gram negative rod shape bath. Now, what's interesting about pseudomonas is, is that pseudomonas means false unit. Aina refers to the blue green color of the like uh you'll see, you know, on the medium as you're growing it in the laboratory or the cultures of it. Now, additionally, Simonis has incredible resistance to antibiotics and common disinfectants um because they have this increased ability to remove the antibiotics from inside the cell and create this biofilm. As a matter of fact, with pseudomonas biofilm is absolutely one of the most worrisome things that, that when you're dealing with pseudomonas because think of it almost as this protective shield that it has uh designed for itself grown in the lab um on medium or a plates, uh monus uh eros has this really distinct smell. Um Some have said it's like corn tortillas or grapes or, or in the uh traditional English sweet uh pear drops. That has not been my experience dealing with pseudo bonus. Uh, but you know, my friends within lab say, yep, it has this sweet kind of interesting smell. And I was like, I don't think I'm putting my nose that close to it. So, anyhow, but Monus, uh, can be this incredible opportunistic foe when it is introduced into the urinary tract and, or the bloodstream. Certainly the lungs as well. Ah, here's our fun guy for him. So, Candida Alkins is what you have battled for ever. And Candis als is this opportunistic pathogen yeast that it, it's common member of the human gut fluoride's when the flora becomes imbalanced. Typically because of antibiotics or other diseases or illnesses. Um, it says move over friends. I'm a growing and boy does it, it's detected in the G I tract and mouse of almost 40 to 60% of healthy adults. Many of us have Candida applicants. Um, and really, and truthfully we were not aware, um, that we have it in our mouth and we have it in our G I track, um, until it becomes this opportunistic, uh, fun guy. So, some interesting facts about it. So, in 18 47 Charles Robin classified the fungus as Odom AINS using Albi which means to widen, to name the fungus causing thrush. I and why? I don't know, but it was reclassified under its current name in 1923 by doctor, uh Burkha typically. Um, it lives as a harmless fungi in our G I track and, and to some of us in our uh dental uh uh uh G uh not G I track, but our urinary track and it is found in over 70% of the population. So as I was just saying, it hangs out with us, but here's what's really interesting is, is that it takes on different forms. As a matter of fact, we're gonna talk about Candida auras and boy, is that a chameleon? Um when you're trying to identify it and Candida applicants is just the same, the main cause of infection with this fungi, as I already stated, was overuse of antibiotics. The longer and the more often that you take in the higher dose that you take, the greater the risk is of of this opportunistic fungi saying I'm moving in uh it forms this complex dynamic three dimensional structures that you know is is biofilm. And so it's able to colonize surfaces with and with this kind of protective shield. Hang on to that because when we talk about Candida a boy, it is amazing what that fungi can do. And so when we look and think about Candida, uh a, we have to um take into account that it is a boat that open the door uh with any antibiotic use or, or any changes in the, the normal flora of the G I track or, or the urinary track or kind of within the mouth with thrush. If you use any kind of steroid inhalers that changes that and it will have that um opportunistic moment uh of growth. Um And so it's one that we have to have this consciousness about but move over folks because Candida or does not want to be left out. So Candida or it, it's a cousin that's my way of saying to uh Candida al uh and it was first identified in 2009 in Japan. Now, retrospective reviews of this strain were able then to identify the is, it's actually back to 1996 in South Korea. Interesting enough. Uh several of the isolates were identified in a pediatric patient in blood samples. So it had entered in the bloodstream. The CDC considers uh Candida or as an emerging pathogen that is uh alarming. Um As a matter of fact, there's been press releases sent out has been in the nightly news, both national and local. There isn't uh a paper that hasn't run headlines about it. Um And, and, and into date, the only country that Candida or has not been identified um is Antarctica. So it's worth so, why is it because it is drug resistance on many of the anti fungal drugs that we use to treat. Candida Al does not touch this. Um Some strains are um resistant to all three available classes of antifungals. It's difficult to identify in standard labs, make sure that your lab has upgraded. There's a uh a special uh type of medium that uh needs to be grown on specifically designed for. Um if the right medium is used, it will present itself as kind of this white growth with this blue halo. Um But if you use uh what is normally used for candid uh uh like uh it will camouflage itself. It's a chameleon, it can be pink, it could be white, it could be purple. Um And so it many times is misidentified which then leads to inappropriate management and mistreatment. Um in trying to get this infection under control. It has caused outbreaks in the UK in the United States, in Venezuela, uh in South Africa and Colombia. And I can go on and on. Why has it caused these outbreaks because it develops a dry biofilm. Remember we talked about this shield. Um And what's happening is is that many of the common health care disinfectants that we are using doesn't touch, it doesn't penetrate this biofilm, this dry biofilm, this shield that it's able to produce. And additionally, um we can be carriers of it on our skin. Uh We know it likes to colonize itself in the nose or the nas loves under the armpits loves under breast, any skin folds in the groin. And what we know is is that we shed like 10 to the six power uh cells. And so we could be shedding Candida a it's hanging out on inanimate objects and then you're having spread. As a matter of fact, one of the uh outbreaks that occurred um was uh uh staff was colonized in their NAS and it then was populated, was colonizing on inanimate objects. And then it was just spreading because they were taking those inanimate objects in and out of, of individuals rooms. Um and they cause it had it caused this huge outbreak. And so Candida or is one that if you have not educated yourself, please do you need to put plans in place uh for prevention and containment strategies and then make sure that the labs that you are working with um are labs that uh are able to properly identify this particular species uh within the Candida family. So the first line of defense against gut pathogens, well, it's skin, you know, and we say that all the time and that skin is our first line of defense and then we pretty much make it uh kind of useless and, and I'm gonna talk about that. But what we also, what we know is that the stratum corneum is that powder layer and it is, it has to be healthy. It is that barrier and it is that production or protection, it has to have production of these lipids. And, and um we'll, we'll touch on that, but just to kind of step back and think about the Strat Corum is the layer that creates the ability for skin to be pliable, for skin to be hydrated, which helps those skin cells to be able to defend and stretch and, and respond. Um and additionally, when it is, is um not in its best condition, then those skin cells start to break open. And that's when you see uh micro fractions and additionally skin and breakdowns. So, you know, this outer layer is just like the shield that we have to give its due respect to. As a matter of fact, what we know about this outer layer is is that it needs a low acidic ph environment to help it uh to be as, as viable as it possibly can remember, I talked about those lipids. That's that mortar that provides that additional structural protection against invasion of pathogens. Um And that it also is this uh most uh critical weapon. It's this unrecognized weapon in this fight against infectious disease and yet pretty much we strip it. So most health systems, most, most health care places are decolonizing patients with uh chloroxine gluten or C H G. Um You again, I said it before, I'll say it again. It is conjure indicated in the per. Um And so you're unable to decolonize. Well, then if you're unable to use it there, I'm seeing people using soap and water. Well, I'm gonna hit on that as well because soap and water really does cause more harm um than good or what are, what are called P H neutral wipes. They do not decolonize the per and they strip away the skin's natural kind of antimicrobial defense uh mechanisms. And so when we're looking at, OK, how is it that we can get that fight? We've got to lean into P H? Now, I wanna walk you through this journey um uh that I have taken into understanding P H. Um And for me, I had to kind of step back for, first of all, um my chemistry when I did my undergraduate uh was painful. And so for me to kind of go OK, I've got a rethink about what I know about P H if uh it was important uh from it. So understanding the importance of P, what we know is the skin has to have this low acidic P H to produce lipids, these free fatty acids. Um and we know that they have this effective antimicrobial action. Well, when you look at at skin P, um I, I, I want you to kind of just pause for a moment if you've been doing other things. I want you to look up. I want you to kind of zero in. Um So look at the area that is kind of that greenish tone neutral P H is seven point oh, most of our tap water is 6.5 to 8.5. Right? And, and when we even look at our alcohol hand sanitizers, it's about 7.3. Now, I am a person who loves, loves smelly soaps. Well, they're alkaline, they on the average are nine point oh to 10 point oh. And actually some are even more alkaline. Why is this important? Because pathogens survive and thrive in a P H environment of six point oh or higher. Hang with that for a second. Soap and water P H of nine point oh to 10 point oh. Tap water is anywhere from 6.5 to 8.5. Our neutral wipes that we use are seven point oh. and yet pathogens bacteria we know thrive and survive at a P H of six point oh. Now, what's even interesting those of you that do wound care. What, what we know is is that when you move the P H from six, even down to 5.4, it allows 50% more oxygenation. Um and it allows the tissue closest to the wound to heal uh faster and better. So the ideal skin P H is 4.7 to 5 point oh, everything we do remember I was talking about that everything we do actually inhibits skin's capability to function and be that first line of defense. As a matter of fact, when we, when we look at the impact of urine and stool P H, um it actually ranges in that kind of 7.0 to 7.5 area. I I had it in my head as a nurse that it was acidic. Um But in truth, it's kind of this neutral. What happens is is when P H tilts individuals who are either urine or fecal incontinent or both, they create this substance which then alters this ph it elevates it on the skin surface and the substance these byproducts such as urea and pneumonia are both high in P H up to 9.5 and fecal material uh contains these enzymes which are extremely active in a high p environment. Remember that high P H is alkaline and they literally become digestive to human skin when in Contin conditions or fecal conditions are such in that they are left on the skin or it's not adequately cleansed or P H balanced back. Um What happens is is that this higher ph condition leads to this uh Degra in skin quality that we, we know as I I ad or incontinent associate dermatitis and additionally can lead to and I have seen folks incredible skin breakdowns, ulcerations in just these open wounds. But it is the alkaline conditions that create this environment for those enzymes um to be able then to become digestive to the human skin. So when we think about our practice, one of the things that we've got to do is is that we've got to rethink about it. We've got to expand peri care to include the biker shorts area. Um I love uh a novel topical that promotes a sustained P H of 4.7 to 5 point oh um and that sustain P H helps skin then to function at the level that it needs to, but it also creates this hostile environment uh to pathogens. And we've got to think about other areas of the body that are entry points for pathogens. And one of the things is, is as you're looking and thinking about kind of this biker short area, we have a tendency to focus in on the perry area or the perineum. Um And yet pathogens, we know love to travel to places uh on the upper thighs area and additionally on the face. Um and the clavicle area or pick areas. How do they travel? Well, they have, you know what I call frequent flyer miles on the hands uh because individuals will touch, they won't necessarily clean. Um And what we know is is that the hands are the highest modes of trans trans associated for pathogens. And so when we rethink our practice putting P H back at 4.7 to this five point oh this low acidic thinking about the biker short area. If you are concerned about candida, a use this low P H has it, it is, it's Achilles heel um under the arms under the breast in the growing area. Um You can use it in the nares. Um It's, it's compatible with mucosa um has a preventative strategy. And on the hands now, the thing is is that when you do this sustained hostile environment, it will wash off the soap and water. So you gotta reapply right um from it, but it's compatible with alcohol. Um So hand sanitizer. So think about how you can do this prevention strategy, creating this low acidic environment um against these pathogens. Um and kind of this hostile environment. I I I kind of I have this mental image of E coli holding its sign up saying I'm number one and there's a no vacancy sign placed out there. So what we know is is we've got to do a new strategy that um opportunistic gut pathogens will continue to become more aggressive and resistant and that skin integrity through this low acidic ph and this lipid production has to be the engagement and one of the top tools that we use in this fight with that. This is my most favorite quote in that small things start us in new ways of thinking. And for that, I wanna say thank you for your time. Um And this concludes the presentation. We're going to be going to questions and hopefully I'll have some answers. Thank you, Marty. As a reminder, you can submit your questions in the Q and A box and we have a few submitted here. All right. The first question we have is I have seen on the news, but so far we have not seen the case. How worried should we be about it? Uh That's a great question, you know. Um I, I if you are in certain states, uh California, Florida, it, it's pretty prevalent on the eastern seaboard, but we're seeing it march across the United States. Um So if you haven't seen a case, I am happy for you. But here's what I would say. Put your preparation in place now because what happens is, is when Candida or gets into a facility, uh it is hard to eradicate. And so think about that prevention strategy that I talked about, put that in place. Uh Now educate your team, educate yourself about this fungi. It doesn't play by the rules, folks, it doesn't play like we've seen other candida species uh play by. And so it is a foe that we have to take seriously. And the other reason that I'm stressing that is, is that, you know, initially what we were seeing with it is, is, is people were getting infected, but we weren't seeing high mortality, we're now seeing mortality. Um And it is, it is getting into the blood stream through the urinary tract through uh actually uh the respiratory track um direct entry in if you, you know, somebody has a central line um into the uh the bloodstream associated uh with that. And what we're now understanding and what we're now seeing is is that depending upon which species of the stream can be a a um some of them, there's no treatment except for the health and well-being of uh the immune system of the individual. And folks that's scary to me. Um And so I would encourage you to uh learn all you can about this, uh get tracker so that, you know, uh new research coming out, you can see it and, and be prepared, just be prepared. Got it. Thank you. The next question we have is it seems like germs are getting the upper hand in our fight against infections. What else can we do to fight back? You know, it's, it's interesting because uh I felt that way with SARS COVID two, I just felt like this is a virus that's just kicking art. And um I had to rethink how uh I was looking at and one of the things that, that I really started to think about and this is something for you also um to be working on and thinking about is, is when we talk about prevention, we have a tendency to talk about it through cleaning disinfectant. Um And you know, I, I touched and I, we talked about this P H. Um And what's fascinating about this uh low acidic P H is, is our colleagues in dermatology and cosmetology are so much farther ahead of us and that they understand that this acid mantle has to be part of skin capability of being uh defensive and also anti aging um from it. So look at your practice, look at what you're doing. Um Are you stripping P H? Uh and, and you know, stripping the skin and then high uh elevating P H. So what part can you be doing with that? Additionally, one of the things that um I always think about is, is what I call the human air factor, human beings because of our strengths and our limitations are going to forget to wash our hands, are going to forget um to, you know, not touch our face or will go in quickly and we'll take care of something in somebody's room and, and you know, we, we think we're, we're gonna go and hand sanitizer and then somebody calls us and, and boom, there it is um from it. So look at your work flow, look at your air exchange, uh make sure that you have the recommended air exchange. But then also think about how can I create the shield of protection this hostile environment on skin for both those that we care for and our employees on our hands on our face um and on our bodies. Um and look at that as I, I look at that as this first layer of P pe. Um and that's how I approached SARS COVID two in the work that I was doing across the nation. And that's my recommendation associated with these pathogens and certainly with Candido. Got it. Thank you, Marty. It seems like those are the only questions we have. Um So with that, I will say thank you to the audience for attending today's webinar. Please take a moment to review our disclaimers and we also invite you to view our upcoming webinars by visiting M MS dot dot com slash educational dash webinars. And in closing, I'd once again like to thank Marty for sharing her expertise with us today and all of you for attending. Have a great day.