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Top Tips for Acing Fellowship Interviews

It is July, and fellowship application season is upon us once again. Watch the UNMC ID blog in the coming weeks for fellowship application content. We begin with a practical guide to fellowship interviews. If you know someone gearing up for this important step, please share this post. A refresher on these skills can always be useful!

Multiple ID faculty contributed to this list, and thus, the credit goes to the entire UNMC Division.

As faculty, we have the amazing opportunity to both mentor and interview residents applying for fellowship in Infectious Diseases, and we have seen it all. From the great, well-prepared interviewee to the one who had the institutional information completely incorrect. We wish we could mentor every resident in person, but since that is not possible, we decided to do the next best thing and offer our tips and tricks to acing the ID (or any other) interview! Tips and tricks are in no particular order. 

  • Be yourself and relax.
  • Articulate why you are interested in this fellowship program, what your ID interests are and where you think you would like your career to go (even if you acknowledge that might change or be a little vague at this time).
  • Have an idea of how the program works and ask specific questions to help deepen that knowledge regarding the education you will receive. What are the strengths, weakness and unique aspects of the program you want to know more about?
  • Remember that you are interviewing the fellowship program as much as they are interviewing you. Do your research and come prepared with questions about everything from how the fellowship will prepare you for your career as an ID physician to where you will park.
    • Need suggestions on how to curate your list of questions?
      • Look up the program and Division on their website.
      • It is helpful to know a little about the faculty you are interviewing with, so if you get a schedule ahead of time find out what their clinical/research interests are and ask them about it – you can check out their publications on PubMed or Google Scholar to focus questions on specific topics.  If you don’t get a schedule ahead of time, ask them what their interests are or what their role is during your interview.
      •  Formulate questions important to you about the program, the institution and the local area regarding resources, lifestyle and more.
  • Be prepared to talk about your successes and the challenges you have encountered. For example, if you have an unexpected break in training, use that as example to illustrate what you learned from that experience. We do not expect perfection, but value honesty and clarity.
  • If you have something on your application that might be viewed negatively (academic difficulties, etc.) take the initiative and explain how you have overcome it and why you are a good candidate now before we have to ask you about it.
  • Consider a “highlight” reel handout for faculty on an updates to your CV since you submitted your application in ERAS. This can be incredibly beneficial if you have had a new publication, presentation or other activities demonstrating your interest in ID and future potential as a fellow.
  • Be friendly and treat everyone, including program coordinators and other office personnel kindly and with respect. Your interview starts from the moment some first meets you (a current fellow, administrative assistant or staff) and ends when you say goodbye to the last person. ALL opinions count. If you are rude to anyone, trust us, we will find out.
  • Be truthful and be yourself. Don’t answer questions with what you think the interviewer wants to hear (e.g. don’t say you want to do academic medicine if you are interested in private practice). This is the only way for both you and the program to determine whether or not you are truly a good fit.
  • Tell us something interesting about yourself, even if it doesn’t relate to ID.  It is important to be well-rounded, and hearing about hobbies, experiences and interests helps keep the interview conversation fun and flowing.
  • Thank the faculty for their time; the emails and cards with a personal comment regarding a specific detail of the interview are both appreciated and noticed.

PharmtoExamTable (Part 2): Why should sulfamethoxazole/trimethoprim (Bactrim) be used with caution in patients with renal impairment or those on dialysis?

This #PharmToExamTable post was authored by Eric Hiatt, PharmD Candidate (2025) at the UNMC College of Pharmacy, and explores Bactrim’s use in those with impaired renal function.

(Content reviewed by Jenna Preusker, PharmD, BCPS, BCIDP)

Recall from Part 1:

Impact of sulfamethoxazole/trimethoprim on Renal FunctionIn patients with renal impairment, administration of sulfamethoxazole/trimethoprim has been shown to have a significant incidence of acute kidney injury (AKI) 
Mechanism of sulfamethoxazole/trimethoprim-Induced AKISulfamethoxazole’s metabolite, N-acetyl-sulfamethoxazole (NASM), may form crystalline structures in acidic urine, causing renal damage in the form of AKI.

In addition to increased risk of AKI, patients with renal impairment are more likely to experience electrolyte abnormalities while taking sulfamethoxazole/trimethoprim, particularly hyperkalemia and hyponatremia. The electrolyte abnormalities are believed to be attributed to the trimethoprim component of sulfamethoxazole/trimethoprim through an amiloride-like effect.4,5 Trimethoprim is structurally like amiloride, a diuretic known to retain potassium and excrete sodium in the kidneys. Furthermore, trimethoprim has been shown to inhibit the same sodium transport channels that amiloride inhibits reversibly. In animal studies, intravenous trimethoprim was shown to decrease potassium and increase sodium urinary excretion by 40% and 46%, respectively.4 These electrolyte abnormalities are reported to be more common with high doses of sulfamethoxazole/trimethoprim in non-renally impaired patients indicating these effects are dose dependent.5

In patients with renal impairment, sulfamethoxazole/trimethoprim can accumulate, resulting in common daily doses causing these electrolyte abnormalities.5 In the case of sulfamethoxazole/trimethoprim, both drugs are primarily eliminated through the kidneys causing accumulation in renal impairment. In severe renal impairment, the half-life of both drugs can significantly increase from 11 and 9 hours each to 45-60 hours. The recommended dose adjustment to prevent accumulation of sulfamethoxazole/trimethoprim occurs when the patient’s creatinine clearance is <30 ml/min.6

CrClDose
CrCl < 30 ml/minStandard dose
CrCl 15-30 ml/minReduce dose by half
CrCl < 15 ml/minUse not recommended 
The FDA recommendations for the adjustment of sulfamethoxazole/trimethoprim based on renal impairment

Notably, the FDA does not recommend sulfamethoxazole/trimethoprim use in patients with CrCl < 15 ml/min; however, it may be the only option available. 

CrClDose
CrCl < 30 ml/minStandard dose
CrCl 15-30 ml/minReduce dose by half
CrCl < 15 ml/minCrCl <15: Adjust to 25-50% of the total daily dose for indication. Use caution and monitor.
HemodialysisDose as CrCl < 15 ml/min, administer after HD on dialysis days 
Nebraska Medicine renal dose adjustment guidelines7

Alternative dosing based on type of dialysis based off the trimethoprim component:

Dialysis Trimethoprim Based Dose IV
Hemodialysis2.5-5 mg/kg every 12 hours; administered after hemodialysis
CVVH2.5-7.5 mg/kg every 12 hours
CVVHD4-5 mg/kg every 6-8 hours
CVVHDF4-5 mg/kg every 6-8 hours
Alternative Dialysis regimens8

Final Take Home Points:

Impact of sulfamethoxazole/trimethoprim on Renal FunctionIn patients with renal impairment, administration of sulfamethoxazole/trimethoprim has been shown to have a significant incidence of acute kidney injury (AKI) 
Mechanism of sulfamethoxazole/trimethoprim-Induced AKISulfamethoxazole’s metabolite, N-acetyl-sulfamethoxazole (NASM), may form crystalline structures in acidic urine, causing renal damage in the form of AKI.
Electrolyte Abnormalities from sulfamethoxazole/trimethoprimPatients with renal impairment on sulfamethoxazole/trimethoprim may develop hyperkalemia and hyponatremia due to trimethoprim’s effect on sodium and potassium transport. These effects are dose-dependent and more likely in patients with impaired renal function due to drug accumulation.
Dosing Adjustments in Renal ImpairmentSulfamethoxazole/trimethoprim’s elimination is primarily renal, with a prolonged half-life in severe renal impairment. FDA dosing adjustments based on CrCl levels: CrCl >30 mL/min: standard dose, CrCl 15-30 mL/min: reduce dose by half, CrCl <15 mL/min: use not recommended, but may be necessary

References:

1. Fraser TN, Avellaneda AA, Graviss EA, et al. Acute kidney injury associated with trimethoprim/sulfamethoxazole. Journal of Antimicrobial Chemotherapy, 2012; 67(5), 1271–1277. https://doi.org/10.1093/jac/dks030

2. Azencot R, Saint-Jacques C, Haymann JP, et al. Sulfamethoxazole-induced crystal nephropathy: Characterization and prognosis in a case series. Scientific Reports, 2024; 14, 6078. https://doi.org/10.1038/s41598-024-56322-9

3. Perazella MA. Crystal-induced acute renal failure. The American Journal of Medicine, 1999; 106(4), 459–465. https://doi.org/10.1016/S0002-9343(99)00041-8

4. Perazella MA. Trimethoprim-Induced Hyperkalaemia. Drug Safety, 2000; 22(3), 227–236. https://doi.org/10.2165/00002018-200022030-00006

5. Mori H, Kuroda Y, Imamura S, et al. Hyponatremia and/or Hyperkalemia in Patients Treated with the Standard Dose of Trimethoprim-sulfamethoxazole. Internal Medicine, 2003; 42(8), 665–669. https://doi.org/10.2169/internalmedicine.42.665

6. Patel RB, Welling PG. Clinical Pharmacokinetics of Co-trimoxazole (trimethoprim-sulphamethoxazole). Clinical Pharmacokinetics, 1980; 5(5), 405–423. https://doi.org/10.2165/00003088-198005050-00001

7. Nebraska Medicine renal guidelines for antibiotics. Accessed May 2024. https://www.unmc.edu/intmed/_documents/id/asp/dose-nm-anti-infective-renal-dosing-guidelines.pdf

8. Golightly LK, Teitelbaum I, Kiser, TH, et al. Renal Pharmacotherapy: Dosage Adjustment of Medications Eliminated by the Kidneys. Springer New York; 2013. https://doi.org/10.1007/978-1-4614-5800-5

National HIV Testing Day: Let’s Stop HIV Together

Content provided by Dr. Sara H. Bares, MD, FIDSA Associate Professor, Division of Infectious Diseases | Let’s Stop HIV Together Clinical Ambassador

National HIV Testing Day (NHTD) was first observed in the United States on June 27, 1995, and has been observed every year since.  Although much progress has been made in the last 29 years, we have a long way to go to successfully end the HIV epidemic. Currently, one in seven people with HIV (14%) are unaware of their status and thus at risk for disease progression and transmission to others.

This year’s NHTD theme is “Level up your self-love: check your status,” an important message that aims to emphasize the ways in which knowing our HIV status enables us to maximize our health. People who test negative for HIV can be offered HIV prevention tools such as pre-exposure prophylaxis (PrEP) and people who test positive for HIV can start antiretroviral therapy (ART) to stay healthy. HIV testing is widely available and can be accessed via Nebraska Medicine as well as community partners such as Nebraska AIDS Project, OneWorld Community Health Centers, North Omaha Area Health clinic, Charles Drew Health Center and the Douglas County Health Department. For those unable to travel to a testing site or who would like anonymity, self-testing kits such as the Together TakeMeHome kits are available at no cost.

While this year’s theme aims to empower community members to get tested for HIV as a form of self-care, I hereby call on providers to “level up” their game and screen all patients between the ages of 13 and 64 at least once during any medical encounter (and annually if they have ongoing risk factors). Nebraska is far behind the national testing goal (only 26% of adults living in Nebraska had ever had an HIV test as of 2022) but, together, we can change this.

I am proud to share that our partners in the University of Nebraska Medical Center’s Emergency Department are now offering HIV tests along with other STI testing and we look forward to expanded testing throughout our hospital and medical center as we all work towards the goal of ending the HIV epidemic together.

tH SH w

PharmtoExamTable (Part 1): Why should sulfamethoxazole/trimethoprim (Bactrim) be used with caution in patients with renal impairment or those on dialysis?

This #PharmToExamTable post was authored by Eric Hiatt, PharmD Candidate (2025) at the UNMC College of Pharmacy, and explores Bactrim’s use in those with impaired renal function.

(Content reviewed by Jenna Preusker, PharmD, BCPS, BCIDP)

In the world of antimicrobial stewardship, finding the right antibiotic for definite therapy against a bacterial infection can be the difference between life and death. Bacterial resistance has emerged with the use and misuse of antibiotics. The result leads to dwindling options and reliance on less-than-ideal antibiotics for specific populations. An example is sulfamethoxazole/trimethoprim in populations with renal impairment or those on dialysis. 

A meta-analysis explored the adverse renal effects of sulfamethoxazole/trimethoprim and included patients who initially received their first dose in the hospital. The study included 573 patients, of which 64 (11%) developed an AKI. Out of the 64 with AKI, the authors noted a significantly higher percentage of patients had pre-existing chronic kidney disease. The inclusion criteria itself has a limitation; with or without sulfamethoxazole/trimethoprim, many hospitalized patients are likely to develop an AKI. To control this limitation, the authors included a comparator group with similar characteristics but who were administered clindamycin instead due to no known AKI-associated events with clindamycin. The clindamycin group consisted of 84 patients, of which none developed an AKI, with only 3 having an increase in serum creatinine and no increase in BUN. The study concluded that since there were patients who developed AKI even with no other known risk factors for renal impairment, sulfamethoxazole/trimethoprim was suggested to be an independent risk factor for AKI.1

Image 1: Example of the crystalline structure form in the urine by NASM

In 2024, a case series of 14 patients investigated whether sulfamethoxazole-induced crystalline structures result in AKI. The crystalline structure results from sulfamethoxazole’s metabolite N-acetyl-sulfamethoxazole (NASM). NASM has been observed to form a crystalline structure in acidic urine, potentially causing renal damage resulting in an AKI. The authors concluded that patients with sulfamethoxazole-induced crystalline nephropathy developed an AKI. They also noted that individuals at risk for crystalline structures forming from NASM include patients who have hypovolemia, hypoalbuminemia, acidic urine, high concentrations of sulfamethoxazole/trimethoprim and NASM in urine, and chronic kidney disease.2

In hospitalized patients, providers can avoid crystallization by giving intravenous normal saline for hydration and promoting diuresis with an agent like a loop diuretic. Another way would be to ensure the pH of the urine is basic (pH > 7.15), as it would increase sulfamethoxazole solubility in the urine, preventing further crystallization. If needed, sodium bicarbonate can be administered to increase urine pH. Additionally, clinicians should monitor the estimated glomerular filtration rate and monitor urine for crystalluria. In acute renal failure resulting from sulfamethoxazole/trimethoprim, the first step is to discontinue it and administer fluids to ensure the patient is euvolemic, followed by diuresis to clear any obstructing crystals within the kidney. If needed, sulfamethoxazole/trimethoprim can also be removed through dialysis.3

To be continued in Part 2 soon!

References:

1. Fraser TN, Avellaneda AA, Graviss EA, et al. Acute kidney injury associated with trimethoprim/sulfamethoxazole. Journal of Antimicrobial Chemotherapy, 2012; 67(5), 1271–1277. https://doi.org/10.1093/jac/dks030

2. Azencot R, Saint-Jacques C, Haymann JP, et al. Sulfamethoxazole-induced crystal nephropathy: Characterization and prognosis in a case series. Scientific Reports, 2024; 14, 6078. https://doi.org/10.1038/s41598-024-56322-9

3. Perazella MA. Crystal-induced acute renal failure. The American Journal of Medicine, 1999; 106(4), 459–465. https://doi.org/10.1016/S0002-9343(99)00041-8

UNMC ID Wins Internal Medicine Residency’s Best Teaching Division Award!

We are proud to announce that, earlier this month, UNMC ID was awarded the Best Teaching Division among all 12 Divisions of UNMC’s Department of Internal Medicine for this academic year! This is a huge honor for UNMC ID, which is voted on by current IM residents and awarded at the annual IM residency graduation celebration.

Dr. Jasmine Marcelin (pictured left) accepted the award on the Division’s behalf, commenting, “Thanks to all our faculty and fellows for your exceptional teaching of our residents!”

Dr. Trevor VanSchooneveld, Director of the ID Fellowship Program and Core Faculty for the Internal Medicine Residency, echoed that sentiment, saying, “The ID Division is exceedingly pleased to receive this award, and the ID faculty deserve the credit for their above and beyond effort to educate and mentor trainees.”

Dr. Andre Kalil also praised the achievement, stating, “Truly an amazing Division accomplishment that will certainly translate into more interest in following an infectious disease career.”

Lastly, Dr. Mark Rupp, Chief of the Division of Infectious Diseases, also commended the award and the work of the UNMC ID community towards training our great IM residents in ID- “What a great recognition of the effort that so many make to contribute to the positive educational environment in the Division.  Great job, team!”

Great job team, indeed! A huge thanks to all our faculty, fellows, APPs, staff, and all others who assist in making resident education a great experience for all!

UNMC Specialty Care Clinic Presents Work at National HIV Conference

Lance (middle) and the two other co-presenters of work on HIV Telehealth Care


Back in March, we ran this Sneak Peak post announcing that Lance L. Burwell, LIMHP, PC, behavioral therapist at the UNMC SCC, was invited to co-present an ongoing project titled “Bridging HIV Care Gaps through Telehealth: An Evidence-Informed Intervention to Support Engagement in Care” at the 2024 National Conference on Social Work and HIV/AIDS. This is a huge honor, and we congratulate Lance on a fantastic presentation and commitment to a project that has improved care for many SCC patients. Read below for Lance’s recap of the presentation and the impact of this important work.

I attended the 2024 National Conference on Social Work and HIV/AIDS and co-presented with the lead presenter Masil Miranda, MSW, a Program Manager from AIDS United, along with Clover C. Cambell-Woods, MA, PsyD, from Georgia Harm Reduction Coalition.  We presented the intervention we have been implementing- “Bridging HIV Care Gaps through Telehealth: An Evidence-Informed Intervention to Support Engagement in Care.” 

The goal of Intervention to Telehealth and Text to Improve Engagement in Care (i2TEC) is to increase engagement in HIV care and viral suppression for people with HIV by raising understanding of the intersection between mental health, substance use, and HIV care.  The hope is that this intervention will reduce or eliminate barriers to care, such as transportation, stigma, and insecurities related to food, income/finances, and housing, not only by connecting people with resources but also by providing an alternative that allows patients to improve their own engagement in their healthcare.  The telehealth option allows patients to participate remotely, thereby minimizing attendance concerns related to transportation and stigma while also increasing patient awareness of how their mental health, substance use, and/or HIV knowledge impacts their treatment, the outcomes, and their overall health, wellness, and life satisfaction.

My portion of the presentation provided information on how our site implemented the intervention, the staff involved, the challenges we faced, and the successes we experienced to date.  Our site demonstrated that, in spite of typical challenges of patient outreach & enrollment, technology, and sustainability concerns, the implementation was hugely successful. Not only were we able to meet patient enrollment goals and integrate them into the clinic using existing staff and technology, but we also provided resources & referrals to patients who utilized these to further reduce barriers and improve health, wellness, and life satisfaction.  More importantly, however, the intervention decreased the stigma associated with mental health counseling as many of those previously hesitant to pursue therapy transitioned into ongoing therapy upon completion of their 12 sessions.  Our site experience demonstrates the ease of implementing an intervention in an existing clinic while providing a valuable option for patients that reduces barriers to care.  This translates to improved treatment consistency and adherence while also providing needed resources to patients, thereby furthering goals of minimizing transmission and improving patient quality of life. 

–Lance L. Burwell, LIMHP, PC

Research Digest: The Practice of ID

Research Digest is a periodic installment that recognizes the world-class clinical research performed right here at UNMC ID. Today, we review three articles covering new developments regarding advancements in how ID professionals practice. As always, check out the linked full articles for more details.

Dr. Cawcutt, author of a recent paper of HIAs

In the first article, authored by Dr. Kelly Cawcutt and others, the authors address how surveillance for healthcare-associated infections (HIAs) is performed in the medical system. Great strides have been made toward efficient and timely monitoring of invasive device-associated infections that arise from things like central lines, ventilators, and catheters. This has enabled the medical community to recognize spikes in infection rates and adjust recommended practices to keep patients safe and devices sterile. However, these devices are not the only nidus that can cause infection in a healthcare environment. Alternative devices, as well as non-ventilator hospital-acquired pneumonia and infectious complications from other conditions, can all increase the risk of HAI. Therefore, the authors discuss alternative performance metrics that can provide a more comprehensive picture of the HAI landscape and identify a wider range of infections that may require systematic intervention. Read the full details here.

Dr. Lawler, co-author on this paper addressing PPI

The second article, written by many from the UNMC community including Sara Donovan and Dr. James Lawler, identifies a core need in the ID community as we face increasing rates of high-consequence infectious disease events; safe and effective donning and doffing protocols for personal protective equipment (PPI). Utilizing knowledge from an exhaustive literature review as well as their own expertise as experts in ID and PPI use, the authors identified a set of cardinal rules to keep in mind when dealing with PPI. While they note that these rules are not all-encompassing, these rules serve as a great starting point and refresher for any who would need it. Read the full text here.

Dr. Van Schooneveld, co-author on a recent paper exploring ID fellowship training

In the final article, authored by Dr. Trevor Van Schooneveld and others, considerations for ID fellowship training are explored. Training ID fellows unavoidably involves a balance between delivering great patient care and managing a high caseload while also protecting the educational environment for trainees. Recently, consult volume has been identified as an area of concern, which has a large effect on the educational environment. To characterize this concern, the authors performed a survey of ID fellowship programs in the United States to assess consult volume trends and any mitigation strategies implemented. This effort was able to quantitatively describe ID program daily new consult and total census rates, which rose as high as 12 and 30, respectively. It also identified shared strategies used to protect trainees and other ID professionals from burnout. The authors conclude that “as we navigate the challenges posed by the consultation surge, it is crucial to strike a balance between ensuring quality patient care, preserving educational opportunities, and safeguarding the well-being of both faculty and fellows.” Read the full article here.

Specialty Care Clinic HIV Team to Share Work at National Conferences

A huge congratulations to our Specialty Care Clinic (SCC) HIV team, who have been hard at work implementing quality improvement programs and clinic implementation efforts and will be sharing updates on their accomplishments with the national ID community throughout the summer. The team will be represented at no less than 6 conferences this summer, with 12 abstracts currently accepted for presentation. We are proud of our SCC team for many reasons, among them their tireless effort to improve the quality and implementation of care for their patients. See below for the details of those who will be sharing their work this summer, and keep an eye on this blog throughout the summer for updates and summaries from presenters. Congratulations, SCC team!

Professional Association of Social Workers in HIV/AIDS Conference in Orlando, FL, May 2024:

Bridging HIV Care Gaps through Telehealth: An Evidence-Informed Intervention to Support Engagement in Care (Miranda, M; Burwell, L; et al)

SYNC2024 in Alexandria, VA, in May 2024:

RWHAP Best Practices Compilation: Sharing Successes in Telehealth and Addressing STIs (Hook, J; Flaherty Dore, K; Regan, N; Nelson, J.)

IAPAC Continuum Conference in Puerto Rico in June 2024:

Determining Capacity and Desire for Age-Friendly Healthcare at a Midwest HIV Clinic (Regan, Essam Nkodo, Fadul, along with colleagues from geriatrics: Jenkins and Porter)

Medicaid insurance expansion and its association with HIV outcomes in Nebraska, USA: An observational prospective cohort study (Essam Nkodo, Arroyo, Fadul, Furl, Lyden)

Data-driven Strategies Towards Case Management Utilizing Tableau Dashboard Reporting and Automation (Glassman, Arroyo, Jones, Fadul)

Leveraging Implementation Science to Address HIV Disparities (Fadul, Essam Nkodo, Furl, Regan)

25th AIDS 2024 Conference in Munich, Germany, in July 2024:

Medicaid insurance expansion and its association with HIV outcomes in Nebraska, USA: An observational prospective cohort study (Essam Nkodo, Arroyo, Fadul, Furl, Lyden)

Ryan White National Conference in D.C. in August 2024:

Bridging the Gap: Multi-Specialty Collaboration to Bring Age-Friendly Care to a HIV Clinic (Regan, Essam Nkodo, Fadul, along with colleagues from geriatrics: Jenkins and Porter)

Telehealth 2.0: Revitalizing a Previously Successful Telehealth Program with Updated Process Mapping (Regan, Cramer, along with colleague from Ohia Advisors: Wetherhold)

Screening is Believing: Increasing Depression Screening in a HIV Primary Care Clinic (Regan, Arroyo, Burwell, Furl)

Data-driven Strategies Towards Case Management Utilizing Tableau Dashboard Reporting and Automation (Glassman, Arroyo, Jones, Fadul)

GLMA as WORKSHOP in Sept/Oct 2024 in Charlotte, NC:

Meeting them where they’re at: Implementing telehealth services in a HIV clinic to increase LGBTQ+ patient engagement (Cramer, Carr, Burwell, Regan)

Updated Antibiotic Guidance for Skin and Soft Tissue Infections and Diabetes-Related Foot Infections

This post was researched and written by Dr. Jonathan Ryder, Assistant Professor and previous UNMC ID Fellow. Dr. Ryder is also Associate Medical Director of the Nebraska Medicine Antimicrobial Stewardship Program and Associate Hospital Epidemiologist. Here, Dr. Ryder shares key changes the Antimicrobial Stewardship Program has recently made in guidance on the treatment of SSTIs.

The Nebraska Medicine Antimicrobial Stewardship Program has published updated local guidance on the management of patients with skin and soft tissue infections (SSTI) and diabetes-related foot infections (DFI). This includes conditions such as non-purulent cellulitis, abscesses, necrotizing skin soft tissue infections, and bite wounds. These changes are due to new 2023 IDSA guidelines on the management of diabetes-related foot infections as well as updates in the microbiology for these infections since the 2014 IDSA guidelines for SSTI.

In this post, we highlight the key changes we have made to our guidance and the rationale behind these changes.

So Long to Clindamycin

Two of the most common pathogens for SSTI and DFI are beta-hemolytic Streptococci (including group A Streptococci [GAS] and group B Streptococci [GBS]) and Staphylococcus aureus. Unfortunately, resistance to clindamycin is rising significantly in these pathogens. Per surveillance data from the Centers for Disease Control, resistance to clindamycin was found in 34.4% of invasive GAS and 51.4% of invasive GBS.1 For Staphylococcus aureus, our 2024 antibiogram shows over 25% resistance to clindamycin.2 Given these high rates of resistance to clindamycin, clindamycin is no longer recommended for empiric treatment of SSTIs or DFI. 

However, there are other reasons why clindamycin has fallen out of favor. Clindamycin is associated with high rates of adverse effects, in particular gastrointestinal side effects in over 20%.3 Specifically, antibiotic-associated diarrhea is found in over 13% of patients.3 Clindamycin is also associated with the highest risk of Clostridioides difficile infection (CDI) compared to other antibiotics, with one study demonstrating 25 times higher odds of CDI when receiving clindamycin.4,5 Clindamycin is also dosed 3-4 times per day, which can make adherence challenging for patients. In a systematic review assessing adherence to therapy, 3-times-daily dosing was associated with only 65% adherence, while 4-times-daily was 51%.6 Thus, clindamycin is also a poor choice for SSTI and DFI given its high rate of adverse events and poor adherence to therapy. 

But What about Patients with Penicillin Allergies?

Clindamycin has frequently been used as an alternative choice in patients with penicillin allergies; however, a better understanding of antibiotic allergies provides more alternatives. New guidelines for management of antibiotic allergies were released in 2022.7 In collaboration with our allergy experts, local guidance for management of penicillin allergy and other beta-lactam allergy were developed. Within the new SSTI and DFI guidance, penicillin allergy guidance is provided for each scenario. Reference to these documents is helpful for finding alternative regimens. Generally speaking, even in the presence of a severe IgE-mediated penicillin allergy (e.g., anaphylaxis), first-line regimens for cellulitis, such as intravenous cefazolin, can still be used.

Alternative Options Exist with Increased Accessibility

Other options for patients with beta-lactam allergy include trimethoprim-sulfamethoxazole (TMP-SMX) and linezolid. Historically, TMP-SMX has been avoided in non-purulent SSTI due to concerns about high rates of resistance to TMP-SMX in GAS. However, this concern about resistance has been found to be a myth .8 Older studies found high rates of resistance to TMP-SMX in vitro as a result of methodologic problems. After these problems were corrected, TMP-SMX susceptibility rates were very high for GAS. In clinical studies, TMP-SMX has performed well in the treatment of SSTI.9 TMP-SMX has been a preferred alternative when allergy precludes first-line regimens.

Linezolid has excellent Staphylococcal and Streptococcal activity, but concerns have existed regarding cost and serotonin syndrome. Fortunately, the price of linezolid has decreased substantially, although there can be variation between outpatient pharmacies on price (ensuring patients can access the drug at a lower price is key for prescribing linezolid outpatient).10 Regarding serotonin syndrome, the risk for this adverse event in patients receiving linezolid is exceedingly low, even in patients on selective serotonin reuptake inhibitors.8 In patients with serious infections, a careful weighing of risks/benefits is warranted. Regardless, linezolid remains a much safer and more effective option compared to clindamycin, especially as an alternative agent in patients with severe penicillin allergies.

Changes in Management of Necrotizing Soft Tissue Infection

Another common indication for clindamycin has been adjunctive antitoxin therapy for necrotizing soft tissue infections due to GAS or Clostridium species. However, there has been debate about whether clindamycin should be replaced by linezolid, which has similar in vitro antitoxin activity.11 The crux of this debate involves the increasing GAS resistance to clindamycin, a lower risk of CDI with linezolid, and replacing empiric vancomycin (and its associated risk of acute kidney injury) with linezolid. Since publishing this debate, two small retrospective studies have demonstrated linezolid and clindamycin have similar efficacy, but replacing clindamycin (and vancomycin) with linezolid reduced a composite risk of death, CDI, and acute kidney injury in one of these studies.12,13 Another study found a lower risk of acute kidney injury with this switch as well.14

Shorter is Better

The new guidance documents include updated antibiotic durations. For non-purulent cellulitis, antibiotic durations of 5-6 days are now the standard.15 For necrotizing soft tissue infections without concurrent bacteremia or cellulitis, antibiotic therapy can likely be stopped within 48 hours of the final debridement.16 Several changes in duration for DFI have also been incorporated from the 2023 IDSA guidance.

Conclusion

The management of patients with SSTI and DFI is changing due to increasing resistance, myth busting, and improved understanding of antibiotic allergies. Our updated guidance accounts for these changes by moving away from clindamycin, recommending more linezolid and TMP-SMX use, and shortening antibiotic durations.

References

  1. US Centers for Disease Control and Prevention. ABCs Bact Facts Interactive Data Dashboard. Accessed May 3, 2024, 2024. https://www.cdc.gov/abcs/bact-facts-interactive-dashboard.html
  2. Nebraska Medicine Antimicrobial Stewardship Program. Antibiograms. Accessed May 3, 2024, 2024. https://www.unmc.edu/intmed/divisions/id/asp/antibiograms.html
  3. Neu HC, Prince A, Neu CO, Garvey GJ. Incidence of diarrhea and colitis associated with clindamycin therapy. J Infect Dis. Mar 1977;135 Suppl:S120-5. doi:10.1093/infdis/135.supplement.s120
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Dr. Rupp Comments on COVID-19 and Avian Flu on Rural Heath Matters

A few weeks ago, we proudly shared that our Chief of Infectious Diseases, Dr. Mark Rupp, was honored with the 2024 Bartee Advocacy of Science Award, which is given to a UNMC scientist who exemplifies and lives out a commitment to community engagement. Illustrating this commitment to public science and medicine outreach, Dr. Rupp recently appeared on Rural Health Matters with the University of Nebraska President Dr. Jeffrey Gold to discuss the current state of COVID-19, avian influenza, and Lyme disease.

Rural Health Matters is a television show that features experts from UNMC discussing various health topics and their impact on farmers, ranchers, and rural Americans. The show is hosted on RFD-TV and features a live call-in segment where viewers can pose questions on a wide range of health-related topics that impact rural America.

Dr. Gold and Dr. Rupp are common features on the show, especially with increased infectious outbreaks in recent years. In this episode, Dr. Gold and Dr. Rupp were able to give actionable advice on how to avoid Lyme disease as we approach the summer months and commented on the current and future risks of avian influenza- which are especially important topics for rural Americans and all who work in agriculture or with animals which may contract or spread disease.

Both Dr. Rupp and Dr. Gold also received multiple comments from callers thanking them for their support on this show throughout the pandemic and continuing to today; a sentiment we would like to echo. Thank you, Dr. Rupp, for your outreach and commitment to ID education and awareness!

Watch the full episode on UNMC’s YouTube page here, and spread the word about Rural Health Matters on RFD-TV to all who may be interested.

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