Division of Infectious Diseases

#PharmToExamTable: Duration of Therapy for Gram-Negative Bacteremia

This #PharmToExamTable post exploring the evidence for a reduced duration of treatment for certain bloodstream infections was authored by Shawna Stricker, PharmD (left) and Austin Dockins, PharmD (right). Shawna is a PGY1 pharmacy resident at Nebraska Medicine who will be continuing her training here next year as a PGY2 oncology pharmacy resident. Austin is also a current PGY1 pharmacy resident at Nebraska Medicine who will be continuing his training here next year as a PGY2 critical care pharmacy resident.

In an era of growing antimicrobial resistance, prolonged antibiotic courses have been reconsidered to determine if shorter treatment durations are just as clinically effective. Shorter treatment durations can lead to fewer drug-related adverse events, shorter hospital length of stay (LOS), and lower risk of antimicrobial resistance. In the case of uncomplicated gram-negative bacteremia, 14 days of therapy has been historically recommended due to lack of data, as until recently, patients with bacteremia had been excluded from many studies on duration of therapy. Over the past few years, more research has been conducted to determine if a shorter course of antibiotics leads to non-inferior outcomes when treating bloodstream infections (BSIs) caused by gram-negative bacteria.¹

What is the evidence supporting shorter durations of therapy?

In a non-inferiority randomized controlled trial by Yahav and colleagues, 604 patients were randomized to 7 or 14 days of antibiotic therapy for uncomplicated, monomicrobial gram-negative BSI. Adult patients were enrolled if hemodynamically stable and afebrile for ≥48 hours. Patients with urinary, intra-abdominal, respiratory, catheter-associated, skin/soft tissue, and unknown sources of infection were included, and source control was required for enrollment. Patients who were neutropenic at the time of randomization, had HIV or a recent stem cell transplant (within 30 days) were excluded from the study. The most common pathogens isolated were Enterobacterales species, though Pseudomonas was the causative pathogen in about 8% of cases. The primary outcome was a composite of 90-day mortality and numerous outcomes associated with clinical failure, including relapse, readmissions, extended LOS, and suppurative complications. There was no difference between the groups for this outcome. The 7-day treatment duration was associated with a reduction in antibiotic days within 90 days and reduced time to functional recovery.²

The SHORTEN trial, another randomized control trial, evaluated the outcomes of 248 patients with Enterobacterales BSI with appropriate source control randomized to receive 7-day or 14-day antibiotic treatment courses.³ Adult patients were enrolled if they had negative follow-up blood cultures and were afebrile for at least 72 hours. Patients receiving chemotherapy with neutropenia expected to last >7days were excluded. The most common organisms isolated were E. coli (62.5%), K. pneumoniae (15.7%), and Enterobacter species (10.5%), and sources of infection included urinary, intra-abdominal, vascular, respiratory, and unknown. There were no significant differences in relapse, mortality, or adverse events between groups, and a desirability of outcome ranking and response adjusted for duration of antibiotic risk (DOOR/RADAR) analysis showed an approximately 78% chance that a 7-day course of therapy would lead to better outcomes compared to a 14-day course.³

How common is adoption of shorter durations in practice?

In 2020, a survey was conducted across 28 countries to determine the adoption of shorter durations of antibiotic therapy for gram-negative BSI. The survey discussed five primary scenarios with pneumonia, vascular catheter infection, urinary tract infection (UTI), intra-abdominal infection and skin/soft tissue infection sources of gram-negative BSI. The survey was completed by 277 participants with 64% of respondents being ID physicians and 31% being ID pharmacists. Overall, the median preferred duration of therapy was 7 days (IQR, 7-10 days); however, the percentage of providers that reported treating gram-negative BSI for ≤7 days was different for different sources of infection. For example, 52% reported treating ≤7 days for intraabdominal sources versus 65% for bacteremic UTIs. This survey found that only approximately half of practitioners report completely adopting the practice of using 7-day durations for gram-negative BSI despite clinical trials suggesting shorter durations are non-inferior to longer therapy durations, though acceptance of shorter durations of therapy is growing.⁴

Discussion on immunocompromised patients

There are still limited data regarding treatment duration of bacteremia in immunocompromised individuals, as often these patients are excluded from research studies or only included in small numbers. An individual participant data meta-analysis performed by Turjeman et al. included 181 immunocompromised patients from the 2 randomized controlled trials discussed above. Patients treated with immunosuppressive drugs, on active chemotherapy, and having a history of solid organ transplantation and stem cell transplantation were included, though patients with HIV infection with CD4 count ≤500 and patients with neutropenia were excluded. Any administration of antibiotics whether it was oral or IV was included in the analysis. The results of this meta-analysis demonstrated non-inferiority of 7 versus 14 days of antibiotic therapy for hemodynamically stable patients, regardless of immune status, and there was no significant difference shown in terms of 90-day mortality, 30-day mortality, hospital readmission rates and relapse of bacteremia in the immunocompromised patients that received 7 days of therapy versus 14 total days of therapy.⁵Hopefully, with ongoing research, even more evidence for short-course antimicrobial therapy in immunocompromised patients will be available through randomized controlled trials.⁶

Discussion on critically ill patients

Critically ill patients are another population that may require special attention when selecting antibiotic duration. Patel et al. conducted a retrospective cohort study evaluating short duration (≤7 days, median 5.5 days) versus extended duration (>7 days, median 15 days) of antibiotic therapy for BSI from intra-abdominal source with appropriate source control in 42 surgical intensive care patients.⁷ Though only a small number of patients had gram-negative BSI (13/42, 31%), there were overall similar rates of recurrence between the short treatment group and the extended treatment group (1/12 (8.3%) vs 4/30 (13.3%), p=0.5), and a numerical increase in risk of secondary fungal infections in the extended therapy group was noted (0% vs 4%, p=0.3).⁷ While this study is retrospective and includes only a small sample size, the results can be used as guidance to suggest shortening antibiotic duration in critically ill patients pending further clinical data. The Bacteremia Antibiotic Length Actually Needed for Clinical Effectiveness (BALANCE) study, which is expected to conclude later this year, is anticipated to include >3600 patients and will evaluate the non-inferiority of a 7-day treatment regimen versus a 14-day regimen for bacteremia in hospitalized patients, including critically ill patients.⁸ This international, multicenter randomized trial could potentially provide the largest amount of evidence in support of a 7-day treatment course for bacteremia to date.

Conclusion

New studies consistently demonstrate the non-inferiority of 7-day treatment courses compared to traditional 14-day courses in patients with gram-negative BSI with effective source control and early clinical improvement. This reduction in the duration of therapy has been shown to produce similar clinical outcomes and can lead to a reduction in medication-related adverse events, hospital LOS, superinfections, and antibiotic resistance. With this continual growth of evidence, 7-day antibiotic treatment courses for gram-negative bacteremia should be considered whenever possible.

References:

Le Fevre L, Timsit JF. Duration of antimicrobial therapy for Gram-negative infections. Curr Opin Infect Dis. 2020;33(6):511-516. doi:10.1097/QCO.0000000000000689
Yahav D, Franceschini E, Koppel F, et al. Seven Versus 14 Days of Antibiotic Therapy for Uncomplicated Gram-negative Bacteremia: A Noninferiority Randomized Controlled Trial. Clin Infect Dis. 2019;69(7):1091-1098. doi:10.1093/cid/ciy1054
Molina J, Montero-Mateos E, Praena-Segovia J, et al. Seven-versus 14-day course of antibiotics for the treatment of bloodstream infections by Enterobacterales: a randomized, controlled trial. Clin Microbiol Infect. 2022;28(4):550-557. doi:10.1016/j.cmi.2021.09.001
Thaden JT, Tamma PD, Pan Q, Doi Y, Daneman N. Survey of infectious diseases providers reveals variability in duration of antibiotic therapy for the treatment of Gram-negative bloodstream infections. JAC Antimicrob Resist. 2022;4(1):dlac005. Published 2022 Feb 9. doi:10.1093/jacamr/dlac005
Turjeman A, von Dach E, Molina J, et al. Duration of antibiotic treatment for Gram-negative bacteremia – Systematic review and individual participant data (IPD) meta-analysis. EClinicalMedicine. 2022;55:101750. Published 2022 Dec 1. doi:10.1016/j.eclinm.2022.101750
Imlay H, Laundy NC, Forrest GN, Slavin MA. Shorter antibiotic courses in the immunocompromised: the impossible dream? [published online ahead of print, 2022 Aug 19]. Clin Microbiol Infect. 2022;S1198-743X(22)00423-2. doi:10.1016/j.cmi.2022.08.007
Patel K, Maguigan KL, Loftus TJ, Mohr AM, Shoulders BR. Optimal Antibiotic Duration for Bloodstream Infections Secondary to Intraabdominal Infection. J Surg Res. 2021;260:82-87. doi:10.1016/j.jss.2020.10.029
Daneman N, Rishu AH, Pinto RL, et al. Bacteremia Antibiotic Length Actually Needed for Clinical Effectiveness (BALANCE) randomised clinical trial: study protocol. BMJ Open. 2020;10(5):e038300. Published 2020 May 11. doi:10.1136/bmjopen-2020-038300

Recognizing our Great Residents and Fellows!

Nebraska Medicine, UNMC and The Gold Humanism Honor Society are excited to celebrate all Residents and Fellows today on Thank a Resident/Fellow Day. Thank a Resident Day offers faculty and students the chance to show their gratitude to the unsung teachers of their medical school clerkship, the house-staff.

_{UNMC ID Directors, Fellows, and Family}

While Residency and Fellowship is an important stage in medical training, it is also a period of peak burn out. Physician burnout affects more than half of U.S. doctors. Burnout is characterized by three symptoms; exhaustion, cynicism or dehumanization, and sense of ineffectiveness and lack of accomplishment. Thank a Resident Day is meant to celebrate our rising medical professionals and explore their resiliency.

A simple, but heart-felt, thank you may carry a larger impact than any of us realize. Please take a moment today to personally thank a resident or fellow for their crucial work.

Here in the ID world, we would like to extend a particular thanks to our residents here in ALL specialties at UNMC, as well as specifically our ID fellows (pictured below). Thank you for EVERYTHING you do to help prevent and treat infections in the community and here in the hospital. We need your help every day in preventing the spread of disease, in antimicrobial stewardship and in providing the best possible care for our patients.

^{Our UNMC ID Fellows (from top left to bottom right): Dr. Nabil Al-Kourainy, Dr. Catherine Cichon, Dr. Timothy Jang, Dr. Mackenzie Keintz, Dr. Timothy McElroy, and Dr. Bryan Walker. Thank you for all you do!}

UNMC Celebrates Black History Month: Next Week’s Events (Week 3)

Since 1976, each February has been host to a series of events recognizing the achievements and contributions of African Americans throughout U.S. history. It is as much a celebration as it is a time of education and reflection. Accordingly, UNMC has planned multiple events to share and commemorate African American culture. Check out the UNMC Newsroom’s post for full details and see below for an abbreviated summary of next week’s events.

Speakers and Panels

February 20th, 3pm
Panel discussion about Black and Black diaspora culture and how it is represented in Omaha. Panelists include Eric Ewing, executive director of the Great Plains Black History Museum; Jade Rodgers, historian and adjunct professor at Metropolitan Community College; and Charles Ahovissi, founder of African Culture Connection. Available via YouTube.

February 21st, 10am
Justin Payne, award-winning composer, playwright, international vocalist and professor of Black studies at the University of Nebraska at Omaha, speaks on the relationship between African Americans and their influence on all musical genres. Presentation via Zoom.

February 22nd, 3pm
Brave Space conversation focusing on the social and ethical impacts that social determinants of health have on the community. Attendees will engage on topics such as defining health equity, health disparities and health inequities; understanding impact of social determinants of health; exploring health status, behaviors and needs of residents of Omaha through a systemic and data-drive approach; and reflect on how health care providers can promote health equity in their practices. Presentation via Zoom.

Other Events

February 6th-24th
Donate to a campuswide diaper and supply drive. Donations will go to A Mother’s Love and the Nebraska Diaper Bank. A list of donations and drop-off locations can be found here.

Heads up for later next week

February 25th
A two-hour guided tour of North Omaha. On this tour, attendees will learn about the rich legacy of the area, the African American community and why North Omaha is a beacon of the past and important for the future. Pre-registration is required.

Microbe Monday: Halteria, the Virus-eating Microbe

Microbe Monday is a monthly installment featuring a microbe of clinical or scientific importance. This month, we discuss Halteria sp. which, while not pathogenic to humans, sheds new light on the competition dynamics between microbes. See here for our previous Microbe Monday posts.

_{Dr. John DeLong of UNL, who recently discovered a new trick from an old microbe. Credit}

In infectious diseases, we tend to focus on the one-directional interaction from microbe to host. This is certainly an important point of view and frames how clinicians treat infections. But it is just a chapter in the lifecycle of most microbes. Many pathogens normally exist outside of humans, whether that be in soil, lakes/rivers, other animal hosts, or elsewhere in the environment. It turns out that, in this environment, microbes can compete fiercely with each other for food and resources. Certain larger microbes even have the ability to eat bacteria. Viruses, on the other hand, have been thought to be too small and contain too little nutrients to fit into the microbe food-chain. Or so we thought…

_{A micrograph of Halteria, the first identified virus-eating microbe.}

A new paper authored by Dr. John DeLong and colleagues at the University of Nebraska-Lincoln has identified the first microbe which acts as a ‘virivore’ or virus-eating organism. Meet Halteria sp. (pictured right), a ciliate which lives in freshwater aquatic environments. This is by no means a new microbe to science; it may have been first identified as far back as 1675 and certain species are found around the world. It is not a picky eater, having been known to consume algae and bacteria for nutrients for some time. But evidence of Halteria consuming viruses is brand new, and was recently published in PNAS earlier this year.

_{Halteria after consuming fluorescently labeled virus (white/light areas).}

In his paper, Dr. DeLong showed that when you put chloroviruses and Halteria in the same flask with no other food sources, viral titers are decreased ~10x while Halteria begin to divide. Furthermore, viral particles were detected inside the ciliate cell. Together, this indicates that the ciliate was consuming virus and using that energy to grow and reproduce. While this is the first evidence of an organism consuming virus, it is not likely the only example in nature. As more scientists start looking for this behavior, we will probably start to see many other microbes exhibiting this trick.

Halteria is not known to cause disease in humans, and it is not a pathogen we encounter in clinical infectious disease. However, this discovery does begin to rewrite the dogma surrounding how we view the microscopic world, and begs the question: what other tricks may microbes be hiding?

UNMC Celebrates Black History Month: Next Week’s Events (Week 2)

Speakers and Panels

February 13th, 7pm
Local media panelists including Terri D. Sanders, publisher of the Omaha Star Newspaper; William King, owner of Media King Communications; Monique Farmer, CEO and founder of Anvil Ready; Serese Cole, KMTV news anchor; and KETV reporters Waverle Monroe and Jonah Gilmore. Available via YouTube.

Other Events

Heads up for later this month

UNMC ID Celebrates National Black Women Physicians Day

192 years ago today, Dr. Lee Crumpler, the first Black woman to receive an M.D. in the United States, was born. We now recognize her birthday as National Black Women Physicians Day to celebrate the contributions of African American woman physicians to medicine.

It is fitting to celebrate Dr. Lee Crumpler’s life and this day of recognition in the broader context of Black History Month and along with the events planned as part of UNMC’s celebration of black history.

Throughout her life, she made essential contributions to medicine, including providing care for newly emancipated slaves under the Freedman’s Bureau, later serving the larger African-American community in Boston, and writing a medical text composed of her notes throughout her career particularly pertaining to the care and prevention of disease in children and mothers. All of these achievements were realized in the face of blatant racism and sexism from colleagues, pharmacists, and the public. Though no known verified image exists of Dr. Lee Crumpler, her triumphs in the face of adversity are inspiring and illustrate the first in a long history of contributions to medicine by African-American woman physicians.

Join us today as we celebrate all African-American woman physicians and their profound contribution to their patients and the medical field.

For more information about Dr. Lee Crumpler, see this article written by Dr. Howard Markel for PBS.

UNMC Celebrates Black History Month: This Week’s Events (Week 1)

Speakers and Panels

February 6th, 7pm
Tiffany Gamble, executive director of Emerging Ladies Academy and CEO of Gamble Tech Firm, along with David Pollock, founder of Code Black, will discuss the need for more African Americans in IT. Presentation via YouTube.

February 7th, 12pm
Presentation by Kia Noelle Johnson, PhD, associate director of the Arthur M. Blank Center for Stuttering Education and Research Satellite in Atlanta and chair of the board of directors for the National Black Association for Speech-Language and Hearing. Zoom link here.

February 8th, 1pm
Preston Love Jr., former University of Nebraska Cornhusker football player, Nebraska Black Sports Hall of Fame inductee and founder of 4Urban, will present “Recent Attempts to Turn Wine into Water.” Love will discuss the fullness and richness of Black history and the deep waters of racism and politics. RSVP here for RSVP here for Zoom link.

Other Events

Heads up for later this month

Remembering Dr. Diana Florescu

It is with profound sadness that the university of Nebraska medical center division of infectious diseases announces the passing of Dr. Diana Florescu. She was a mentor to countless trainees and faculty in Transplant ID, and an inspiration to many more. She was recently honored with the UNMC Scientist Laureate Award, the highest recognition given to UNMC faculty researchers for their contributions to advancing the science of healthcare.

Dr. Florescu will be remembered for her tenacity, grit, kindness, determination, and a positive energy that lit up every room, especially the ballroom when she danced.

We were blessed to have her as an esteemed faculty member in our division and are so grateful that she got her flowers while she was still with us. Our division of ID, and department of internal medicine are devastated, heartbroken as we surround her family with the love and support they need during this time.

More details can be found in this remembrance posting from UNMC, and information about her memorial service can be found in her obituary. Please keep her home and work families in your prayers.

#PharmToExamTable: Oral Therapy for Gram-Negative Rod (GNR) Bacteremia: Can We Go PO?

The following post exploring a switch from IV to oral antibiotics for treatment of bacteremia was written by Molly Miller, PharmD, ID Pharmacist at Nebraska Medicine.

How do we usually treat bloodstream infections?

Standard management of bloodstream infections (BSIs) due to Gram-negative rods (GNRs) is empiric IV therapy with an active antimicrobial agent (typically a third or fourth generation cephalosporin, piperacillin-tazobactam, a fluoroquinolone, or a carbapenem) followed by eventual narrowing to definitive therapy based on culture results and susceptibilities. In addition to antibiotic therapy, perhaps the most important aspect of management is source control, which is accomplished by eliminating any nidus of infection (i.e., removing infected catheters/devices, draining abscesses or fluid collections). Treatment of GNR bacteremia is generally recommended for a duration of 7-14 days, but this can be extended for longer durations if the infection is complicated and source control is not achieved.

There has been recent interest in using oral therapy for many serious infections which were traditionally treated exclusively with IV therapy. Recent studies include the POET and OVIVA trials for endocarditis and bone and joint infections, respectively.^1,2 Current evidence shows that there are several potential benefits to using oral therapy over extended courses of IV therapy, including reduction in catheter-related complications such as infection and thrombosis, reduction in length of stay (LOS), improvement in patient satisfaction and comfort, and reduction in healthcare costs.^1-5

What specifically is the evidence for the use of oral antibiotics in this infection?

Though there have been no prospective, randomized, controlled trials published thus far regarding the use of oral therapy for GNR bacteremia (the SOAB trial is in progress), there is a growing body of observational data supporting this approach. In 2019, Tamma and colleagues published a multicenter, propensity-matched, retrospective cohort study comparing outcomes between adults with monomicrobial bacteremia due to Enterobacterales species who received oral step-down therapy versus continued IV therapy.³ Eligible patients had source control, clinical improvement on initial therapy, an active oral agent available to treat the causative organism, and the ability to take and absorb oral medication. Of the patients transitioned to oral therapy, most (84%) received a “highly bioavailable” antibiotic (fluoroquinolone or trimethoprim-sulfamethoxazole). The median time to oral switch was 3 days of IV therapy. There was no difference in all-cause mortality or recurrent bacteremia at 30 days between the oral and IV therapy groups; however, there was a shorter median time to discharge (5 days vs 7 days) in the oral step-down group.³ A number of smaller retrospective studies have shown similar results, with transition to oral therapy resulting in similar clinical outcomes with reductions in hospital LOS and IV line-associated complications.^4,5

In 2016, a retrospective study was published by Kutob and colleagues, which included patients with GNR BSI and compared outcomes between patients receiving high, moderate, and low bioavailability agents.⁶ This study found that high bioavailability oral agents were effective definitive therapy; however, a higher failure rate was observed in patients receiving a moderate to low bioavailability agent compared to a high bioavailability agent (12-14% vs 2%). This poses the question: which oral antibiotics are suitable for use as step-down therapy in GNR BSI? A recent meta-analysis compared outcomes of oral step down to fluoroquinolones (FQs) or trimethoprim-sulfamethoxazole (TMP-SMX) versus oral beta-lactams (OBLs) for Enterobacterales BSI.⁷ This meta-analysis pooled a population of 2,289 patients, of whom 65% received FQs, 7.7% received TMP-SMX, and 27.2% received OBL therapy. Across the studies, patients were transitioned to oral therapy after a median of 3-5 days of IV therapy. There was no difference in mortality noted between groups receiving FQ or TMP-SMX compared to OBL (5.1% vs 3.5%, p = 0.63); however, patients receiving OBLs had a 2x higher odds of recurrent infection versus FQs. An important thing to note, however, is that bioavailability is only part of the equation, and other pharmacokinetic and pharmacodynamic (PK/PD) principles are important to consider when dosing oral antibiotics to treat serious infections. One specific concern the authors of this meta-analysis had was that 30-50% of patients in the included studies received suboptimal doses of OBLs. Another concern is that OBLs require every 6-8 hour dosing to attain target levels compared to every 12-24 hour dosing for TMP-SMX or FQs, which may introduce adherence issues and therefore increase the risk of treatment failure as well.

Though FQs and TMP-SMX have benefits compared to OBLs for the reasons discussed above, note that these therapies have significant toxicities, and it is important to consider drug- and patient-specific factors when choosing an oral antibiotic. FQs have many boxed warnings for serious adverse events, including tendon rupture, aortic aneurysm rupture, central nervous system effects, QT prolongation, dysglycemias, and increased risk of C. difficileinfection. TMP-SMX may cause blood dyscrasias, severe dermatologic reactions, hyperkalemia, and increased serum creatinine, and it also carries some drug-drug interactions, particularly with warfarin and other agents causing increased serum potassium. In comparison, OBLs are fairly well-tolerated, with rash and gastrointestinal side effects being most common. As always, patient co-morbidities, allergies/intolerances, and drug-drug interactions should be taken into account when choosing appropriate therapy.

In summary…

Patients who have achieved effective source control and are clinically stable (including hemodynamically stable and afebrile) who are able to tolerate and absorb oral antibiotics with no contraindications can be considered for transition to oral therapy if there is assurance of good adherence and close monitoring and follow-up. Oral antibiotics with high bioavailability have the most supportive evidence for use in these circumstances. While most often this is a FQ or potentially TMP-SMX, there is emerging evidence that some OBLs may be acceptable if dosed appropriately. Other considerations include patient-specific factors (allergies, co-morbidities, and drug-drug interactions), antibiotic penetration to the site of infection, and antimicrobial susceptibility. By transitioning patients to oral therapy when possible, we can reduce the risk of IV line-related complications, reduce length of stay, and improve patient satisfaction and comfort.

References:

Iversen K, Ihlemann N, Gill SU, et al. Partial Oral versus Intravenous Antibiotic Treatment of Endocarditis. New Engl J Med. 2019;380(5):415-24.
Li H-K, Rombach I, Zambellas R, et al. Oral versus Intravenous Antibiotics for Bone and Joint Infection. New Engl J Med. 2019;380(5):425-36.
Tamma PD, Conley AT, Cosgrove SE, Harris AD, Lautenbach E, Amoah J, Avdic E, Tolomeo P, Wise J, Subudhi S, Han JH; Antibacterial Resistance Leadership Group. Association of 30-Day Mortality With Oral Step-Down vs Continued Intravenous Therapy in Patients Hospitalized With Enterobacteriaceae Bacteremia. JAMA Intern Med. 2019 Mar 1;179(3):316-323. doi: 10.1001/jamainternmed.2018.6226. Erratum in: JAMA Intern Med. 2019 Nov 1;179(11):1607. PMID: 30667477; PMCID: PMC6439703.
Rieger KL, Bosso JA, MacVane SH, Temple Z, Wahlquist A, Bohm N. Intravenous-only or intravenous transitioned to oral antimicrobials for Enterobacteriaceae-associated bacteremic urinary tract infection. Pharmacotherapy. 2017;37(11): 1479-1483. doi:10.1002/phar.2024
Thurber KM, Arnold JR, Narayanan PP, Dierkhising RA, Sampathkumar P. Comparison of intravenous and oral definitive antibiotic regimens in hospitalised patients with Gram-negative bacteraemia from a urinary tract infection. J Glob Antimicrob Resist. 2019 Sep;18:243-248. doi: 10.1016/j.jgar.2019.03.013. Epub 2019 Mar 26. PMID: 30926468.
Kutob LF, Justo JA, Bookstaver PB, Kohn J, Albrecht H, Al-Hasan MN. Effectiveness of oral antibiotics for definitive therapy of Gram-negative bloodstream infections. Int J Antimicrob Agents. 2016;48(5):498-503.
Punjabi C, Tien V, Meng L, et al. Oral Fluoroquinolone or Trimethoprim-Sulfamethoxazole vs beta-lactams as step-down therapy for Enterobacteriaceae Bacteremia: Systematic Review and Meta-analysis. Open Forum Infect Dis. 2019; 6(10): ofz364.

Recognizing Dr. Diana Florescu, Scientist Laureate

Last week Dr. Diana F. Florescu was honored at a celebration recognizing her recent achievement of being named the UNMC Scientist Laureate, the highest award UNMC bestows upon its researchers.

Dr. Florescu is a Professor in the Division of Infectious Diseases here at UNMC. She came to UNMC first in 2009 as a phenomenal clinician with a focus in treating infections in immunocompromised hosts (solid organ transplant recipients and individuals with malignancy), and over the next 14 years would develop a distinguished research career focused on viral infections in solid organ transplant recipients, including treatment and vaccines. This work has been nationally and internationally recognized with nearly 100 peer-reviewed articles, and in 2020, she was a recipient of the UNMC Distinguished Scientist award, recognizing the most productive researchers at UNMC in the previous 5 years. She did not slow this work during the COVID-19 pandemic, in fact, she escalated her clinical research, leading investigation as a top enrolling site for the Novovax (NVX-CoV2373) COVID-19 vaccine clinical trial, as well as other COVID-19 treatment trials and other non-COVID-19 studies in immunocompromised patients.

In addition to her extraordinary contributions to research and clinical care, Dr. Florescu has served as an invaluable mentor to the UNMC ID Faculty, residents, and APPs in the transplant ID service line. Outside of the hospital, she has been an advocate for her immunocompromised patients and patients experiencing homelessness in Omaha, and combines her love (and talent!) for ballroom dancing with this service, competing in and winning many dance competition fundraisers. UNMC ID is immensely proud of Dr. Florescu and excited to celebrate this recognition with her.

Here are some highlights of her outstanding accomplishments and comments made by a few of her mentors, colleagues, mentees, and friends celebrating her recognition. Congratulations, Dr. Florescu!

Division of Infectious Diseases

#PharmToExamTable: Duration of Therapy for Gram-Negative Bacteremia

Recognizing our Great Residents and Fellows!

UNMC Celebrates Black History Month: Next Week’s Events (Week 3)

Microbe Monday: Halteria, the Virus-eating Microbe

UNMC Celebrates Black History Month: Next Week’s Events (Week 2)

UNMC ID Celebrates National Black Women Physicians Day

UNMC Celebrates Black History Month: This Week’s Events (Week 1)

Remembering Dr. Diana Florescu

#PharmToExamTable: Oral Therapy for Gram-Negative Rod (GNR) Bacteremia: Can We Go PO?

Recognizing Dr. Diana Florescu, Scientist Laureate

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