Nebraska ASAP will be hosting its annual Nebraska Antimicrobial Stewardship Summit in-person on Friday, August 12, at the Embassy Suites by Hilton in Downtown Omaha. There will be a combined morning session with speakers from CDC, Nebraska Medicine, and other organizations, followed by afternoon breakout sessions with targeted presentations in long-term care and acute care/outpatient settings tracks. Registration for the Summit is $99 per attendee, which includes parking, food, and CE credits for physicians, nurses, pharmacists, pharmacy technicians, and medical laboratory scientists. Read on below for more information and to register!
About the Summit:
With workload increases and staffing limitations due to COVID-19, the focus has been shifted away from antimicrobial stewardship in many facilities across diverse healthcare settings. Unfortunately, inappropriate antibiotic prescribing is common and can result in sub-optimal patient outcomes, development of antimicrobial resistance, and serious adverse reactions such as Clostridioides difficile infection. This summit is designed to highlight the importance of antimicrobial stewardship and focus on implementation strategies to promote facility-wide incorporation and improved antimicrobial use and patient outcomes.
Summit Date: Friday, August 12th
Location: Embassy Suites by Hilton Omaha—Downtown Old Market
We are excited to welcome Dr. Timothy Jang as a new fellow in our Infectious Diseases program! Read on to learn a little more about him.
Tell us about the position you are starting.
I am excited to be starting out as an infectious diseases fellow at the University of Nebraska Medical Center! I will be taking care of patients on both an inpatient and outpatient basis, under the guidance of a fantastic team of seasoned infectious diseases clinicians.
Tell us about your background.
I grew up in San Francisco, went to college at UC Berkeley, and majored in European history with a focus on politics, diplomacy, and international relations of the 18th-20th centuries. I have always believed that a good understanding of history helps us understand the shaping of the modern world. History is also the study of humanity, and all of the characteristics that make us human – our adaptability, compassion, and desire to broaden our horizons. It was these aspects that drew me to medicine as a career. I attended medical school at Indiana University School of Medicine and did my residency training in internal medicine at Wright State University in Dayton, Ohio.
Why did you choose to come to work at UNMC?
Before the COVID pandemic began, I had visited UNMC and Omaha for internal medicine residency interviews, and I was considerably impressed by the medical facilities, the strength of the educational program, and the tranquility of the city. One of the faculty that I had interviewed with for residency interviews was Dr. Mark Rupp, the chief of the ID division, and I had promised him that regardless of where I ended up for residency, I would apply to UNMC for ID fellowship. So when I matched to UNMC for ID fellowship, I knew I had matched to the right place!
What makes you excited about working in ID?
My favorite subject in medical school was microbiology, and my favorite rotation in residency was infectious diseases. I have always appreciated the depth of insight that infectious diseases consultants bring to the table. A great infectious diseases doctor once told me that it often takes a good hour of thought to complete a thorough consult for a complex patient – an important reminder that we are here to spend our time giving the best care possible to our patients. In addition, the breadth of ID spans multiple body systems overlapping with many medical specialties, and this provides the opportunity to see a very diverse spectrum of diseases.
Within infectious diseases, I am interested in antimicrobial stewardship and medical education. One of the most satisfying aspects of residency was working with medical students, and I am excited to continue teaching residents and medical students in my fellowship years and beyond.
Tell us something about yourself that is unrelated to medicine.
In my free time, I am quite passionate about competitive gaming, particularly PC strategy games with a historical setting. This culminated in winning the E3 2019 Champion award at the E3 gaming convention.
I also love to travel, and once the COVID pandemic dies down, I plan to continue my adventures around the US and abroad.
Join us in welcoming three great new additions to UNMC ID Faculty: Dr. Carlos Gomez, Dr. Subhadra Mandadi, and Dr. Jonathan Ryder. Keep an eye out for more detailed introduction posts in the coming weeks. But for now, see below for a snapshot about these fantastic new faculty members.
Dr. Carlos Gomez completed his residency training in Internal Medicine at the University of Pittsburgh and fellowship in ID at Stanford University. He joins UNMC as an associate professor on the Solid Organ Transplant service line. Welcome Dr. Gomez!
Dr. Subhadra Mandadi completed her residency training in Internal Medicine at Hurley Medical Center and fellowship in ID at the University of Buffalo. She joins us as an assistant professor working on the Community ID service line. Glad to have you, Dr. Subhadra!
Dr. Jonathan Ryder completed his residency training at Indiana University and fellowship in ID here at UNMC (see his recent ‘last words’ post here). He joins us as an instructor working on the General ID service line. He is also completing a 3rd year fellowship in Antimicrobial Stewardship. Congratulations Dr. Ryder!
For a quick introduction to each new faculty member, see their linked UNMC Faculty page.
We are excited to welcome Dr. Catherine Cichon as a new fellow in our Infectious Diseases program! Read on to learn a little more about her.
Tell us about the position you are starting.
I am excited to be joining the University of Nebraska Medical Center (UNMC) as a first year Infectious Disease fellow! I will spend the next few years learning about disorders caused by bacteria, viruses, fungi, and parasites, the people affected by them, and the medications that treat them.
Tell us about your background.
I grew up in Colorado Springs, Colorado, and I have since gone on to explore and learn from cities around the country. I studied Anthropology as an undergraduate student at the University of Notre Dame, which led me to become interested in the interplay of culture and medicine. This drew me towards public health, and as a result I completed my combined MD and Master of Public Health (MPH) at the University of Miami Miller School of Medicine (UMMSM). Over the years I continued to develop an interest in global health and “local global” health, which led me to complete my combined Internal Medicine and Pediatrics residency at the University of California San Diego (UCSD), 15 minutes from one of the busiest land-border crossings in the world. I look forward to continuing to grow my public health and infectious disease knowledge through the ID fellowship at UNMC!
(2) I have family here in Omaha, and Omaha is much closer to my family in Colorado. It’s great to be close to your support system!
(3) Omaha itself is a great city! There is so much to eat, do, and see here. The affordable cost-of-living adds to the attraction.
What makes you excited about working in ID?
ID is a field that is rooted in history (I’m a huge medical history nerd) and yet perpetually looking towards the future. In the last few years we have seen this in action via surges of both old and new diseases – from measles to SARS-CoV-2 to monkeypox. ID specialists can work in both clinical and public health settings to address these diseases, and I am excited for those opportunities. From the clinical perspective, I am curious by nature (#medpeds), and ID cases are often the most challenging from a diagnostic and therapeutic standpoint. Finally, from the public health perspective, I am interested in exploring the ways we can address the disproportionate effect that infectious diseases have on our most underserved communities, both locally and globally.
Tell us something about yourself that is unrelated to medicine.
I am an amateur medical illustrator! Sorry, I suppose that is somewhat related to medicine. During medical school I taught myself how to illustrate digitally using an iPad, and since then I have had my art published in several papers, books, and online. I occasionally post some of this art on my social media accounts, which you can follow @DocScribbles 😊 Look forward to more ID-themed art over the next few years.
On a totally “unrelated to medicine” note, I adopted a pandemic dog and named him Loki, just in time for the Marvel series of the same name!
The following was provided by Dr. Bergman regarding new ID pharmacy opportunities at UNMC ID. If you know the perfect match for this position, please share!
UNMC ID is looking for a Nebraska ASAP Program Coordinator and State of Nebraska Antimicrobial Stewardship Lead Pharmacist.
Nebraska Medicine is offering an exciting opportunity for an Infectious Diseases (ID)-trained pharmacist to lead Antimicrobial Stewardship in the state and become Pharmacy Coordinator for our Nebraska ASAP (Antimicrobial Stewardship Assessment and Promotion) outreach program. This individual will work alongside Medical Directors for ASAP and the Nebraska DHHS healthcare-associated infection and antimicrobial resistance (HAI/AR) program to direct statewide antimicrobial stewardship efforts. This is an established role that convenes the statewide Antibiotic Stewardship subcommittee of the HAI Committee to discuss ideas, issues, and initiatives that foster stewardship improvements across the state and facilitate any future Nebraska Antimicrobial Stewardship Summit. In addition, the successful candidate for this position will provide one-on-one discussions with acute care hospitals, long-term care facilities, and urgent care centers, present webinar-style educational sessions, and update/maintain the educational content on the Nebraska ASAP website and YouTube channel.
The role of ASAP Program Coordinator involves developing tailored guidance to help healthcare facilities mitigate gaps in CDC Core Elements for antibiotic stewardship programs identified during assessments conducted in coordination with an ASAP medical director. Nebraska ASAP works with Nebraska DHHS to review annual NHSN Survey responses and Antimicrobial Use/AR results to identify additional facilities needing assistance with Core Element implementation to promote appropriate utilization, surveillance, and governance of antimicrobial agents. A significant portion of functions can be accomplished remotely, but in- person meetings will be required. Office space is available in an academic environment with the nationally recognized Nebraska Medicine Antimicrobial Stewardship Program in Omaha where collaboration and cross-coverage can occur. Adjunct faculty status is available in the College of Pharmacy at the University of Nebraska Medical Center.
Ideal candidates will be formally trained and have significant experience in Infectious Diseases pharmacy practice. Public speaking, development of engaging educational content, and the ability to build strong relationships with stakeholders is essential. Interest in research and publication is strongly encouraged.
We are excited to welcome Dr. Nabil Al-Kourainy as a new fellow in our Infectious Diseases program! Read on to learn a little more about him.
Tell us about the position you are starting.
Hi, I’m Nabil Al-Kourainy former Chief Medical Resident, Clinical Assistant Professor and Academic Hospitalist at Wayne State University School of Medicine (WSU), published author and speaker. I am excited to start my journey as an infectious diseases fellow and candidate of the Health Educators and Leadership (HEAL) track at the University of Nebraska Medical Center!
Tell us about your background.
Dr. Al-Kourainy exploring the Hidden Lake trail at Glacier National Park, Montana.
I grew up in San Diego, California, but am originally from the Midwest. I come from a mixed cultural and ethnic background of Arabic, French, and Irish. My friends often say that I have never met a stranger. I pride myself on my ability to listen to, understand and relate to patients and learners while trying to help them in any way that I can. Prior to medical school, I received a Bachelor of Arts with a focus in contemporary American history at the University of California, Los Angeles. My study of the humanities along with my upbringing and sociable nature helps me to connect with patients from diverse cultural and socioeconomic backgrounds.
While attending medical school at WSU, I helped found Street Medicine Detroit, the first organization of its kind in the state of Michigan, with a mission to provide street and shelter based medical care for Detroit’s unreached and service-resistant housing insecure population. As an infectious diseases specialist, I intend to continue my efforts to advocate for greater healthcare access for the medically disenfranchised.
I completed my internal medicine and chief medical residency at Wayne State before continuing as an academic hospitalist and a clinical assistant professor at the Detroit Medical Center, Karmanos Cancer Institute and John D. Dingell VA Medical Center. Precepting residents and medical students while working at a safety net hospital and a dedicated cancer center was a wonderful learning experience that allowed me to gain exposure to challenging ID cases while honing my clinical acumen and approach to medical education.
Why did you choose to come work at UNMC?
UNMC has a rich tradition for being a center of clinical and scholarly excellence while promoting education through mentorship and fostering initiative and collaboration. The Medical Center is also committed to providing empathetic, evidenced-based, and patient-centered care while serving a diverse and often medically underrepresented population. I look forward to experiencing this collegial and supportive atmosphere during fellowship training. The HEAL track also represents an amazing opportunity to further advance my knowledge and skills in medical education and leadership!
What makes you excited about working in ID?
I see the field of infectious diseases as a specialty primed for exploration and discovery. And, if the COVID-19 pandemic has taught us anything it is that we cannot always know the where, when, why, and how the next global crisis will present. I am excited to gain the expertise and confidence needed to help educate and advocate toward pandemic preparedness planning and treatment of current and future affected patients.
With over 80% of U.S. counties without a dedicated ID physician, there is an incredible opportunity to make a positive impact on the quality of life and patient outcomes for those often misunderstood, judged, and marginalized by society such as patients living with HIV or Hepatitis C, persons who inject drugs, as well as members of the LGBTQ+ community who are disproportionately affected by sexually transmitted infections. I have seen firsthand how social determinants of health and lack of medical care access can have a profound impact on patient adherence and health status. Through fellowship, I will gain the tools needed to advocate for and promote social change in support of these vulnerable populations.
Working in ID will also provide me with the skills and expertise required to make complex diagnosis and treatment recommendations for cases where a detailed history and examination of clinical data can lead to a turning point in patient care. Knowing that I have played a small role in helping patients and colleagues by making recommendations based on risk factors, antimicrobial resistance patterns and available literature evidence will provide me with both intellectual and professional satisfaction.
Dr. Al-Kourainy and wife Valia.
Tell us something about yourself that is unrelated to medicine.
I am incredibly blessed to have the love and support of my beautiful and compassionate wife Valia and our infant daughter Sofia. Being a husband and father fills me with a great sense of pride and purpose. I also have a wonderfully supportive mother and father as well as two brothers and a close-knit extended family. I am an explorer of nature and history through hiking national trails and urban spelunking. My creative passions are macro and landscape photography as well as photo editing. My wife and I also love to travel while experiencing a diversity of history, culture, music, and of course food! Basketball is a lifelong interest of mine so feel free to ask me about anything NBA. I’m excited to begin the next chapter in my career at UNMC!
Dr. Diana Florescu, UNMC ID Physician and co-author of two recent publications exploring transplant ID.
One of the most profound medical developments of the past century, organ transplantation, can prove to be one of the most dangerous. Infectious pathogens can hide in transplanted organs which, in combination with the immune-suppressive drugs crucial to transplantation success, makes post-transplant infectious complications a high priority for healthcare. This is the basis for Transplant ID, as a close working relationship with transplant surgery teams and ID physicians are necessary to manage these complex patients and resulting infections. Luckily, there is a science to preventing these infections using techniques ranging from donor screening to medical management post-surgery. As is the case with most of medicine, these techniques are informed by the research- of which our very own Dr. Florescu is a strong contributor, most recently in two publications exploring transplant infection surveillance and treatment, respectively. Read on for a brief summary of their findings.
One of the most feared pathogen which can be transmitted via organ donation is Mycobacterium tuberculosis (TB). In the first article, Dr. Florescu and other authors examine potential cases of donor-derived tuberculosis reported between 2008 and 2018. Of the 51 cases reported during this time period, 9 donors resulted in probable disease transmission to 35 organ recipients. Each of these donors were associated with at least one TB-related risk factor. On average, detection of transmission took 104 days and no reported recipient died of the infection. The authors note that these results underscore the importance of obtaining a detailed donor history based on known TB risk factors. Read the full paper here.
Another transplant associated infection is caused by cytomegalovirus (CMV). Unfortunately, current therapies for this infection are accompanied by significant concerns of toxicity. In the second article, the authors conduct a phase 3 clinical trial evaluating the use of maribavir as a superior treatment for refractory CMV infections in organ transplant recipients. They found that maribavir was superior to valganciclovir/ganciclovir, foscarnet, or cidofovir treatment in viral clearance, being 32% more effective than other tested regimens. Additionally, maribavir use was associated with significantly less toxicity, with lower reported rates of acute kidney injury and neutropenia. Read more here.
Congratulations Dr. Florescu on the interesting, impactful, and medically relevant work!
We are excited to welcome three new fellows to our UNMC Infectious Diseases program this month! Over the next few weeks, we will feature each new fellow in their own welcome post. But for now, we welcome Dr. Nabil Al-Kourainy, Dr. Catherine Cichon, and Dr. Timothy Jang to UNMC. Read on for a brief introduction.
Dr. Nabil Al-Kourainy
“Hi, I’m Nabil Al-Kourainy former Chief Medical Resident, Clinical Assistant Professor and Academic Hospitalist at Wayne State University School of Medicine (WSU), published author and speaker. I am excited to start my journey as an infectious diseases fellow and candidate of the Health Educators and Leadership (HEAL) track at the University of Nebraska Medical Center!“
Welcome Dr. Al-Kourainy!
Dr. Catherine Cichon
“I am excited to be joining the University of Nebraska Medical Center (UNMC) as a first year Infectious Disease fellow! I will spend the next few years learning about disorders caused by bacteria, viruses, fungi, and parasites, the people affected by them, and the medications that treat them.“
Dr. Cichon completed her combined Internal Medicine and Pediatrics residency at the University of California San Diego (UCSD).
Welcome Dr. Cichon!
Dr. Timothy Jang
“I am excited to be starting out as an infectious diseases fellow at the University of Nebraska Medical Center! I will be taking care of patients on both an inpatient and outpatient basis, under the guidance of a fantastic team of seasoned infectious diseases clinicians.”
Dr. Jang completed his residency training in Internal Medicine at Wright State University in Dayton, Ohio.
Welcome to the program Dr. Jang!
Stay tuned in the coming weeks to learn more about these new additions to UNMC ID.
A #PharmToExamTable question about cefiderocol and its clinical uses, answered byAaron Hunsaker, PharmD, a previous PGY1 pharmacy resident at UNMC and current PGY2 pharmacy resident a the University of Utah Health.
(Reviewed by Andrew Watkins, PharmD)
In the area of increased gram-negative bacterial resistance, practitioners have longed for a horse with which they could ride into battle. Cefiderocol, or Fetroja, could possibly be that fix. The brand name even hints to its novel mechanism and their website pulls on this, showing Roman soldiers going into battle with their trojan horse. The goal of this review is to summarize the pharmacology, pharmacokinetics, and literature of cefiderocol and where it has the potential to be used.
Pharmacology1
Mechanism of action: Cefiderocol is a cephalosporin that has activity against gram-negative aerobic bacteria. Like other beta lactam antibiotics, it enters the cell via passive diffusion through porin channels. It also functions as a siderophore and binds extracellular free iron. This allows cefiderocol to enter the cell via bacterial siderophore iron uptake, which allows the molecule to overcome porin channel deletions.
Recommended Dosage: 2 grams every 8 hours infused over 3 hours
Primary Literature Review:
APEKS-cUTI by Portsmouth et al 2
This is a phase 2 clinical trial that compared cefiderocol to imipenem-cilastatin for the treatment of complicated urinary tract infections (cUTI) caused by gram-negative bacteria. With a sample size of 371, Cefiderocol was a non-inferior treatment compared to imipenemin the treatment of cUTI.
APEKS-NP by Wunderink et al 3
This was a phase 3 clinical trial that compared cefiderocol to extended infusion meropenem for the treatment of gram-negative nosocomial pneumonia. The trial was able to recruit 251 participants, among which the most common pathogen was Klebsiella pneumoniae (32%) followed by Pseudomonas aeruginosa (16%). This was a relatively sick population with a majority of patients in the ICU at baseline (77%). Cefiderocol was also non-inferior to extended infusion meropenem in prevention of mortality from nosocomial pneumonia infections. The safety profile was similar between the two medication groups.
CREDIBLE-CR by Bassetti et al.
This is a phase 3 descriptive trial that studies the efficacy and safety of cefiderocol to best available therapy for the treatment of serious infections caused by carbapenem-resistant gram-negative bacteria. Among the 150 recruited participants, the most common source of infection was nosocomial pneumonia (45% in both groups) followed by bloodstream infections (~30-35% in both groups). Acinetobacter baumannii and Klebsiella pneumoniae were the two most common carbapenem-resistant gram-negative pathogens. Clinical cure for nosocomial pneumonia occurred in 60% cefiderocol treated patients (24/40) and 63% in best available therapy treated patients (12/19). Clinical cure for bloodstream infections or sepsis occurred in 70% of cefiderocol treated patients (16/23) and 50% in best available therapy (7/14), but all-cause mortality was higher in the cefiderocol group when patients had an infection caused by Acinetobacter spp. or in pulmonary and bloodstream infections, but not with cUTIs.
Conclusion:
Cefiderocol is a novel cephalosporin that has a broad spectrum of activity against gram negative organisms. However, what do these differences in data mean for the future of cefiderocol? Well:
APEKS-cUTI and APEKS-NP showed that cefiderocol can be used in complicated urinary tract infections and pneumonia caused by multi drug resistant gram-negative organisms.
All three trials showed positive outcomes in infections caused by Klebsiella pneumoniae, Pseudomonas aeruginosa, and Escherichia coli. APEKS-NP also showed us the potential use of cefiderocol in a relatively sick patient population.
However, the CREDIBLE-CR trial complicates the recommendation for the use of cefiderocol in patients with a pulmonary infection and bloodstream infection, especially infections caused by Acinetobacter spp.andStenotrophomonas.
While the differences were likely significant, it is important to note that no statistical tests were run, the trial was an open labeled study, and the patient population was small, leaving us with a desire for more data to further support the use of cefiderocol in these types of infections. Therefore, the use of cefiderocol in pulmonary infections or bloodstream infections should be used with caution and if it is considered, it should be used as a last-ditch effort. Further studies with larger populations and statistical analyses are needed to fully make a recommendation.
Simon Portsmouth et al. Cefiderocol versus imipenem-cilastatin for the treatment of complicated urinary tract infections caused by Gram-negative uropathogens: a phase 2, randomised, double-blind, non-inferiority trial. Lancet Infect Dis. 2018 Dec;18(12):1319-1328. doi: 10.1016/S1473-3099(18)30554-1.
Richard G Wunderink et al. Cefiderocol versus high-dose, extended-infusion meropenem for the treatment of Gram-negative nosocomial pneumonia (APEKS-NP): a randomised, double-blind, phase 3, non-inferiority trial. Lancet Infect Dis. 2020 Oct 12;S1473-3099(20)30731-3. doi: 10.1016/S1473-3099(20)30731-3.
Matteo Bassetti et al. Efficacy and safety of cefiderocol or best available therapy for the treatment of serious infections caused by carbapenem-resistant Gram-negative bacteria (CREDIBLE-CR): a randomised, open-label, multicentre, pathogen-focused, descriptive, phase 3 trial. Lancet Infect Dis. 2020 Oct 12;S1473-3099(20)30796-9. doi: 10.1016/S1473-3099(20)30796-9
The following content was provided by graduating UNMC ID fellow, Dr. Laura Selby (pictured left).
Dr. Selby will be transitioning to an infectious diseases faculty position in Bend, Oregon. Congratulations Laura!
If one word could sum up my clinical experience of the last two years of Infectious Diseases fellowship it would be “pandemic”. When I moved to Nebraska and started training at UNMC in July of 2020, the United States was only a few months into the COVID-19 pandemic. There was limited evidence for what treatments worked best, vaccines were not yet available, and PPE shortages continued to make news nationwide.
So much of my learning as an ID fellow happened through the lens of COVID. I learned how to treat multi-drug resistant secondary bacterial pneumonia from COVID patients. Differentiating viral vs bacterial infections was nearly every COVID consult. Hospital epidemiology and infection prevention lessons were learned through COVID outbreak investigations. I worked on my patient communication skills by explaining the importance of COVID vaccination to my HIV Clinic patients. My research projects pivoted to, you guessed it, COVID.
This is not to say that I wasn’t well trained in all areas of Infectious Diseases during my fellowship. With the notable exceptions of low influenza rates, and travel medicine consults, throughout the pandemic people still had bacteremias, prosthetic joint infections, neutropenic fevers, and newly diagnosed HIV requiring ID consultation and management. Patients still got cancer treatment and organ transplants, so my experience with immunocompromised hosts wasn’t compromised (no pun intended). Yet, for nearly every diagnostic mystery consult, COVID was added to my differential right next to syphilis, TB, and histoplasmosis.
Amid the stress, overwork, and death that the COVID-19 pandemic has brought, watching the faculty of the UNMC ID Division practice and model compassion for patients, evidence-based medicine, and conduct research, all while still finding time to give lectures and teach on rounds, has shaped me as a physician and a person. I could fill pages with all the lessons I have learned from each of the standout faculty at UNMC such as learning the intricacies of randomized controlled trials from Dr. Andre Kalil during journal club and rounds, training in high consequence pathogen preparedness and PPE with Drs. Elizabeth Schnaubelt, David Kline, and Angela Hewlett, lessons on travel medicine with Drs. James Lawler and David Brett-Major while rounding on patients who haven’t traveled (thanks COVID), diagnostic stewardship skills from Drs. Trevor Van Schooneveld and Kelly Cawcutt, how to conduct a hospital outbreak investigation from Dr. Mark Rupp, employee health management in a pandemic with Dr. Rick Starlin who was also a wonderful research mentor, how to practice evidence-based medicine when the evidence is questionable at best from Dr. Nicolas Cortes-Penfield, management of patients with HIV from Drs. Sara Bares, Nada Fadul, Sue Swindells, and Jasmine Marcelin, and all the other amazing faculty I have neglected to name.
As I prepare to leave fellowship and move onto the next stage of my career, I am grateful that I had the opportunity to train at such an amazing program. It has been a privilege to work with the UNMC Infectious Diseases Division.
– Dr. Laura Selby, Graduating UNMC ID Fellow, June 2022
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