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Hot Topics in Healthcare – HAIs and Infection Prevention Post-Pandemic

Post written by Dr. Kelly Cawcutt & originally posted at https://www.cloroxpro.com/blog/hot-topics-in-healthcare-hais-infection-prevention-post-pandemic/

The COVID-19 pandemic has brought unprecedented changes to healthcare throughout the world. Fraught with high volumes of patients and paucity of resources and testing, combined with personal protective equipment (PPE) and staffing shortages the past year has taught the healthcare community lasting lessons in resilience.  The rapidly advancing knowledge around the SARS-CoV-2, the virus that causes COVID-19, has also prompted a shift in the standard of care. In the face of such multifaceted challenges, the world of Infection Prevention and the capacity to monitor and prevent healthcare-associated infections (HAIs), changed.

How, why, and what changes have occurred?

Stevens et al described the impact on HAI prevention efforts as notable due to diversion of human resources for surveillance and case identification, process measures for prevention of HAIs (such as hand hygiene), mitigation resources (lack of real-time feedback), and the lack of adequate supplies of PPE for traditional HAIs resulting in potential increased risk of cross-contamination.

The transmission of SARS-CoV-2  lacked clarity, but was described to spread via aerosol and surface contamination in 2020. Infection prevention resources were critical in this environment of uncertainty, both for adequate disinfection of surfaces, but also for appropriate use of PPE. Although the overall risk of surface contamination resulting in transmission of SARS-CoV-2 was ultimately deemed to be low, effective disinfection practices were still necessary, adding to the workload burden of already overstretched infection prevention teams.

Furthermore, the level of illness of patients affected by COVID-19 combined with the limited PPE resources, resulted in changes in patient care that could be unpredictable at times. In clinical care settings for example, the long length of hospital stay, particularly in the intensive care unit (ICU), was accompanied by longer durations of support devices, such as endotracheal tubes, central venous catheters (CVCs), and urinary catheters. The longer duration of which increased the numbers of opportunities for in the failure of executing process measures to prevent HAIs.

 The increased use of prone positioning, even amongst non-ventilated patients, may have negatively impacted visible access to many dressings and device sites for several hours per day. Finally, with PPE limitations, many adjustments were made to decrease required trips and time spent in  patient rooms, such as transitioning intravenous medication pumps to outside of patient rooms. Such changes may have positively impacted PPE utilization rates, but may have carried negative counterbalances with increased risks of HAIs due to lack of direct visualization, longer tubing with possible increased risks of contamination, and potential preference for more durable catheters, such as CVCs to minimize risk of dislodgement or need for new access placement. Finally, it was would be remiss to not acknowledge that all of the above were further augmented by the fear and anxiety that resulted from the many unknowns and struggles faced by healthcare workers, and may have increased the risk for error.

What was the result?

The data is still evolving, but increased rates of HAIs have been reported. Amongst the critically ill, one study showed a 46% increase in HAIs, with ventilator-associated pneumonia (VAP) and central line associated bloodstream infections (CLABSIs) as leading causes. Interestingly, within this group, only the intubated patients were noted to have HAIs. A review similarly showed several studies with increased CLABSIs amongst patients with COVID-19, as compared to those without. Moreover, a study of CLABSI data from the National Health Safety Network as similarly demonstrated a 28% increase in CLABSI from early in the pandemic. Of interest, Clostridiodes difficile rates have decreased in some studies, without concurrent decreases in antibiotic use, highlighting that strong infection prevention measures including environmental cleaning and use of PPE and handwashing remain critical in the prevention of nosocomial spread of this infection.

So, where do we go from here?

We must recognize the impact the pandemic has had on healthcare, with rapid changes in practice, high work burdens with increasing burnout, and the need to move forward. Hardwiring our HAI prevention practices to ensure consistency in both the best and worst of times is critical. Considering how to identify, implement and amplify the positive innovations and changes throughout the field is necessary. Of paramount importance is ensuring robust infection prevention teams have adequate resources for surveillance, mitigation, education and quality improvement.

Thank you to all of the tireless Infection Prevention teams, continuing to strive to provide the safest care for our patients and healthcare teams around the world!

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High-level Review: Updated STI Guidelines Part 2

In July 2021 the Center for Disease Control and Prevention (CDC) released their sexually transmitted infections (STI) treatment guideline, an update from 2015.1 Below, senior ID fellow Dr. Jonathan Ryder highlights significant (but by no means comprehensive) changes in this new guideline that can be incorporated into clinical practice and some of the evidence supporting these changes. Part 2 – Bacterial Vaginosis, Trichomonas, Pelvic Inflammatory Disease

Bacterial Vaginosis (BV)

Photomicrograph of vaginal smear with normal epithelia cell and epithelia cell covered with bacteria, known as a clue cell. Image Source: CDC Public Health Image Library https://phil.cdc.gov/Details.aspx?pid=14574

            In a fairly interesting and somewhat controversial recommendation given current medical teachings, the CDC guidelines reversed course on counseling against alcohol consumption during treatment with metronidazole. Citing a Norwegian study, the guideline authors comment that no studies have demonstrating convincing evidence of a clear interaction between alcohol and metronidazole causing a disulfiram-like reaction.6 A study supporting this recommendation from 2002 included 12 healthy volunteers randomized to either oral metronidazole 200mg three times daily or placebo followed by drinking 0.4g/kg of ethanol found no difference in blood acetaldehyde levels or any subjective or objective evidence of a disulfiram-type reaction.7

            Treatment recommendations for BV remain the same with oral metronidazole 500mg twice daily for 7 days or either topical metronidazole gel or clindamycin cream being the preferred options.

Trichomonas

Trichomonas vaginalis protozoan parasites. Image Source: CDC Public Health Image Library https://phil.cdc.gov/Details.aspx?pid=14500

            New guidelines recommend a 7-day course of oral metronidazole 500mg twice daily for women with trichomonas, which differs from the prior recommendation of one dose of oral metronidazole 2g. However, in men, the single dose of oral metronidazole 2g is still recommended. The evidence for this change comes from a randomized controlled trial in women with HIV showing increased effectiveness of the 7-day treatment course compared to single dose as well as a meta-analysis including women without HIV showing the same.8 A single dose of oral tinidazole 2g remains an alternative treatment for both men and women.

Pelvic Inflammatory Disease (PID)

            The recommended treatment for PID now includes anaerobic coverage, specifically with metronidazole. Based on a randomized controlled trial comparing ceftriaxone and doxycycline with or without metronidazole, the metronidazole group was found to have decreased presence of endometrial anaerobes, less Mycoplasma genitalium, and reduced pelvic tenderness.10 Therefore, the preferred regimen for PID is ceftriaxone 1g daily plus doxycycline 100mg twice daily plus oral metronidazole 500mg twice daily. Cefotetan or cefoxitin with doxycycline are also recommended. Notably, the higher dose ceftriaxone used for gonorrhea above should be used for PID as well when given as an outpatient.

For another summary of the changes, Ina Park, MD has an excellent Twitter thread:

References

  1. Fjeld H, Raknes G. Er det virkelig farlig å kombinere metronidazol og alkohol? [Is combining metronidazole and alcohol really hazardous?]. Tidsskr Nor Laegeforen. 2014;134(17):1661-1663. Published 2014 Sep 16. doi:10.4045/tidsskr.14.0081
  2. Visapää JP, Tillonen JS, Kaihovaara PS, Salaspuro MP. Lack of disulfiram-like reaction with metronidazole and ethanol. Ann Pharmacother. 2002;36(6):971-974. doi:10.1345/aph.1A066
  3. Kissinger P, Mena L, Levison J, et al. A randomized treatment trial: single versus 7-day dose of metronidazole for the treatment of Trichomonas vaginalis among HIV-infected women. J Acquir Immune Defic Syndr. 2010;55(5):565-571. doi:10.1097/QAI.0b013e3181eda955
  4. Howe K, Kissinger PJ. Single-Dose Compared With Multidose Metronidazole for the Treatment of Trichomoniasis in Women: A Meta-Analysis. Sex Transm Dis. 2017;44(1):29-34. doi:10.1097/OLQ.0000000000000537
  5. Wiesenfeld HC, Meyn LA, Darville T, Macio IS, Hillier SL. A Randomized Controlled Trial of Ceftriaxone and Doxycycline, With or Without Metronidazole, for the Treatment of Acute Pelvic Inflammatory Disease. Clin Infect Dis. 2021;72(7):1181-1189. doi:10.1093/cid/ciaa101

High-level Review: Updated STI Guidelines Part 1

In July 2021 the Center for Disease Control and Prevention (CDC) released their sexually transmitted infections (STI) treatment guideline, an update from 2015.1 Below, senior ID fellow Dr. Jonathan Ryder highlights significant (but by no means comprehensive) changes in this new guideline that can be incorporated into clinical practice and some of the evidence supporting these changes. Part 1 – Chlamydia, Gonorrhea, Mycoplasma genitalium:

Chlamydia

Intracellular inclusion bodies of Chlamydia trachomatis. Image Source: CDC Public Health Image Library https://phil.cdc.gov/Details.aspx?pid=6428  

Preferred treatment regimen for chlamydia is now oral doxycycline 100mg twice per day for 7 days. Oral azithromycin 1g for a single dose is now an alternative regimen instead of a preferred regimen.

There are multiple reasons for this change. First, several randomized controlled trials have shown superiority of doxycycline to azithromycin for treatment of chlamydia, including two trials in men who have sex with men (MSM) with rectal chlamydia and one trial in adolescents with urogenital chlamydia.2-4 Second, there is increasing concern for azithromycin resistance in Neisseria gonorrhea, Streptococcus pneumoniae, Mycoplasma genitalium, Shigella, and Campylobacter infections; thus, by changing recommended therapies, we can reduce the selective pressure on these other pathogens.5

There are a few exceptional instances in which a single dose of azithromycin is preferable to a week of doxycycline: pregnancy and concern for nonadherence.

Gonorrhea

Gram-negative, Neisseria gonorrhoeae intracellular diplococci. Image Source: CDC Public Health Image Library https://phil.cdc.gov/Details.aspx?pid=3846

            Prior guidelines recommended treatment of gonorrhea with a single dose of intramuscular ceftriaxone 250mg plus a single dose of oral azithromycin 1g. In late 2020 the CDC released a new update in Morbidity and Mortality Weekly Report (MMWR), which is now reflected in the current guidelines.5 The new recommended treatment for uncomplicated gonococcal infections of any site is a single dose of intramuscular ceftriaxone 500mg. However, if the patient weighs ³150kg (300 lb), then 1g of intramuscular ceftriaxone should be administered instead.

The change in therapy for gonococcal infections is due to emerging resistance, antimicrobial stewardship concerns, and pharmacologic reasons. As shown in the figure below, azithromycin resistance in gonorrhea has increased nearly tenfold from 2013 (0.6%) to 2019 (5.1%).5 As mentioned above, continued azithromycin use has raised concerns in antimicrobial stewardship due to increasing resistance in other pathogens as well as its decreased effectiveness against chlamydia. Lastly, higher doses of ceftriaxone are more likely to achieve adequate time above the MIC, especially in the pharynx, a location known to be more difficult to eradicate N. gonorrhoeae, and in gonococcal strains with higher MICs.

From: St Cyr S, Barbee L, Workowski KA, et al. Update to CDC’s Treatment Guidelines for Gonococcal Infection, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(50):1911-1916.

            Alternative regimens for gonorrheal infections now include higher dose oral cefixime (800mg for one dose instead of 400mg) as well as intramuscular gentamicin 240mg for one dose combined with a single dose of oral azithromycin 2g. These alternative regimens are not considered reliable for pharyngeal gonorrhea.

Check out this episode from the National STD Curriculum podcast for more on the gonorrhea update: https://www.std.uw.edu/podcast/episode/hot-topic/gonorrhea-treatment-updates

Mycoplasma genitalium

Medical illustration of drug-resistant, Mycoplasma genitalium bacteria. Image Source: CDC Public Health Image Library https://phil.cdc.gov/Details.aspx?pid=23243

            A new development for M. genitalium is the presence of an FDA approved nucleic acid amplification test for multiple specimen types. Testing for M. genitalium should be performed in men with recurrent non-gonoccocal urethritis and women with recurrent cervicitis or pelvic inflammatory disease (PID). Asymptomatic screening is not yet advised due to uncertain clinical benefit.

            Treatment for M. genitalium has also changed since prior guidelines due to increasing azithromycin resistance. If resistance testing for macrolide susceptibility is available and performed, that should dictate the treatment regimen. If macrolide sensitive M. genitalium, then oral doxycycline 100mg twice per day for 7 days followed by oral azithromycin 1g first dose then 3 additional days of 500mg daily should be given. However, if macrolide resistant or if susceptibility testing cannot be performed, then a 7-day course of oral doxycycline 100mg twice daily should be followed by oral moxifloxacin 400mg once daily for 7 days.

            For more on this topic, the National STD Curriculum podcast also covered M. genitalium: https://www.std.uw.edu/podcast/episode/literature-review/mycoplasma-genitalium

References

  1. Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep. 2021;70(4):1-187. Published 2021 Jul 23. doi:10.15585/mmwr.rr7004a1
  2. Lau A, Kong FYS, Fairley CK, et al. Azithromycin or Doxycycline for Asymptomatic Rectal Chlamydia trachomatis. N Engl J Med. 2021;384(25):2418-2427. doi:10.1056/NEJMoa2031631
  3. Dombrowski JC, Wierzbicki MR, Newman LM, et al. Doxycycline Versus Azithromycin for the Treatment of Rectal Chlamydia in Men Who Have Sex With Men: A Randomized Controlled Trial [published online ahead of print, 2021 Feb 19]. Clin Infect Dis. 2021;ciab153. doi:10.1093/cid/ciab153
  4. Geisler WM, Uniyal A, Lee JY, et al. Azithromycin versus Doxycycline for Urogenital Chlamydia trachomatis Infection. N Engl J Med. 2015;373(26):2512-2521. doi:10.1056/NEJMoa1502599
  5. St Cyr S, Barbee L, Workowski KA, et al. Update to CDC’s Treatment Guidelines for Gonococcal Infection, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(50):1911-1916. Published 2020 Dec 18. doi:10.15585/mmwr.mm6950a6

Diversity in Probiotics and Diversity in Clinical Trials: Opportunities for Improvement

This is a Journal Club review of “A randomized controlled trial of Lactobacillus rhamnosus GG on antimicrobial-resistant organism colonization“: Rauseo, A., Hink, T., Reske, K., … Dubberke, E. Infection Control & Hospital Epidemiology, (2021).

As antibiotic resistance threatens to return us to the pre-antibiotic era where mere skin infections were harbingers of death, we have only a few tools in our box to slow what seems to be inevitable. The 2019  CDC Antimicrobial Resistance Threat report demonstrated 18% fewer deaths from antibiotic resistance overall, and 28% fewer antibiotic-resistance related deaths among hospitalized people since 2013. Despite this, the CDC still reported almost 3 million deaths and over 35K deaths annually from antibiotic resistant infections. Addressing antibiotic resistance includes developing new treatments (hindered by a currently limited, slow pipeline), prevention of spread using infection control, and slowing development of resistance using antimicrobial stewardship. These approaches have been challenged by inconsistent adoption of best practices, emergence of new threats, and incomplete surveillance

The gut microbiota have been examined as organisms of interest in the quest against antimicrobial resistance because while they can be disrupted by systemic antimicrobial use, the gut microbiota themselves may prevent overgrowth and colonization by pathogenic bacteria. Thus the interest in probiotics, with multiple potential advantages including relative safety, low cost, ease of administration and diversity of activity. However, there is still much to learn about the potential benefit, including its use in immunocompromised patients, adequate dosing for efficacy, and which strains are actually useful (McFarland et al.). Prior studies have demonstrated lower rates of C. difficile infection in probiotic recipients compared with placebo recipients (Johnson et. al).  Conversely, other studies have shown no benefit; for example in an RCT pilot of Lactobacillus rahmnosus in ICU patients there were no significant differences in acquisition or loss of any multi-drug resistant organisms compared with placebo (Kwon et. al.)

So this is what we end up telling patients when they ask us about probiotics to prevent C. difficile and antibiotic resistance:

Hence, the important aim of this study by Rauseo et al.: To determine whether Lactobacillus rhamnosus GG (LGG) can safely prevent intestinal colonization due to antimicrobial resistant organisms (AROs).

This was a single center double-blinded, randomized, placebo-controlled pilot trial conducted at Barnes-Jewish Hospital, St. Louis, MO from January 2014-September 2015 among hospitalized adults over 18yrs. Anyone who was immunocompromised, actively dying, or currently having diarrhea was excluded. Interestingly, they also excluded any non-English-speaking individuals. People randomized received either LGG or placebo by orally from enrollment until discharge, and stool/rectal swabs obtained on enrollment and every 3 days until discharge. Primary outcome was overall ARO acquisition, secondary outcomes focused on loss/acquisition of individual ARO, and they collected safety endpoints like mortality and development of Lactobacillus systemic infection.

The groups were pretty similar, and the pilot enrollment was small with only 44 patients in each arm. There were differences in proportion with infection as primary cause of admission and likelihood of previous FQ use. There was no difference in acquisition or loss of ARO for primary or secondary endpoints, and bonus was that it seemed safe overall, with no concerning safety signals.

So can Lactobacillus rhamnosus GG (LGG) can safely prevent intestinal colonization due to antimicrobial resistant organisms (AROs)? The answer based on this study is: NOPE. Unfortunately, there were no practice changing conclusions from this study, but negative studies are important and should be reported. While it is disappointing that we don’t have anything new to tell our patients based on this study, it is still important that we can tell them that there is still not data that probiotics will harm them if they choose to take them.

While the RCT design was desirable, some of the limitations of this study include small sample size; short duration on study drug; potential impact of missed doses and systemic antibiotics on the Lactobacillus effectiveness; and the use of a single organism probiotic instead of a cocktail. Perhaps with a larger, multicenter design based on this preliminary data, the authors may finally be able to help us find the answer to this important question.

With respect to its aim of evaluating the impact of probiotics on ARO, this study is not that controversial or groundbreaking. However, it is perplexing that the authors chose to lump individuals into White/Nonwhite categories only, because that assumes White is the default, when in fact, the Black and White populations of St. Louis are almost equal. Additionally, the “nonwhite category” only includes Black and Asian participants; the ethnicity category in the demographics is absent (despite the fact that the city of St. Louis includes about 4% Hispanic/Latino people); and the authors excluded non-English speaking people, without explanation or scientific justification in the article regarding these choices. These represent some missed opportunities by both the authors and the journal to ensure that equity is adequately addressed in research assessing the impact of therapeutics on clinical disease.

Check out a letter to the editor I submitted about these points in collaboration with Nada Fadul MD, Kelly Cawcutt MD, and Jacinda Abdul-Mutakabbir PharmD, with some suggestions on how researchers and journals can commit to equity even if the topic of scholarship is not health disparities. 

Health Equity scholars like Dr. Rhea Boyd and others have been calling for a systematic approach to addressing race and equity in biomedical research and publishing for some time now, and I hope that researchers and journals are listening.  

Jasmine Marcelin, MD, FACP, FIDSA

Welcoming our New Infectious Diseases Fellows: Dr. Timothy McElroy

We are excited to welcome Dr. Timothy McElroy 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, my name is Tim McElroy and I’m excited to be joining the ID team at UNMC this year!

Tell us about your background
I was born and raised in central Illinois before moving to the University of Chicago for my undergraduate degree. After some frigid winters, it was a blessing to do my medical school at Ross University on the island of Dominica in the Caribbean before returning to Chicago to complete clinical rotations. Residency took me to Geisinger Medical Center in Danville, PA for four great years of Med-Peds training. There I met my wife Chelsea who has made life so much better! While she was finishing her Med-Peds residency, I worked as a Nocturnist for a year before coming to Omaha for fellowship training.

Why did you choose to come work at UNMC
I chose to specialize in Infectious Disease because it is endlessly fascinating. You get to be involved in the care of a diverse set of patients from all walks of life. There is a mix of inpatient consults, often on the most complex or puzzling presentations in the hospital across all medical and surgical specialties. You also get the privilege of caring for people on an outpatient basis in HIV clinic as well as general clinics.

What makes you excited about working in ID
I am very interested in how we can best and most efficiently use our available antibiotics to slow down the rise of antimicrobial resistance and am looking forward to working with our ID pharmacists as well as the rest of the Stewardship team. 

Tell us something about yourself that is unrelated to medicine
Outside of the hospital I like to travel and experience different cultures through their local foods. I also like to cook, although my meals tend to be too elaborate and take too long to prepare (ask Chelsea!). Our Weimaraner Kane also fills a lot of our time as he loves to go for runs and walks as well as play fetch for hours. Chelsea and I look forward to finding and building a community in Omaha as we move into this season of life. Can’t wait to get started! Please get your Covid-19 vaccine if you have not yet gotten one!

photo of a black Weimaraner dog's face.
Dr. McElroy’s dog, Kane

Learn more about the UNMC Infectious Diseases Fellowship here.

Welcoming our New Infectious Diseases Fellows: Dr. Mackenzie Keintz

We are excited to welcome Dr. Mackenzie Keintz 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 will be starting my Infectious Disease fellowship at University of Nebraska Medical Center. I will spend the next two (or three?!?) years learning about infectious diseases and antimicrobials. I plan to focus on antimicrobial stewardship and general infectious diseases but look forward to learning about all areas in the next few years!

Tell us about your background
I was born in a small town in northern Wisconsin. I did my undergraduate studies at University of Wisconsin-Madison in Madison, WI where I majored in Medical Microbiology and Immunology and Biology. This is where I first developed my love for infectious diseases! I then went to medical school at St. George’s University. I spent my first two years in Grenada where I got to see tropical infectious diseases first hand. I then moved to Atlanta, Georgia to finish medical school. I came to UNMC for my Internal Medicine residency and am very excited to be staying for my Infectious Diseases fellowship.

Why did you choose to come work at UNMC
I chose UNMC for Internal Medicine residency in part because of the strong Infectious Diseases fellowship program. During residency, I was able to form strong mentorship bonds that truly made leaving the program incredibly hard. Working with the incredible faculty throughout my three years made staying at UNMC the right decision for my career. My interest in ID is antimicrobial stewardship. Our stewardship team is one of the best in the country (maybe I’m biased?), and I look forward to training under them throughout my fellowship. Furthermore, having access to the biocontainment unit and leaders in the field of emerging pathogens is an experience I don’t know I would be able to get anywhere else. Our training here is well balanced between general ID, immunocompromised services, and antimicrobial stewardship so I know that when I come out of fellowship I will be prepared for whatever position I decide to take.

What makes you excited about working in ID
Initially what attracted me to ID was getting to play detective on the strange and interesting cases. The part of ID that I find most interesting (or maybe equally interesting) at this point in my career is antimicrobial stewardship. I really enjoy taking care of patients with very complex problems, determining when/and if antibiotics are required and if we can narrow our spectrum to fight antimicrobial resistance.

Tell us something about yourself that is unrelated to medicine
In addition to my interest in microbes, I also have an interest in other flora and fauna. Within my house you will find two rabbits, two cats, a planted aquarium full of fish and innumerable shrimp, as well as orchids, mushrooms, cacti, and many other plants. It is honestly a wonder that everyone manages to coexist.

Dr. Keintz’s rabbits, Reggie (L) and Fay (R)

Learn more about the UNMC Infectious Diseases Fellowship here.

Welcoming our New Infectious Diseases Fellows: Dr. Bryan Walker

We are excited to welcome Dr. Bryan Walker 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 beginning my first year in infectious diseases training at the University of Nebraska Medical Center (UNMC). Over the next two years I will be immersed in the sub-specialty of infectious diseases, both in the inpatient and outpatient settings. My hope is that my time here will help me become a clinician expertly prepared to assess and care for those affected by infectious diseases.     

Tell us about your background
I am from East Tennessee and went to college at the University of Tennessee in Knoxville.  My undergraduate degree was in microbiology, which is where I first became interested in infectious diseases.  After college, I moved to Maryland to work at the National Institute of Allergy and Infectious Diseases, where I studied and worked on fungal genomics.  My boss in Maryland was an infectious diseases doctor and he largely propelled me toward a career in medicine.  Subsequently, I attended medical school at the George Washington University School of Medicine and Health Sciences in Washington, DC. I came back down to Knoxville, Tennessee for internal medicine residency.  Throughout my clinical training, infectious diseases have remained a key interest.   

Why did you choose to come work at UNMC
I originally visited Omaha and UNMC when I was interviewing for internal medicine residency back in 2017.  After my interview, I knew that it was a special place in terms of internal medicine practice and training. It stayed on my mind throughout residency as a definite place of interest.  After researching the program for infectious diseases fellowship, I was especially struck at how both comprehensive and well-organized the training program appeared to be. Having dedicated clinical experiences in orthopedics, oncology, and transplant, for example, caught my eye.  After my interview day, I learned that the program’s strongpoints were largely the result of a dedicated program leadership and faculty.  There is a sincere interest at UNMC in helping me become the clinician I hope to be.   

What makes you excited about working in ID
I am excited to work in ID for so many reasons! For one, I love how pervasive the field is. Perhaps more so than any other specialty, it is fundamentally shaped by humankind, our interactions with one another, and our role in nature. As a result, there is not a single patient, culture, or community unaffected by it. There will always be a new problem to solve and challenge to overcome.  Secondly, I identify with the culture (no pun intended!) of infectious diseases medicine.  Patient advocacy, scholarship, and a general conscientiousness toward patient care are characteristics exemplified by my own clinical role models. It seems more than just a coincidence that most all of them are infectious diseases practitioners.   

Tell us something about yourself that is unrelated to medicine
Outside of medicine, I have been fortunately married to the smartest and coolest person I know for six years now and we are expecting our first child this summer! We like to cook, eat, watch movies, read, and work-out together.  I’ve also played guitar since I was a kid and still enjoy trying to play when I have a chance to. I just picked up rollerblading again after an 18-year hiatus and have not broken any bones yet. Overall, my wife and I are excited about living here in Omaha, seeing what the area has to offer and seeing in what ways we can help!  

Learn more about the UNMC Infectious Diseases Fellowship here.

UNMC ID is growing and we want you to join us!

Due to unprecedented growth and success, the Division of Infectious Diseases at the University of Nebraska Medical Center in Omaha, NE is recruiting for three (3) faculty members to join our team. 

Oncology & Solid Organ Transplant (SOT) ID

  • Provide care for immunocompromised patients in inpatient and outpatient settings with experienced advanced practice providers
  • Collaborate with highly accomplished colleagues in SOT/Oncology ID
  • Abundant clinical and translational research opportunities
  • State-of-the-art Fred & Pamela Buffet Cancer Center
  • Teach medical students, residents, and ID fellows on the Oncology-ID and SOT-ID consult service

Apply here: https://unmc.peopleadmin.com/postings/58781

General ID

  • Join the team including ID Physicians, advanced practice providers, and clinical and research support personnel.
  • Provide care for both inpatients and outpatients at Nebraska Medicine and through our collaborative relationships
  • Explore abundant clinical and research opportunities.
  • Teach medical students, residents, and ID fellows on the General ID consult service
  • Opportunity to participate in collaborative work with the federally-funded Infection Control and Antimicrobial Stewardship programs (ICAP/ASAP) to offer guidance to healthcare facilities throughout the state and region

Apply here:  https://unmc.peopleadmin.com/postings/59815

Community ID

  • Provide inpatient and outpatient care with skilled advanced practice providers
  • Provide ambulatory telehealth ID consultation services in several communities across Nebraska 
  • Collaborative activities with the ICAP/ASAP Program to offer infection control and antimicrobial stewardship guidance to healthcare facilities across Nebraska 
  • Abundant clinical and/or research opportunities

Apply here:  https://unmc.peopleadmin.com/postings/59954

About UNMC:

The Division is a robust group comprised of 27 ID physicians, advanced practice providers, and clinical and research support staff. We provide full spectrum infectious disease care at our clinical partner, Nebraska Medicine.   Members of the division pursue specialty interests in all areas of infectious diseases including Biopreparedness, Critical Care, Orthopedic ID, HIV, Infection Control, Antimicrobial Stewardship, Occupational Health, Clinical Microbiology, Oncology ID, Solid Organ Transplantation ID, etc. We enjoy productive collaborative relationships with clinicians and scientists in numerous departments. We have a full portfolio of funded research and a robust educational mission including a thriving ID fellowship training program.    

The successful candidate must be an MD/DO (or equivalent degree) who is board certified/eligible in Infectious Diseases with excellent clinical skills and enthusiasm for patient care, teaching, and clinical research. Our compensation package is extremely competitive.  In addition, comprehensive benefits and relocation assistance are offered. Academic rank is dependent on qualifications. Individuals from diverse backgrounds are encouraged to apply.

Learn more at:

Publication Alert: De-Isolation of COVID19 Patients

UNMC ID Fellowship graduate (’21), Clayton Mowrer, D.O., MBA.

Content by Dr. Clayton Mowrer, 2021 UNMC ID graduate.

Early in the pandemic, it became clear that patients with COVID-19 can demonstrate prolonged detection of viral RNA (as along as weeks to months), which can lead to prolonged hospitalizations, especially for those patients with more severe disease. One of the difficulties often encountered in managing these patients was in determining how long they were required to be in isolation. Initially, the policy for removal of isolation at UNMC involved two sequential negative molecular testing 24 hours apart. However, after studies surfaced demonstrating the probability of isolating replication-competent SARS-CoV-2 virus was rare after 14 days of illness and at cycle-threshold (Ct) values greater than 30, UNMC revised our policy to reflect a conservative approach based on these findings. In June 2020, the revised policy stated that, in a patient who continues to test positive, isolation precautions could be removed 21 days after 1st positive test after review by the COVID ID team.  

In this study recently published in Infection Control & Hospital Epidemiology, we set out to: 

  • Evaluate UNMC de-isolation policy 
  • Describe the clinical characteristics of these patients 
  • Describe the Ct values 

We performed a retrospective study of adult hospitalized patients with persistently positive SARS-CoV-2 molecular testing who were removed from isolation after 21 days from their first positive test. Of the 23 patients we evaluated, we found that 4 (17%) of patients were considered to be immunocompromised. 19 (83%) of patients were considered to have severe disease (per NIH criteria), with 7 (30%) still mechanically ventilated.  

With regards to the Ct values, we compiled and evaluated 94 total tests these 23 patients. We found that, as demonstrated in the below table and figure, Ct values showed a general upwards trend over time and that there was a statistically significant difference in the mean Ct values between time interval. All Ct values after 21 days from first positive test were shown to be >30.  

Chart, scatter chart Description automatically generated

These findings, combined with the fact that no cases of transmission within our healthcare system have been linked to patients who have been removed from isolation at day 21, suggest that our 21-day de-isolation policy – which utilizes clinical criteria in conjunction with ID expert consultation – is a reasonable and safe approach. Furthermore, the Ct value, indeed, may be a useful addition in the overall assessment.   

Read the full article here.

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Faculty Spotlight – Dr. Anum Abbas

Tell us about your background:

I was born and raised in Cleveland, Ohio. I did my internal medicine residency and infectious disease fellowship at Creighton University and a third year fellowship at Cleveland Clinic for transplant infectious disease. I am married and have two sons, ages 6 years and 18 months. 

Why UNMC?

UNMC has a robust transplant program in both solid organ transplant and bone marrow transplant. My interest in immunocompromised patients makes UNMC a great place to practice infectious diseases and the collegial work environment here makes this place especially unique!

What about ID makes you excited?

With the detective work involved, treating rare and unusual pathogens, and the different/unusual patient exposures and risks there is never a dull moment in ID.

Tell us something interesting about yourself UNRELATED to medicine:

I love basketball and LeBron James is my favorite player! I also enjoy cooking, playing cards and traveling with my family. 

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