Photo of Drs. Mark Ridder and Clayton Mowrer, UNMC ID 2nd year fellows.
Content provided by Drs. Hewlett, Ridder and Mowrer.
Beginning in 2019, the UNMC ID Fellows have participated in Biopreparedness Training during their 2nd year of fellowship. The ID Fellows learn about emerging infectious diseases and biopreparedness through didactic teaching sessions with internationally-recognized experts in the field, and also participate in specialized PPE training in the Davis Global Center and National Quarantine Unit alongside the Nebraska Biocontainment Unit team. Course directors include Drs. Angela Hewlett, James Lawler & David Brett-Major. Shradar Morgan, RN was a key educator for our fellows this year also.
“We are so fortunate to have the opportunity to learn from folk at the Davis Global Center and the National Quarantine Unit. With so few institutions that have programs such as these, it is truly an incredibly unique experience that allows (and encourages) us to work with and learn from international experts in the field of biopreparedness. It has been one of the highlights of my training here at UNMC.”
– Dr. Clayton Mowrer, 2nd year UNMC ID fellow.
“I appreciated the opportunity to see hands on the process for receiving individuals with exposures to pathogens. To experience directly what we are able to do to maximize patient and provider safety and our preparedness for significant outbreaks was truly eye opening and an enriching experience. I’m happy to have had the chance to take part and learn from world experts.”
Inappropriate outpatient antibiotic use remains a problem needing to be addressed as part of the strategy to reduce antimicrobial resistance. Nebraska (NE) ranks among the highest states for per capita antibiotic (AB) use in outpatient (OP) settings. Nebraska Medicine (NM) partnered with NE Antimicrobial Stewardship Assessment and Promotion Program (ASAP), a program funded by NE DHHS via a CDC grant, to reduce AB prescribing for acute bronchitis in OP settings.
Jasmine Marcelin, MD and Phil Chung, PharmD led a multifaceted approach to reducing antibiotic use in ambulatory clinics within our Nebraska Medicine hospital system. This approach included use of both clinician and patient-focused education with active and passive components.
The antimicrobial stewardship (AS) pilot program targeted Nebraska Medicine ambulatory clinics in three groups during winter 2018. Antibiotic prescribing rates for acute bronchitis were recorded between January-April 2017 and January-April 2018 among the 3 groups.Antibiotic prescribing rates for acute bronchitis for the 15 sites decreased from 53. 7% to 43. 6% (p = 0. 02). There was a sustained reduction in antibiotic prescription in the intervention groups compared with baseline.
The materials used in this quality initiative are available freely on the Nebraska Medicine Antimicrobial Stewardship Program/Nebraska Antimicrobial Stewardship Assessment and Promotion Program website, and this manuscript provides a blueprint for other institutions to implement using these materials. We presented this work as an Oral Abstract at IDWeek2019, Washington DC, and the full results were published in Infection Control and Hospital Epidemiology in May 2021.
Article citation: Chung, P., Nailon, R., Ashraf, M., Bergman, S., Micheels, T., Rupp, M., . . . Marcelin, J. (2021). Improving antibiotic prescribing for acute bronchitis in the ambulatory setting using a multifaceted approach. Infection Control & Hospital Epidemiology, 1-3. doi:10.1017/ice.2021.164
Fellowship application season is open and as the leaders of our ID fellowship, we wanted to highlight some of the exciting aspects of our program. Our program and our division are growing. We began in 2011 with 2 fellows, grew to 4 in 2017, 5 in 2020, and now our full complement is six fellows. Our faculty also continues to grow, as we now have 23 physician faculty and 4 full time ID pharmacists with diverse expertise. Dr. Trevor Van Schooneveld is the Program Director and Director of the Antimicrobial Stewardship program. Dr. Andrea Zimmer is Associate Program Director and also the director of the Oncology ID program. COVID-19 has provided opportunities for us to be flexible and nimble with our recruiting process; we were excited with the amazing fellows we matched last year through virtual interviews, and this year we are looking forward to meeting you on our remote interviews via zoom!
ID Fellows L-R: Drs. Mark Ridder (’21), Jonathan Ryder (’22), Casey Zelus (’22), Clayton Mowrer (’21), Laura Selby (’22)
Fellows at UNMC enjoy a robust clinical experience that includes not only the typically complex patients seen at a tertiary referral center, but also includes extensive experience caring for immunosuppressed patients. In addition to our General ID service, where our fellows gain experience in teaching medical students and Internal Medicine residents, we have two separate immunocompromised services that care for oncology and solid organ transplant patients. We also have an orthopedic infectious diseases rotation where fellows gain experience managing these complex patients and work with faculty who have extensive experience in this area. Fellows have the opportunity to spend time in the non-tuberculous mycobacteria (NTM) clinic, the microbiology laboratory, as well as learn infection control and antimicrobial stewardship. The faculty at UNMC are nationally recognized experts in their field, and are also very approachable and devoted to the education and success of trainees. They have created extensive educational opportunities, covering topics from opportunistic infections in solid organ and hematopoietic stem recipients to emerging global pathogens and biopreparedness. Fellows gain knowledge in HIV/AIDS management working in our multidisciplinary HIV clinic which cares for over 1200 people with HIV. In addition to having access to world class ID expert antimicrobial stewardship, OPAT, and HIV pharmacists, our division also includes an ID pharmacy residency program and opportunities for research collaboration and rounding with pharmacy students, residents and faculty.
Recent graduate Dr. Clayton Mowrer (’21) leading General ID rounds; IM residents and ID Fellow Dr. Jonathan Ryder listen
As new career opportunities develop for ID physicians, we have worked to provide our fellows with the skills to engage in these fields. UNMC ID fellows receive extensive experience in the area of infection control and antimicrobial stewardship. UNMC also offers the opportunity to stay for an option third year to further develop a research portfolio or pursue additional clinical expertise in subspecialty areas.
An important part of fellowship is developing skills in interpreting and performing research, and we provide our fellows with six months of mentored research experience centered on their career goals. A research committee assists fellows in mentor identification and project development. Fellows also participate in a week-long UNMC sponsored research training program, and typically present their work at national conferences like IDWeek and SHEA. Fellows interested in medical education have the opportunity to participate in the UNMC Internal Medicine Health Educator and Academic Leaders (HEAL) Track.
Our goal as program directors is to provide fellows with an educational experience that provides them with skills and knowledge to make them successful in whatever career path they choose. The opportunities available to ID physicians continue to expand and we hope you will consider UNMC ID. If you are interested in more information, please feel free to visit our website where you can check out a video to learn more about us. You can also contact us at the following:
Dr. Trevor Van Schooneveld Program Director, Infectious Diseases Fellowship Medical Director, Antimicrobial Stewardship Program University of Nebraska Medical Center 985400 Nebraska Medical Center Omaha, NE 68198-9400 Email: tvanscho@unmc.edu
Dr. Andrea J. Zimmer Associate Program Director, Infectious Diseases Fellowship Director, Oncology Infectious Diseases University of Nebraska Medical Center 985400 Nebraska Medical Center Omaha, NE 68198-9400 Email: andreaj.zimmer@unmc.edu
On Wednesday, June 3, 2021, the Infectious Diseases Division gathered to celebrate two outstanding fellows, Drs. Mark Ridder and Clayton Mowrer. Both are graduating and moving on to amazing (and different) next steps. These fellows joined our division in July 2019, a mere 6 months before our world would change as a result of the COVID-19 pandemic. They adapted to zoom lectures and conferences, and underwent tremendous growth over the last two years. Thanks to vaccines, we were able to gather to celebrate their graduation in person together.
(best viewed in full screen mode!)
Dr. Ridder and Dr. Mowrer joined our fellowship as we had just gotten used to having 2 fellows per year, and the year after they joined, we expanded to 3 fellows per year. We were honored to help them both grow and develop their infectious diseases knowledge, leadership and team management skills, the art of medical education, and most importantly, to expand their skills in delivering compassionate patient care. We also enjoyed getting to know them as amazing people, share laughs with them, and celebrate milestones with them.
(left photo, Dr. Mark Ridder and Dr. Marcelin with GenID team on rounds; right photo, Dr. Clayton Mowrer and GenID team on rounds)
Dr. Mark Ridder (back 2nd from left) with Specialty Care Center clinic staff: (L-R back Jeremy Johnson, Precious Davis RN, Dan Cramer APRN; L-R front Sara Bares MD, Sheila Daniel Cobos RN, Genie Shumaker)Dr. Clayton Mowrer (middle, back) with clinic staff (L-R) Precious Davis RN, Rachelle Carr, Daniel Cobos RN
During fellowship, Dr. Clayton Mowrer published a manuscript describing an approach to using cycle threshold values for COVID-19 de-isolation. Dr. Mowrer is moving to our division of Pediatric Infectious Diseases, where he will complete his Pediatric ID fellowship at Children’s Hospital. We look forward to still having him around for conferences and collaboration!
Dr. Mark Ridder (Left) and Dr. Clayton Mowrer (Right) in the throes of the annual Specialty Care Center Annual Graduating Fellows’ Farewell Dance Day (this is a legitimate tradition started by our Nurse Case Manager Precious Davis RN, who always encourages our fellows to let loose and enjoy ‘shenanigans’ every once in a while. Every graduating fellow has to do a dance before they leave clinic for the last time)
We will certainly miss them both dearly, but wish them all the best in their journeys, and hope to keep sharing their news along the way!
Household contacts to active SARS-Cov2 to infectious cases has been identified as a significant risk factor for acquisition of infection since early in the pandemic. We identified this as one of our biggest risk factors for colleague acquisition of SARS-CoV2 to infection at Nebraska Medicine as well. This brief report written by a team from Nebraska Medicine/UNMC, shows our experience of our colleagues with household contacts post vaccination. This suggests several important points of the pandemic and fully healthcare providers. The vaccines are very effective (we are ready knew that) however breakthrough cases have been reported. Household contact remains a significant risk factor in these breakthrough cases. As the United States and other locations open up society, we need to keep in mind that all contacts to infections are not equal and consideration for household contacts and needing close monitoring and testing is still warranted. The single biggest thing healthcare providers can continue to do to protect themselves, their families, their colleagues and their patients is to not only get themselves immunized but to get their families immunized, especially their domestic partners. We have continued this program and more data will soon be available.
It took some time to find an a way to accurately summarize the last two years. I’ll start with one easy sentence:
This was a fantastic fellowship, and I would instantly choose it again.
I feel so fortunate that not only did we received such a breadth of training in all aspects of ID (ASP, SOT, ortho), but that we had the unique privilege to work with experts in public health, health security/biodefense, as well as some who were at the forefront of the COVID response.
It was a joy to work with a group of physicians who were such advocates for us fellows and who truly helped us not only become better ID clinicians/researchers but helped us grow as humans – the two of which, in my opinion, go hand-in-hand. I will defer to my colleague’s – Dr. Mark Ridder – elaboration on this in an earlier post, of which I am in full agreement; he is much more eloquent than I.
Regardless, I have lost count of how many of the faculty I consider mentors. And my co-fellows? Absolute Rockstars.
As for my next step: I’m not quite through with my training (cue eye roll for everyone who knows me). I’m headed to complete two years of pediatric ID fellowship next, along with pursuing an MPH here at UNMC. I have yet to determine my next steps following that, but I have developed a passion for emerging pathogens and health security and hope to dive deeper into that world throughout my career.
– Dr. Clayton Mowrer, graduating ID Fellow, June 2021 – heading to Pediatric ID fellowship/MPH at UNMC
As my time draws to a close, I been asked to put forward some final words about fellowship. It is difficult to place in the words all the different things in which I have encountered, learned, and grown from in the past 2 years but I will make my best effort. It is well-known amongst the fellow’s office that I may be not the most succinct, nor the wittiest of our office, but I would like to say that I hope I am remembered for my earnestness. I mean the following words from the bottom of my heart.
The beginning of fellowship was certainly a rocky one. Having spent my time as an internist I was comforted by the degree with which I could feel certain of protocols, treatment modalities, diagnostics, that generally were expected by my peers. It was a challenge to start into a field with which the questions being asked are by their very nature controversial. With time however, I grew to learn and appreciate that these are the exact sort of questions which make medicine all the more enticing, and real. I have learned how to discern the best course of action amid at best mixed evidence, and in particular difficult situations for our patients. It has been exhausting, but with time rewarding and in the end of life giving. With time and growth, I found myself slowly talking the language of my attendings. Being able to speak to different ways in which my colleagues would approach situations, problems, etc. and being able to find for myself which of these was my own style. It was easy to believe that I had reached the pinnacle after completing internal medicine training where I had very clean endpoints within the realm of practice. However, training within infectious diseases I found myself with time becoming comfortable the controversy and individualize patient care based upon the best evidence that I had available.
I think in the end, I believe that training in infectious disease truly rounded out my education.
Furthermore, this training highlighted to me the significant gaps within American health care. Unfortunately, infectious diseases disproportionately affect the marginalized. This has been highlighted in the midst of a pandemic, racial injustices, and political uprising which were the hallmark of my senior year of fellowship. I have been inspired by my mentors and teachers with their foresight and decision making early on in this pandemic. Their tenacity throughout its course was powerful. I am hopeful that by at least being trained by these remarkable individuals that someday I too may be able to tackle these incredibly complex problems with half the degree of grace that they were able to carry on through the course this crisis. It has highlighted to me the requirement of incredible leadership mixed with empathy and recognition of the fear of both patients and clinicians, providing guidance when perhaps there is no clear evidence of the proper way forward.
I think above all else, my time here has underscored the importance of recognizing the humanity of both our patients and ourselves. I have had to come to grips with my own limitations and realize what I am able and unable at times to do, and when I truly need help. I have repeatedly seen time and time again that no matter the aptitude of the clinician, the ultimate requirement for excellent patient care is the ability to reach the individual. I personally experienced, from those who taught me the significance of this approach, and it is my hope that I have learned at least a partial bit of their skill, and I hope to continue to dedicate my life to this practice.
This training has changed me to the core. It has taught me the skills to treat my patients with confidence, using the most targeted strategies possible. It has taught me to be a scrupulous discerner of evidence-based medicine, to be able to apply the best data available while recognizing the limitations for applying my findings globally to my patients. And finally, it has taught me that I need to be an empathetic and available provider in order to access my patients and provide the best possible care. I have a great deal of gratitude for UNMC Infectious Diseases, and I am very privileged to have been able to train here. I thank you all for your time your expertise in your incredible patience.
Dr. Mark Ridder – graduating UNMC ID fellowship June 2021, headed to Marshfield Clinic in Wisconsin
To say that dealing with the COVID-19 pandemic has been challenging may be the understatement of the year. Yet despite COVID-19, our faculty and staff are continuing to publish impactful papers, engage with their communities, transform medical education, practice extraordinary medicine, and change people’s lives.
In this post, we want to highlight our division members who have been honored with local, regional, and national awards over the last several months. This is just a snapshot of the excellence you can find within the UNMC Division of Infectious Diseases, but rather than list all of the accolades, we wanted to SHOW you!
Our Division Chief, Dr. Mark Rupp said “The recent recognition and awards received by the UNMC ID Division is truly remarkable. Not only was the Division recognized for heroic efforts surrounding the COVID-19 pandemic, but while we were all working overtime on COVID, we also received accolades for our accomplishments in teaching, patient care, and research – a real testament to the dedication and passion of the ID faculty, APPs, fellows, and staff. I am incredibly proud of the ID Division and our commitment to excellence in all phases of our mission – delivering compassionate patient care, educating the next generation of healthcare providers, pushing the boundaries of our knowledge, and providing valuable service to our community and our profession”.
We are very proud of the work that our UNMC ID family has been doing over the last year and they deserve all of the awards and recognition. Congratulations to everyone, and we look forward to seeing what we can accomplish in 2021!
Sudan emerged from a 30-year dictatorship in 2019 to face the COVID-19 pandemic with a fragile health system and a half-finished transitional government structure. During the dictatorship, the majority of GDP was spent on military and security forces and very little was spent on health. This led to privatization of healthcare and a near complete collapse of the previously well-structured public health sector. In the beginning of the pandemic, the country did not have any infrastructure or funding for public health services which made it difficult to conduct proper testing and contact tracing. Transitional government officials elected to enter a state or lockdown which was poorly received by the public due to the economic hardships the country was going through. In addition, conspiracy theories from the previous regime allies spread rapidly promoting the myth that COVID-19 does not exist and that the transitional government is using it as an excuse to suppress protestors. In our recently published article, “Re-opening Sudan: the Balance Between Maintaining Daily Living and Avoiding the Next Peak of COVID-19”, we emphasize the role that the community (including religious leaders, youth neighborhood committees and diaspora organizations) played and continue to play in the fight against COVID-19 and we urge the government to develop a formal mechanism to channel these efforts so that their outcomes can be tracked and documented.
Content written by Drs. Van Schooneveld and Stohs.
Antimicrobial stewardship programs improve patient outcomes, efficiency of care, and are a key tool in combating antimicrobial resistance. The field of antimicrobial stewardship is rapidly expanding and while ID fellows have the foundation for leading antimicrobial stewardship efforts, leading such programs require unique skills and knowledge. To meet this need, in 2016 the Infectious Diseases Society of America began to develop a curriculum designed to prepare fellows to lead antimicrobial stewardship programs. UNMC faculty and fellows have been involved in the development and evaluation of this curriculum with a description of the content development and purpose recently published in Clinical Infectious Diseases. The curriculum was created in two parts, a core and an advanced program. Both programs are designed to be integrated into ID fellowship and interactive online learning coupled with application exercises designed to be completed with local stewardship experts.
The core program lays the foundation for understanding antimicrobial stewardship exploring topics like the role of the microbiology lab in stewardship, how to apply stewardship principles to clinical situations, communication of stewardship recommendations, and program logistics. The UNMC fellowship program participated in the initial trial of the curriculum with local faculty with Jasmine Marcelin MD, Scott Bergman PharmD, and Trevor Van Schooneveld MD facilitating the training which included case-based learning, communications training, and role-playing of interactions with clinicians. Fellows found these communication training sessions particularly useful. The core curriculum is currently being updated and Dr. Trevor Van Schooneveld and Dr. Erica Stohs are assisting in this revision.
In addition to the core program, an advanced curriculum was developed targeted at fellows pursuing a career track in antimicrobial stewardship. This program focused on program logistics in much greater detail along with helping fellows understand the role of the stewardship program within the hospital leadership structure. Training was provided on how to “pitch” a program expansion to hospital executives along with advanced communication skills. Fellows were trained in how to go about implementing stewardship in specialized populations such as immunocompromised patients and unique settings such as long-term care, the emergency department, and ambulatory areas. Finally, career development resources were also provided. Dr. Van Schooneveld was part of the team which created the content on stewardship in specialized settings and populations and UNMC fellows have been piloting the advanced curriculum with Dr. Van Schooneveld and Dr. Stohs. IDSA reports that both the revised core curriculum and the advanced curriculum will be available this fall.
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