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At the center of the 2018 West Nile Virus season, UNMC ID physicians encountered an unusual presentation

In 2018, we experienced a particularly severe West Nile Virus season, with an unusually high amount of neuroinvasive disease. Last summer, our senior ID Fellow Dr. Lindsey Rearigh shared an informational blog post about the disease, and more recently, she and Dr. Sara Bares published a case report in the Journal of Neurovirology describing a a patient with an unusual presentation of West Nile Virus disease. Dr. Rearigh shared a summary of her case with us:

What is your publication about?

This is a case presentation that describes a young, healthy adult patient who presented with uveomeningeal syndrome as the initial manifestation of neuroinvasive West Nile Virus (WNV) disease. Uveomeningeal syndrome includes intraocular and meningeal inflammation often from an infectious process such as WNV and would be classified as neuroinvasive disease (i.e. involving the central nervous system).  WNV can have an array of clinical presentations ranging from asymptomatic to febrile illness with vomiting and diffuse myalgias (muscle aches) and even to neuroinvasive disease characterized by meningioencephalitis and flaccid paralysis.

Why is this interesting?

Previously, neuroinvasive and ocular WNV were seen primarily in patients who were elderly (age>50) or had compromised immune systems (due to conditions such as diabetes or malignancy). Our patient was young and healthy, raising concerns for increased WNV virulence. This is coupled with concerns of increased prevalence of neuroinvasive WNV seen in 2018, a year in which approximately half of all cases in Nebraska were diagnosed as neuroinvasive disease.

What future questions does this case raise?

Interestingly, our patient improved on high dose steroids. The standard of care for WNV is usually supportive; the role of corticosteroids remains controversial with concerns for prolonged recovery. There are case reports demonstrating improved outcomes in WNV-associated flaccid paralysis and meningoencephalitis but the evidence is still limited, leaving room for further research in this area.

Citation: Rearigh, L., Kedar, S. & Bares, S.H. J. Neurovirol. (2019). https://doi.org/10.1007/s13365-019-00808-0 

Contraception and Antiretroviral Therapy: Important Interactions to Keep in Mind

Dr. Kimberly Scarsi recently published an important study in Lancet HIV: “Antiretroviral therapy and vaginally administered contraceptive hormones: a three-arm, pharmacokinetic study.”  We were excited to learn more about and feature her work!

Could you please give us a brief summary of the study you performed?

This was a pharmacokinetic evaluation of the effect of antiretroviral therapy (ART) on vaginally administered hormones. Overall, 84 women participated in the study across 21 AIDS Clinical Trials Group (ACTG) and IMPAACT clinical trial sites in Asia, South America, sub-Saharan Africa, and the United States. The participants were all women living with HIV, either not yet on ART or were receiving ART containing efavirenz- or atazanavir/ritonavir, and agreed to use a vaginal ring containing ethinyl estradiol and etonogestrel continuously over 3 weeks. We were able to compare the hormone (ethinyl estradiol and etonogestrel) exposure in both ART groups compared to the control group of women not yet receiving ART.

What was the impetus to conduct this study?

Effective family planning, which often involves the use of hormonal contraception, is an important component of care for women living with HIV. It allows women to plan for desired pregnancies, and planned pregnancies are associated with lower maternal and infant morbidity and mortality, particularly in low- and middle-income countries. Unfortunately, some hormones have drug interactions with some antiretrovirals that may jeopardize hormone effectiveness or tolerability. This is especially true for efavirenz-based ART, which is still the most commonly used regimen worldwide, particularly in low- and middle-income countries where most women with HIV live.

Non-orally administered hormones was believed to reduce the risk of these drug-drug interactions. For hormones administered by a vaginal ring, the mechanism of their effectiveness is systemic exposure (e.g. in the plasma) and ovulation suppression, rather than only local effects (like an intrauterine device). Therefore, the impact of the drug interaction between orally administered medications that may influence hormone exposure is important to understand, yet had not been performed. The study team sought to determine whether estrogen and progestin administered by a vaginal ring would be affected by oral ART containing either efavirenz or atazanavir/ritonavir.

What were some key findings?

The results showed that hormone concentrations were significantly changed by both types of ART. Efavirenz-based ART decreased both ethinyl estradiol and etonogestrel hormones, raising concerns for lack of efficacy and the risk of unintended pregnancies. While the atazanavir/ritonavir-based ART increased progestin exposure (providing reassurance that the contraceptive effectiveness would be maintained), it decreased estrogen exposure, which may increase the risk of mid-cycle bleeding.

While the findings are directionally similar to what we’ve seen with ART and oral hormones to date, the vaginal ring ART-hormone interaction resulted in even larger changes in hormone exposure than what was observed in the oral studies. We aren’t sure if difference is related to the difference in route of hormone administration, or perhaps more likely, differences in the studied population (primarily Caucasian, healthy volunteer in the oral study, racially and ethnically diverse women living with HIV in our study).

What are future directions for work studying the interaction between contraceptives and ART?

The importance of understanding the pharmacology of vaginally administered drugs has particular relevance as vaginal rings are being developed for multipurpose prevention of both HIV and pregnancy. This study has raised awareness that both local and systemic drug interactions need to be evaluated early in vaginal ring development in order to optimize co-prescribing therapies.

For this study, we have ongoing work evaluating the influence of pharmacogenetics on the extent of the drug interaction observed between the vaginally administered hormone and ART. In addition, we are evaluating the effect of the vaginal ring on the vaginal microbiome, as well as the effect of the vaginal microbiome on hormone exposure.

My work outside of this study is includes evaluating and managing drug interactions with other types of contraceptives, especially subdermal implants, with antiretroviral therapy. I have a study that is going to be wrapping up soon in Uganda, which is evaluating using dose adjustment of hormones to overcome the common drug-drug interaction with efavirnez-based ART.

You can read more about Dr. Scarsi’s work here, as well as a commentary from other HIV researchers expanding on the value of this study.  Follow Dr. Scarsi on Twitter at @KimScarsi, and her co-author Dr. Katy Godfrey @katygodfrey6. 


 

Journal Club: Should vancomycin be given as prophylaxis for Clostridioides difficile infections?

The following is a review by one of our fellows, Dr. Randy McCreery, who at a recent journal club presented a paper by Johnson, et al.: Effectiveness of Oral Vancomycin for Prevention of Healthcare Facility-Onset Clostridioides difficile Infection in Targeted Patients During Systemic Antibiotic Exposure, Clinical Infectious Diseases, 28 September 2019.

In addition, Drs. McCreery, Cawcutt, Cortes-Penfield & Van Schooneveld published a letter to the editor of Clinical Infectious Diseases based on this journal club review and blog post. Read the official letter here. A formal reply to this letter, was also published here.

Why was it important to review this article?

This article attempts to address an important question: with nearly 500,000 infections and 15,000 deaths annually (CDC) attributed to Clostridioides difficile, how might we further reduce the incidence of this disease beyond the antimicrobial stewardship and infection control procedures that we are already employing?  To date, most of the data on chemoprophylaxis for preventing Clostridioides difficile infections (CDI) is retrospective, and thus, more prospective, randomized data is needed.  This article not only provides important new data from a prospective randomized trial, but it also provides a summary of the available retrospective data to date.

Who did they study?

Admitted patients who were felt to be high risk for developing healthcare facility onset CDI were studied.  High risk was based upon age (> 60), recent hospitalization (< 30 days), and recent and current use of antibiotics (during the prior and current hospitalization).

What did they do and where did they do it?

Patients were enrolled over a 7-month period at a single, 961-bed, tertiary hospital in Winston-Salem, North Carolina, in a prospective, randomized, open-label study. One hundred high risk patients were randomized, 50 in each arm, to receive either oral vancomycin prophylaxis (OVP) or no prophylactic therapy.  OVP was given for the duration of systemic antibiotic therapy plus an additional 5 days at a dose of 125 mg daily.  Patients received an average of 12 days of OVP.

What did they find?

They found that 6 patients in the control arm developed healthcare facility onset CDI (the primary end point) vs none in the prophylactic arm, and this was statistically significant (p = 0.03).

Key points from the article:

  • The article attempts to answer an important question, but drawing definitive conclusions from this trial remains difficult.
  • The screening method used in this study to identify patients at high risk of developing CDI may not perform similarly in all institutions. Thus, the external validity of this study remains questionable.
  • The trial was small and without a placebo arm, both of which can be a source of bias.
    • Randomization of small numbers of patients may not evenly distribute important risk factors. While the authors argue that the imbalances in risk factors in this study, mainly high-risk antibiotic exposure, likely favored development of more CDI in the prophylaxis group thus strengthening their conclusion that OVP can prevent CDI, a larger trial with more balanced exposures would present a clearer picture as to the true effect of OVP in preventing CDI.
    • Related to the lack of a placebo, nowhere in the article does it account for how many tests for CDI were run in either group nor the number of patients in each group that developed diarrhea.  These are important data to include because they are the components of the primary end point.  Differences in these data between groups may have been due to procedural bias due to a lack of placebo and blinding of both patients and healthcare personnel leading to differences in the primary outcome.

  • The definition of healthcare facility onset CDI did not include a toxin assay. Given that CDI is a toxin mediated disease, toxin reporting (or PCR cycle time that predicts toxin as has been recently reported by Senchyna et al.) may have been able to distinguish disease from colonization in the control group.  This calls into question the method by which the primary outcome measurement was made.  Is it possible that given no toxin assay was performed in the control group, that only colonization was detected, and diarrhea was present for another reason?  Is it possible that colonization would have been detected in the OVP group had the vancomycin not decreased colonization causing PCR assays to be negative?
  • New VRE colonization was evaluated as a secondary endpoint. While no patients in the OVP arm were found to have new VRE colonization, there was a baseline colonization rate of 42%, and 36% of patients in the OVP group were not tested.  With such a high rate of baseline colonization and so many patients that did not undergo analysis, the study design is likely underpowered to detect any meaningful difference in conversion from VRE negative to VRE positive in the OVP group.  The control group should also be tested to account for any baseline conversion rates.  This metric was not reported either.
  • Telephone surveys completed post-discharge were low, < 50% in each arm making any conclusions related to outcomes beyond the hospital stay challenging to assess.
  • No information was included regarding how many patients were screened versus the number enrolled. The algorithm to identify those eligible was simple and did not seem excessively restrictive.  The exclusion criteria may have made many who were started on antibiotics at admission difficult to enroll because the expiration time for starting OVP (< 72hrs after antibiotic initiation) would lapse at or near the time the patients became eligible for enrollment (admitted for > 72 hrs).  If this was the case, the authors should say so in addition to any other reason why it took 7 months to enroll 106 patients in a 961-bed hospital.
  • OVP also seemed to be well tolerated
  • Cost estimates were quite favorable in the OVP group with around $26 per prophylactic course. With a number needed to treat of 9, that would equate to an average of $236 to prevent one case of CDI.  That was compared to the authors estimate of $2,648 in additional hospital costs per episode of hospital onset CDI.

Conclusion:

While this study demonstrated less positive PCR tests in the OVP group, the lack of key clinical data makes the conclusion limited and inadequate to inform active clinical practice. The jury remains out on the efficacy of OVP pending a larger, randomized, ideally placebo controlled, multicenter study.

Steven W Johnson, Shannon V Brown, David H Priest, Effectiveness of Oral Vancomycin for Prevention of Healthcare Facility-Onset Clostridioides difficile Infection in Targeted Patients During Systemic Antibiotic Exposure, Clinical Infectious Diseases, , ciz966, https://doi.org/10.1093/cid/ciz966


 

About our First Year Fellows – Dr. Clayton Mowrer

Tell us about the position you are starting:

I am a quarter of the way through my first two years of a four year adventure as an Internal Medicine/Pediatrics Infectious Diseases fellow here at UNMC. I will spend these first two years here learning adult ID, followed by two years at Children’s Hospital and Medical Center here in Omaha, where I will learn pediatric ID. I could not be more excited!

Tell us about your background:

I was born and raised in Kansas City. Went to undergrad in Tulsa, then moved up to the NW for a while before moving back to KC for med school at Kansas City University of Medicine and Biosciences (KCUMB) and grad school for my MBA at Rockhurst University, then moved on to med-peds residency at University of Missouri-Kansas City (UMKC). #ChiefsKingdom!

Why did you choose to come work at UNMC?

There was an unmistakable sense of friendliness, collegiality, and sense of collaboration within the department when I interviewed. And there was not a single interview that I did not actually enjoy. Add on top of that the fact that UNMC has a fantastic reputation in the field of ID, with a wide range of experts in their respective fields. It was also important to me to have a vast breadth of clinical exposure, as well as support for various research and academic endeavors. This has certainly proven true, and the support and guidance we receive as fellows is top notch.

What makes you excited about working in ID?

I could go on and on, but I’ll hold back. To put it briefly, ID is a field in which the microscopic world interacts with macroscopic individual and population in ways that are extraordinarily complex and beautiful. It is a field which touches on all systems of the body and requires knowledge of all sub-specialties. And it is a constantly evolving (sorry for the pun) field – a field of study that was made for the curious.

Tell us something about yourself that is unrelated to medicine?

My wife and I love to travel, and we do so at every opportunity we get. I have personally road-tripped to every state in the continental US, and between the two of us, we have been all over the world. I love camping and hiking and just being as outdoors and active as possible. I’m also a prior soccer and tennis player.

COVID-19 – What is UNMC ID doing?

Although it has not been officially declared a pandemic by the World Health Organization (WHO), as of this morning, there were 81, 191 confirmed cases of COVID-19 and 2,768 deaths worldwide. To date, 57 of these cases are within US borders, and there are increasing cases throughout the world.

UNMC & Nebraska Medicine have had our quarantine and biocontainment units active and caring for patients with known COVID-19 (also known as SARS-CoV-2) infection. Our multidisciplinary teams are working hard to prevent spread of infection, to care for those with infection and now, we are launching into research for future treatments.  

The first study in the US, a NIH sponsored randomized, controlled trial of the antiviral medication (remdesivir) has begun. Dr. André Kalil is the Primary Investigator, with several co-investigators from our team caring for patients with COVID-19. See a short video clip of Dr. Kalil discussing the trial here.

Dr. Andre Kalil – PI for the new clinical trial on remdesivir for treatment of COVID-19.

With no known effective treatments to date, the trial starts at a critical time, as officials from the CDC have cautioned that Americans should prepare for community spread of COVID-19 here within the US borders. The CDC has guidance on ways to prepare here.

There are several ways our UNMC, Nebraska Medicine, NETEC and state-wide infection control assessment and promotion program (ICAP) are working on providing the best possible care for current and future patients.

There are resources for donning and doffing (of personal protective equipment), updates, training and education from NETEC; and ongoing updates from UNMC/NM and our Global Center for Health and Security. As always, we will strive to keep you updated on our mission to continue to provide exceptional care for our patients.

Freedom is in the Air: My Visit to Sudan, a Born-again Country

Here at UNMC ID, we are thrilled to share the global, and personal efforts, of our faculty. Please take a moment to read this excellent piece by Dr. Nada Fadul; Associate Professor, Division of Infectious Diseases, UNMC

Sudan felt different this time. It was the middle of December 2019, the first anniversary of the Sudanese Revolution that caught the world’s attention. The country is going through a severe economic crisis; bread and gas lines are everywhere, yet the atmosphere is full of hope and enthusiasm. 

Our visit was organized by the Association of Sudanese American Professors in America (www.asapa.online). As part of the visit, we toured several universities to conduct informational sessions and needs assessments.  We were met with great enthusiasm about the possibility of collaboration with US high education institutions due to sanctions listing Sudan as a State Sponsor of Terrorism (SST) for over 24 years.  Being on the SST list prevented Sudan from accessing new technology and knowledge exchange with the US. The needs  in the institutions we visited are enormous and the faculty are doing their best with very limited resources. Our agenda at the University of Shendi included a meeting with the Dean of Medicine, the Preisdent of the University, and other faculty, followed by a ceremony celebrating the anniversary of the revolution. I gave a presentation on “Updates in Infectious Diseases” and we had an interesting discussion on the challenges around handwashing, a basic infection control method in the hospital where there is only one sink in the whole floor. The next day we were taken on a tour of the Bajrawia pyramids in the Kingdom of Meroe,  one of the ancient Nubian kingdoms, by a graduate of the University of Shendi School of Archeology.The highlight of my trip was our visit to the HIV clinic and the National Tropical Diseases Hospital. On the way there, we passed by the Army Headquarters and I was mesmerized by the revolutionary murals.  We arrived at the Tropical Diseases Hospital shortly after noon. The medical director was gracious enough to take time from her busy day to give us a tour of the hospital, their small lab with little microbiology capabilities, and the outpatient clinic. We then proceeded to the Omdurman VCT and ART Center,the largest HIV clinic in the country providing care to over 4,000 patients. The center was a renovated building sponsored by the United Nations Development Program. Sudan is not a recipient of President Emergency Plan for AIDS Relief (PEPFAR) which puts it at a disadvantage when attempting to control the epidemic. The Global Fund provides the antiretroviral medications to the clinic’s pharmacy which then distribute them to patients. The regimens were mostly outdated and limited in options. The HIV clinic lab did not have capabilities for viral load nor CD4 count, making clinical assessment the only way to assess response to antiretrovirals. 

In spite of the difficult working environment, the HIV clinic staff is dedicated to making a difference in these patients’ lives. The center is well equipped with highly skilled counselors who conduct  needs assessments of patients’ medical, psychosocial, and mental health. All of their assessments are done and stored in paper files as the center does not access to an electronic medical record. There is a dedicated pediatrics clinic space and waiting room as well as a dedicated pediatrics counselor. Several needs were identified including staff training and capacity building, assistance with equipment, and assistance with access to US agencies funding programs for comprehensive HIV care and prevention. Stigma was identified as a major challenge to retaining patients in HIV care as well as concerns about confidentiality.

We concluded our trip with a 1-day conference “Towards Sustainable Development in Sudan: Challenges and Opportunities” attended by the Ministers of Health, Economics, and Irrigation. The Minister of Health delivered a presentation on his transitional period health strategy, including an outbreak response and improving access to preventive services. He emphasized the need to address health disparities in the country, especially war-torn regions in Darfur and Nuba Mountains among other regions. I followed with a presentation on “How Research can Inform Healthcare Policy” and emphasized the role of implementation and dissemination science as well as health outcomes research in the next phase of health transformation. The conference provided a great opportunity for networking with faculty from different universities and staff from the Minister of Health. 

Overall, our visit was successful and we were very inspired to see a new Sudan that is full of hope for a bright future. The economy is in bad shape and the healthcare system is in dire need of help, but I am confident that the dedicated Sudanese inside and outside of Sudan will be able to rebuild the country. 

Helping Our Patients Beyond the Clinic

Rachelle Carr (left) and Dr. Susan Swindells receive donations for the Specialty Care Clinic hygiene pantry

As we start a new year, we thought it would be appropriate to share a story that reminds me of what is fundamental to a life in medicine: helping those we have the power to help.

The Nebraska Medicine Specialty Care Center houses our HIV clinic as well as a hygiene pantry that stocks supplies to help patients who don’t have access to these products, supplementing the medical care patients receive and helping break down some of the barriers to good health.  In October, Carly McCulloch, an education graduate student at the College of Saint Mary, organized a hygiene drive to benefit our pantry.

“Access to hygiene items brings a sense of dignity to tough situations,” Mary wrote in her letter asking folks to contribute to her drive.  In addition to collecting a huge number of personal hygiene products, Mary included notes of positivity from herself and donors to support those receiving the supplies.

Let’s keep Carly’s example in mind and remember that there are always ways to help those who need it, and the most fundamental supplies can make a huge impact.  We are so grateful to Carly for the time and effort she spent collecting and organizing donations of our hygiene pantry.

Hygiene supplies and notes of positivity ready to go out to patients!


 

Introducing AMDA UTI Consensus Statement for Diagnosis, Treatment and Prevention of Urinary Tract Infections

Content provided by Dr. Salman Ashraf, Medical Director, Nebraska ASAP

The AMDA – The Society for Post-Acute and Long Term-Care Medicine convened a UTI consensus statement workgroup in 2017 to outline best practices for the management of UTI in post-acute and long-term care (PALTC) settings. The workgroup consisted of various national and international subject matter experts and was chaired by UNMC faculty Dr. Muhammad Salman Ashraf, who is an Associate Professor in the Division of Infectious Diseases. In addition to making recommendations for diagnosis, treatment and prevention of urinary tract infections (UTIs), the workgroup also outlined how PALTC settings can initiate an antimicrobial stewardship project focused on improving UTI management and incorporate it into their Quality Assurance and Performance Improvement (QAPI) program.

Diagnosis, treatment and prevention of UTIs in older adults remains very challenging, especially in PALTC settings. The magnitude of the problem can be assessed by the fact that over 50% of antibiotics prescribed for UTIs in PALTC settings have been found to be inappropriate in some studies. Antibiotic use is the primary driver for selection of multi-drug resistant organisms. It also increases the risk for C. difficile infection. Since, PALTC residents are at increased risk for colonization with multidrug-resistant organisms and C. difficile, improving UTI management in these settings should be a priority. Several guidance documents have been published in the past that address various aspects of UTI management in PALTC settings but there was a need for a comprehensive guidance document which covers diagnosis, treatment, and prevention of UTIs in PALTC residents.

While some of the recommendations of UTI consensus statement concur with previous guidelines about UTI in general, there are several new recommendations specific to PALTC settings. For example, the consensus statement recommends that PALTC settings should incorporate one of the published clinical algorithms for diagnosis and management of UTI into their antibiotic stewardship policy and use that algorithm for guiding the diagnosis and decision to initiate antibiotics for residents with a suspected UTI. They included four examples of such algorithms including Loeb Minimum Criteria, AHRQ decision tool (Suspected UTI SBAR Form), IOU Consensus Guideline and International Delphi Consensus Decision Tool. PALTC settings are advised to choose one of these criteria that seems most closely aligned with their current practices.

When discussing collection of urine specimen from residents with indwelling urinary catheter, the consensus statement agree with previously published recommendations that a catheter should be replaced prior to collecting a urine specimen in residents with urinary catheter present for over two weeks. It also adds that when a urinary catheter have been in place for shorter than two weeks duration, the decision to obtain a urine sample from the sampling port of the existing catheter or to remove the catheter before obtaining a urine sample should be made on case-by-case basis. The underlying reason for this recommendation is that shorter interval between catheterization and development of bacteriuria is possible but it is acknowledged that further studies are needed in this area.

One of the most important recommendations related to the treatment of suspected UTI is about using an “Active Monitoring” protocol for those residents who do not meet clinical criteria for UTI and do not have any warning signs (such as fever, rigors, acute delirium, or unstable vital signs), but for whom clinical concern for UTI still exist. Such a protocol include frequent monitoring of vital signs, addressing hydration status and repeated clinical assessments by nursing home staff. Use of such protocols has the potential to decrease inappropriate prescribing for suspected UTI. An example of an active monitoring order set is also included in the document.

The consensus statement also emphasized that clinicians should not prolong treatment duration for nursing home residents with UTIs just because of their advanced age. PALTC residents with cystitis who are not severely ill and are not at high risk for developing complications can be treated with fewer than 7 days of antibiotics. The consensus statement include a table that describe factors that may predispose residents with a UTI to treatment failure or complications. For those residents who may be at higher risk for treatment failure, the length of antibiotic therapy is recommended to be based on the severity of the illness and response to the treatment. However, it has been mentioned that for most of these residents, 7 days of antibiotic treatment should be adequate if they respond promptly to antibiotics (within 72 hours). Duration longer than that (10-14 days) is considered reasonable for residents with severe illness such as those with bacteremia or a delayed response to treatment.

The UTI consensus statement encouraged the use of local (vaginal) estrogen therapy in postmenopausal women for prevention of recurrent UTIs and recommended against long-term antibiotic prophylaxis because of the potential harms associated with long-term antibiotic use and the prevalence of multidrug-resistant organisms among PALTC residents. It was also highlighted that implementing comprehensive infection prevention and control efforts is a safe and effective strategy to reduce CAUTI in PALTC settings.

The document includes a table which outlines the 7 CDC-recommended core elements for antibiotic stewardship in Nursing Homes and provides practical examples of how to apply these core elements to develop a program that focuses on improving the diagnosis, treatment and prevention of UTIs in PALTC settings.

In short, the AMDA UTI Consensus Statement is a comprehensive guidance document for management of UTI in older adults residing in post-acute and long-term care setting. The document provides guidance to various healthcare professionals including clinicians, administrators, infection preventionists and quality program leaders. The complete document (including the supplementary summary of the recommendations) can be downloaded from the following link https://www.jamda.com/article/S1525-8610(19)30806-0/abstract

 

References:

Ashraf MS, Gaur S, Bushen OY et al. Diagnosis, Treatment, and Prevention of Urinary Tract Infections in Post-Acute and Long-Term Care Settings: A Consensus Statement From AMDA’s Infection Advisory Subcommittee. J Am Med Dir Assoc. 2020 Jan;21(1):12-24.e2.

Loeb M, Bentley DW, Bradley S, et al. Development of minimum criteria for the initiation of antibiotics in residents of long-term-care facilities: results of a consensus conference. Infect Control Hosp Epidemiol. 2001;22(2):120-124.

Nace DA, Perera SK, Hanlon JT, et al. The Improving Outcomes of UTI Management in Long-Term Care Project (IOU) Consensus Guidelines for the Diagnosis of Uncomplicated Cystitis in Nursing Home Residents. Journal of the American Medical Directors Association. 2018;19(9):765-769.e3.

van Buul LW, Vreeken HL, Bradley SF, et al. The Development of a Decision Tool for the Empiric Treatment of Suspected Urinary Tract Infection in Frail Older Adults: A Delphi Consensus Procedure. Journal of the American Medical Directors Association. 2018;19(9):757-764.

Toolkit 1. Start an Antimicrobial Stewardship Program | Agency for Healthcare Research and Quality. (Available at: https://www.ahrq.gov/nhguide/toolkits/implement-monitor-sustain-program/toolkit1-start-program.html Date accessed 1/13/20)

 

 

How Should Clinicians Respond to International Public Health Emergencies?

Dr. Angela Hewlett, Medical Director of the Nebraska Biocontainment Unit, recently co-authored an article that appeared in the AMA Journal of Ethics entitled; “How Should Clinicians Respond to International Public Health Emergencies?” Dr. Hewlett shared a brief summary of the paper below:

The paper is a case-based analysis of issues surrounding clinicians who respond to international public health emergencies, including outbreaks of highly hazardous communicable diseases.  Issues with clinicians providing care during outbreaks, including monitoring on return, ability to resume patient care activities, and even whether they should travel at all were encountered during the 2014-2016 Ebola outbreak in West Africa, and continue to occur currently.  The ethical discussion in this paper centers around the balance of global health programs and global solidarity, along with the real or perceived local risks by healthcare systems and the public when clinicians return home from providing care during outbreaks.

Citation: Abbey Lowe, MA, Angela Hewlett, MD, MS, and Toby Schonfeld, PhD. AMA J Ethics. 2020;22(1):E16-21. doi: 10.100/amajethics.2020.16.

About our First Year Fellows – Mark Ridder, MD

Tell us about your current position

I a first year fellow of infectious disease at University of NE Medical Center. For the next 2 years I’ll be learning all I can from experts in the field for the diagnosis, treatment, and management of a wide variety of infectious diseases ranging from parasites and fungal disease to complicated blood stream infections. I’ll be learning about these infections in patients with an intact immune system as well as those with underlying conditions that leave patients vulnerable to all sorts of ‘unusual’ infections.

Tell us about your background

I spent the first 4 years of my life in the town of Randolf, NE. However, afterwards, my family moved to Sioux Falls, SD where I lived the majority of my childhood. I generally loved biking around the city with my brother, flying kites, camping and sailing.

Originally, my passion was physics while in high school. I loved being able to extrapolate a large amount of information from a single piece of datum as well as apply it to so many real world situations. However, wanting to broaden my horizons, I took a sharp turn in college and studied philosophy at Creighton University here in Omaha. This culminated in my thesis On the Phenomenology of Love and Relationship: An Experiential Approach to Relationships in Unequal and Equally Autonomous Relationships, which has probably been one of my most rewarding experiences in my life to take time to write. After that I returned to my home state of South Dakota and again taking a sharp turn in my studies, studied medicine at U of South Dakota in Vermillion. Afterwards, I continued my training and completed my Internal Medicine Residency at the Marshfield Clinic in Marshfield, Wisconsin which was an absolutely wonderful experience. If you can believe it, I actually miss winter there!

Why did you choose to come work at UNMC?

Many reasons. One was to be closer to family. However, the center has quickly become known for its expertise in many areas. There were few programs that had both such depth and breadth as UNMC. I appreciated both their standard of excellence, as well as friendly and approachable faculty and fellows!

What makes you excited about working in ID?

Many aspects. Firstly, in a world of increasingly ‘reactionary’ medicine, one of the aspects I love about ID is sleuthing though information and assessing adequately what information is signal and what information is noise. Often we are presented with pieces of data that complicate patient presentations that years ago would not have been available. We now have imaging studies as well as molecular tests and others which can be falsely positive or negative. It’s great to get back at the roots of medicine with a very thorough history and physical looking foremost at the patient first, not at our testing, to judiciously guide the use of diagnostics and treatment. Within the practice of ID we can then recognize what is likely to be meaningful information we get from our fancy machines versus what is perhaps noise that is misleading us. In the end, the patients are our best means of arriving at our diagnosis, and I love that.

However, the other aspects that drew me to ID were its global implications. We wear many hats in this subspecialty. While we are expected to be excellent clinicians we also grow in the craft of epidemiology and public health. It is truly wonderful to gain training both looking at our patient and also all around to identify outbreaks, minimize adverse events, and maximize benefit in the treatment of many diseases. In infectious disease we can accomplish this by a thorough understanding of the incidence and prevalence of diseases in certain populations. This in turn helps us guide our clinical decisions for our individual patients, as well as for the general public to keep our patients from harm and save lives.

Altogether, what drew me to ID was that I wanted to be the best clinician I could be.  I am humbled and blessed to be given the opportunity of training to gain access to every tool in the toolbox to achieve that goal which include but are not limited to: a deep understanding of our diagnostic tools, an understanding of the disease in a population, and most importantly a thorough grounding in proper assessment and treatment of our patients.

Tell us something about yourself that is unrelated to medicine?

My family always had a passion for camping. We used to take trips across the country each year on generally a 2 week excursion and explore a ‘quarter’ of the US. (One year it was the east coast seeing Virginia and DC, another we explored to the northwest through Wyoming and Montana, another the 4 corners). However, our last year of doing this our family was doing a southern tour when I was about 12. We were travelling from the Grand Canyon to San Antonio. We hit a cross wind and our camper swayed and even jackknifed hitting both sides of our van. All of the tires blew on the camper, the frame was sprung on the camper. When we pulled off the road the Texas mesquite (Which is hard as nails by the way) punctured the rest of our tires on the van. We managed to get our rig patched up enough to limp our way back home and after that we sold our camper.

Being put out having lost the camper, my mom decided to plan next year’s family vacation, which was usually my dad’s role. She found this cute cabin in a place called Door County, Wisconsin. My 3 siblings and I thought this was a super dull sounding idea and we pouted about it basically the whole summer until we got there… It was lovely. Completely lovely. My brother and I learned how to sail, we hiked and biked every day. He had never known a vacation of just sitting in a place and enjoying as prior we had always been on the move from one site to the next.

More than a decade later we still go there every year. And every year we still love it.

Now I always listen to my mom.

 

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