Division of Infectious Diseases

Farewell 2019…another year of growth for UNMCID

2019 continued the theme of growth for our Division of Infectious Diseases. We have added several new faculty to our group (and still actively hiring), continued to redesign the College of Medicine Infectious Diseases curriculum, established a new Community Infectious Diseases service line, expanded our social media presence, joined and led multiple national Infectious Diseases committees, and again hosted the successful regional HIV and Antimicrobial Stewardship conferences. We had a huge presence at #IDWeek2019, with 10 of our faculty either presenting or moderating on the national stage, and many more presenting posters. We are extremely proud of our trainees – the Division supported eight students, residents, and fellows to attend, three of whom gave oral presentations! Finally, we expanded our ID fellowship program and matched three fantastic physicians to join us next summer (with a goal of a final complement of six ID fellows by 2021).

Amidst all of that, our Division was once again among the top publication performers in the Department of Medicine, with our faculty publishing over 70 peer-reviewed journal articles and book chapters crossing several areas of expertise, including HIV, Biopreparedness, Infections in Solid-organ and Stem-cell transplant patients, Antimicrobial Stewardship, Hospital Epidemiology & Infection Control, Diversity & Equity, Social Media, and Infections in critically-ill patients. Curious about the depth and breadth of expertise at UNMC ID? Below is a full list of the publications for your perusal, with convenient links to the referenced articles. It’s long, so consider bookmarking and keep referring to it whenever you need a bit of expertise.

We want to thank Librarian Teresa Hartman (@thartman2u) at the UNMC McGoogan Library for helping us compile this list of publications.

Stay tuned to our blog and follow us on Twitter @UNMC_ID to see all that we have in store for 2020!

2019 UNMC ID Faculty Publications

  1. Abdalla, M. Y., Ahmad, I. M., Rachagani, S., Banerjee, K., Thompson, C. M., Maurer, H. C., . . . Kumar, S. (2019). Enhancing responsiveness of pancreatic cancer cells to gemcitabine treatment under hypoxia by heme oxygenase-1 inhibition. Translational Research, 207, 56-69. doi:10.1016/j.trsl.2018.12.008
  2. Aitken, S. L., Nagel, J. L., Abbo, L., Alegria, W., Barreto, J. N., Dadwal, S., . . . Seo, S. K. (2019). Antimicrobial stewardship in patients with cancer: The time is now. JNCCN Journal of the National Comprehensive Cancer Network, 17(7), 772-775. doi:10.6004/jnccn.2019.7318
  3. Anemüller, R., Belden, K., Brause, B., Citak, M., Del Pozo, J. L., Frommelt, L., . . . Zimmerli, W. (2019). Hip and knee section, treatment, antimicrobials: Proceedings of international consensus on orthopedic infections. Journal of Arthroplasty, 34(2), S463-S475. doi:10.1016/j.arth.2018.09.032
  4. Beam, E. L., Schwedhelm, M. M., Boulter, K. C., Vasa, A. M., Larson, L., Cieslak, T. J., . . . Hewlett, A. L. (2019). Ebola virus disease: Clinical challenges, recognition, and management. Nursing Clinics of North America, 54(2), 169-180. doi:10.1016/j.cnur.2019.02.001
  5. Bos, L. D. J., & Kalil, A. C. (2019). Changes in lung microbiome do not explain the development of ventilator-associated pneumonia. Intensive Care Medicine, 45(8), 1133-1135. doi:10.1007/s00134-019-05691-1
  6. Calabrò, F., Coen, M., Franceschini, M., Franco-Cendejas, R., Hewlett, A., Segreti, J., & Senneville, E. (2019). Hip and knee section, treatment, antimicrobial suppression: Proceedings of international consensus on orthopedic infections. Journal of Arthroplasty, 34(2), S483-S485. doi:10.1016/j.arth.2018.09.034
  7. Cawcutt, K. A., Erdahl, L. M., Englander, M. J., Radford, D. M., Oxentenko, A. S., Girgis, L., . . . Silver, J. K. (2019). Use of a coordinated social media strategy to improve dissemination of research and collect solutions related to workforce gender equity. Journal of Women’s Health, 28(6), 849-862. doi:10.1089/jwh.2018.7515
  8. Cawcutt, K. A., Hankins, R. J., Micheels, T. A., & Rupp, M. E. (2019). Optimizing vascular-access device decision-making in the era of midline catheters.Infection. Control and Hospital Epidemiology, 40(6), 674-680. doi:10.1017/ice.2019.49
  9. Cawcutt, K. A., & Kalil, A. C. (2019). Saved from sepsis: Can immunotherapy improve acute and postacute outcomes? Critical Care Medicine, 47(5), 733-735. doi:10.1097/CCM.0000000000003702
  10. Cawcutt, K. A., Marcelin, J. R., & Silver, J. K. (2019). Using social media to disseminate research in infection prevention, hospital epidemiology, and antimicrobial stewardship. Infection Control and Hospital Epidemiology, 40(11), 1262-1268. doi:10.1017/ice.2019.231
  11. Cawcutt, K. A., & Zimmer, A. (2019). Management of infection in patients with kidney transplant. Critical care nephrology: Third edition (pp. 552-560.e1) Elsevier Inc. doi:10.1016/B978-0-323-44942-7.00095-9
  12. Chaisson, R. E., Ramchandani, R., & Swindells, S. (2019). One month of rifapentine plus isoniazid to prevent HIV-related tuberculosis. reply. The New England Journal of Medicine, 381(11), e23. doi:10.1056/NEJMc1908492
  13. Choi, S. -., Britigan, B. E., & Narayanasamy, P. (2019). Dual inhibition of klebsiella pneumoniae and pseudomonas aeruginosa iron metabolism using gallium porphyrin and gallium nitrate. ACS Infectious Diseases, 5(9), 1559-1569. doi:10.1021/acsinfecdis.9b00100
  14. Choi, S. -., Britigan, B. E., & Narayanasamy, P. (2019). Iron/heme metabolism-targeted gallium(III) nanoparticles are active against extracellular and intracellular pseudomonas aeruginosa and acinetobacter baumannii. Antimicrobial Agents and Chemotherapy, 63(4) doi:10.1128/AAC.02643-18
  15. Choi, S. -., Britigan, B. E., & Narayanasamy, P. (2019). Treatment of virulent mycobacterium tuberculosis and HIV coinfected macrophages with gallium nanoparticles inhibits pathogen growth and modulates macrophage cytokine production. Msphere, 4(4) doi:10.1128/mSphere.00443-19
  16. Churchyard, G. J., & Swindells, S. (2019). Controlling latent TB tuberculosis infection in high-burden countries: A neglected strategy to end TB. PLoS Medicine, 16(4) doi:10.1371/journal.pmed.1002787
  17. Cieslak, T. J., Herstein, J. J., Kortepeter, M. G., & Hewlett, A. L. (2019). A methodology for determining which diseases warrant care in a high-level containment care unit. Viruses, 11(9) doi:10.3390/v11090773
  18. El Ramahi, R., & Freifeld, A. (2019). Epidemiology, diagnosis, treatment, and prevention of influenza infection in oncology patients. Journal of Oncology Practice, 15(7), 177-184. doi:10.1200/JOP.19.00350
  19. Endres, J. L., Yajjala, V. K., Fey, P. D., & Bayles, K. W. (2019). Construction of a sequence-defined transposon mutant library in staphylococcus aureus. Humana Press Inc. doi:10.1007/978-1-4939-9570-7_3
  20. Fehring, T. K., Fehring, K. A., Hewlett, A., Higuera, C. A., Otero, J. E., & Tande, A. (2019). What’s new in musculoskeletal infection. Journal of Bone and Joint Surgery – American Volume, 101(14), 1237-1244. doi:10.2106/JBJS.19.00403
  21. Flexner, C., Thomas, D. L., & Swindells, S. (2019). Creating demand for long-acting formulations for the treatment and prevention of HIV, tuberculosis, and viral hepatitis. Current Opinion in HIV and AIDS, 14(1), 13-20. doi:10.1097/COH.0000000000000510
  22. Florescu, D. F., Schaenman, J. M., & on behalf of the AST Infectious Diseases Community of Practice. (2019). Adenovirus in solid organ transplant recipients: Guidelines from the american society of transplantation infectious diseases community of practice. Clinical Transplantation, 33(9) doi:10.1111/ctr.13527
  23. Florescu, D. F., & Stohs, E. J. (2019). Approach to infection and disease due to adenoviruses in solid organ transplantation. Current Opinion in Infectious Diseases, 32(4), 300-306. doi:10.1097/QCO.0000000000000558
  24. Gandhi, M., Smeaton, L. M., Vernon, C., Scully, E. P., Gianella, S., Poongulali, S., . . . for the Women’s Health Inter-Network Scientific Committee (WHISC). (2019). Low rate of sex-specific analyses in presentations at the conference on retroviruses and opportunistic infections (CROI) meeting, 2018: Room to improve. Journal of Acquired Immune Deficiency Syndromes, 81(5), E158-E160. doi:10.1097/QAI.0000000000002073
  25. Gibbs, S. G., Herstein, J. J., Le, A. B., Beam, E. L., Cieslak, T. J., Lawler, J. V., . . . Lowe, J. J. (2019). Review of literature for air medical evacuation high-level containment transport. Air Medical Journal, 38(5), 359-365. doi:10.1016/j.amj.2019.06.006
  26. Gibbs, S. G., Herstein, J. J., Le, A. B., Beam, E. L., Cieslak, T. J., Lawler, J. V., . . . Lowe, J. J. (2019). Need for aeromedical evacuation high-level containment transport guidelines. Emerging Infectious Diseases, 25(5), 1033-1034. doi:10.3201/eid2505.181948
  27. Gnann, J. W., Jr., Agrawal, A., Hart, J., Buitrago, M., Carson, P., Hanfelt-Goade, D., . . . the National Institute of Allergy and Infectious Diseases Collaborative Antiviral Study Group. (2019). Lack of efficacy of high-titered immunoglobulin in patients with west nile virus central nervous system disease. Emerging Infectious Diseases, 25(11), 2064-2073. doi:10.3201/eid2511.190537
  28. Hankins, R., Majorant, O. D., Rupp, M. E., Cavalieri, R. J., Fey, P. D., Lyden, E., & Cawcutt, K. A. (2019). Microbial colonization of intravascular catheter connectors in hospitalized patients. American Journal of Infection Control, 47(12), 1489-1492. doi:10.1016/j.ajic.2019.05.024
  29. Havens, J. P., Podany, A. T., Scarsi, K. K., & Fletcher, C. V. (2019). Clinical pharmacokinetics and pharmacodynamics of etravirine: An updated review. Clinical Pharmacokinetics, doi:10.1007/s40262-019-00830-9
  30. Havens, J. P., Scarsi, K. K., Sayles, H., Klepser, D. G., Swindells, S., & Bares, S. H. (2019). Acceptability and feasibility of a pharmacist-led human immunodeficiency virus pre-exposure prophylaxis program in the midwestern united states. Open Forum Infectious Diseases, 6(10) doi:10.1093/ofid/ofz365
  31. Hewlett, A. L., Hohenberger, H., Murphy, C. N., Helget, L., Hausmann, H., Lyden, E., . . . Hicks, R. (2019). Evaluation of the bacterial burden of gel nails, standard nail polish and natural nails on the hands of health care workers. [Beurteilung der bakteriellen Belastung von Gelnägeln, Standard-Nagellack und Naturnägel auf den Händen von Gesundheitspersonal] Krankenhaushygiene Und Infektionsverhutung, 41(2), 40-43. doi:10.1016/j.khinf.2019.03.001
  32. Kalil, A. C. (2019). Controversies in nosocomial pneumonias in 2019. Clinical Microbiology and Infection, 25(10), 1171-1172. doi:10.1016/j.cmi.2019.07.003
  33. Kalil, A. C., Gilbert, D. N., Winslow, D. L., Masur, H., & Klompas, M. (2019). Reply to al-hasan and justo. Clinical Infectious Diseases, 68(8), 1432. doi:10.1093/cid/ciy679
  34. Kalil, A. C., Holubar, M., Deresinski, S., & Chambers, H. F. (2019). Is daptomycin plus ceftaroline associated with better clinical outcomes than standard of care monotherapy for staphylococcus aureus bacteremia? Antimicrobial Agents and Chemotherapy, 63(11) doi:10.1128/AAC.00900-19
  35. Kalil, A. C., & Lisboa, T. (2019). To procalcitonin, or not to procalcitonin? Chest, 155(6), 1085-1087. doi:10.1016/j.chest.2019.02.327
  36. Kalil, A. C., & Machado, F. R. (2019). Quick sequential organ failure assessment is not good for ruling sepsis in or out. Chest, 156(2), 197-199. doi:10.1016/j.chest.2019.06.003
  37. Kalil, A. C., & Thomas, P. G. (2019). Influenza virus-related critical illness: Pathophysiology and epidemiology. Critical Care, 23(1) doi:10.1186/s13054-019-2539-x
  38. Kalil, A. C., & Zavascki, A. P. (2019). Can ceftolozane–tazobactam treat nosocomial pneumonia? The Lancet Infectious Diseases, 19(12), 1266-1267. doi:10.1016/S1473-3099(19)30523-7
  39. Keshavjee, S., Amanullah, F., Cattamanchi, A., Chaisson, R., Dobos, K. M., Fox, G. J., . . . Nahid, P. (2019). Moving toward tuberculosis elimination critical issues for research in diagnostics and therapeutics for tuberculosis infection. American Journal of Respiratory and Critical Care Medicine, 199(5), 564-571. doi:10.1164/rccm.201806-1053PP
  40. Kuhn, J. H., Adachi, T., Adhikari, N. K. J., Arribas, J. R., Bah, I. E., Bausch, D. G., . . . Yoti, Z. (2019). New filovirus disease classification and nomenclature. Nature Reviews Microbiology, doi:10.1038/s41579-019-0187-4
  41. Li, X., Gong, W., Wang, H., Li, T., Attri, K. S., Lewis, R. E., . . . Wen, H. (2019). Erratum: O-GlcNAc transferase suppresses inflammation and necroptosis by targeting receptor-interacting Serine/Threonine-protein kinase 3 (immunity (2019) 50(3) (576–590.e6), (S1074761319300305), (10.1016/j.immuni.2019.01.007)). Immunity, 50(4), 1115. doi:10.1016/j.immuni.2019.03.008
  42. Li, X., Gong, W., Wang, H., Li, T., Attri, K. S., Lewis, R. E., . . . Wen, H. (2019). O-GlcNAc transferase suppresses inflammation and necroptosis by targeting receptor-interacting Serine/Threonine-protein kinase 3. Immunity, 50(3), 576-590.e6. doi:10.1016/j.immuni.2019.01.007
  43. Marcelin, J. R., Bares, S. H., & Fadul, N. (2019). Improved infectious diseases physician compensation but continued disparities for women and underrepresented minorities. Open Forum Infectious Diseases, 6(2) doi:10.1093/ofid/ofz042
  44. Marcelin, J. R., Brewer, C., Beachy, M., Lyden, E., Winterboer, T., Murphy, C. N., . . . Van Schooneveld, T. C. (2019). Hardwiring diagnostic stewardship using electronic ordering restrictions for gastrointestinal pathogen testing. Infection Control and Hospital Epidemiology, 40(6), 668-673. doi:10.1017/ice.2019.78
  45. Marcelin, J. R., Manne-Goehler, J., & Silver, J. K. (2019). Supporting inclusion, diversity, access, and equity in the infectious disease workforce. Journal of Infectious Diseases, 220, S50-S61. doi:10.1093/infdis/jiz213
  46. Marcelin, J. R., Siraj, D. S., Victor, R., Kotadia, S., & Maldonado, Y. A. (2019). The impact of unconscious bias in healthcare: How to recognize and mitigate it. Journal of Infectious Diseases, 220, S62-S73. doi:10.1093/infdis/jiz214
  47. Mathur, S., Roberts-Toler, C., Tassiopoulos, K., Goodkin, K., McLaughlin, M., Bares, S., . . . ACTG A5322 Study Team. (2019). Detrimental effects of psychotropic medications differ by sex in aging people with HIV. Journal of Acquired Immune Deficiency Syndromes (1999), 82(1), 88-95. doi:10.1097/QAI.0000000000002100
  48. Mehta, B., Pedro, S., Ozen, G., Kalil, A., Wolfe, F., Mikuls, T., & Michaud, K. (2019). Serious infection risk in rheumatoid arthritis compared with non-inflammatory rheumatic and musculoskeletal diseases: A US national cohort study. RMD Open, 5(1) doi:10.1136/rmdopen-2019-000935
  49. Nailon, R. E., & Rupp, M. E. (2019). Surveillance of home health central venous catheter care outcomes: Challenges and future directions. American Journal of Infection Control, 47(11), 1382-1387. doi:10.1016/j.ajic.2019.04.177
  50. Nailon, R. E., Rupp, M. E., & Lyden, E. (2019). A day in the life of a CVAD. Journal of Infusion Nursing, 42(3), 125-131. doi:10.1097/NAN.0000000000000321
  51. Neary, M., Chappell, C. A., Scarsi, K. K., Nakalema, S., Matovu, J., Achilles, S. L., . . . Lamorde, M. (2019). Effect of patient genetics on etonogestrel pharmacokinetics when combined with efavirenz or nevirapine ART. The Journal of Antimicrobial Chemotherapy, 74(10), 3003-3010. doi:10.1093/jac/dkz298
  52. Neemann, K., Olateju, E. K., Izevbigie, N., Akaba, G., Olanipekun, G. M., Richard, J. C., . . . Obaro, S. (2019). Neonatal outcomes associated with maternal recto-vaginal colonization with extended-spectrum β-lactamase producing enterobacteriaceae in nigeria: A prospective, cross-sectional study. Clinical Microbiology and Infection, doi:10.1016/j.cmi.2019.07.013
  53. O’Horo, J. C., & Cawcutt, K. A. (2019). Critical care viral infections. Critical care nephrology: Third edition (pp. 560-567.e1) Elsevier Inc. doi:10.1016/B978-0-323-44942-7.00096-0
  54. O’Horo, J. C., Marcelin, J. R., Saleh, O. M. A., Barwise, A. K., Odean, P. M., Rivera, C. G., . . . Tosh, P. K. (2019). Standardizing febrile neutropenia management: Antimicrobial stewardship in the hematologic malignancy population. Journal of Oncology Practice, 15(9), E843-E848. doi:10.1200/JOP.18.00775
  55. Patel, R. C., Stalter, R. M., Thomas, K. K., Tamraz, B., Blue, S. W., Erikson, D. W., . . . Scarsi, K. K. (2019). A pharmacokinetic and pharmacogenetic evaluation of contraceptive implants and antiretroviral therapy among women in kenya and uganda. Aids, 33(13), 1995-2004. doi:10.1097/QAD.0000000000002308
  56. Rawizza, H. E., Darin, K. M., Oladokun, R., Brown, B., Ogunbosi, B., David, N., . . . Kanki, P. J. (2019). Safety and efficacy of rifabutin among HIV/TB-coinfected children on lopinavir/ritonavir-based ART. Journal of Antimicrobial Chemotherapy, 74(9), 2707-2715. doi:10.1093/jac/dkz219
  57. Rearigh, L., Kedar, S., & Bares, S. H. (2019). Uveomeningeal syndrome in a healthy, young male: An unusual presentation of west nile virus. Journal of Neurovirology, doi:10.1007/s13365-019-00808-0
  58. Reed, H. L., Van Schooneveld, T. C., Reha, C. G., & Bergman, S. J. (2019). Use of a best practice alert linking clostridioides difficile infection test results to a severity-based treatment order set. Infection Control and Hospital Epidemiology, 40(4), 467-469. doi:10.1017/ice.2019.18
  59. Reinecke, J., Lowas, S., Snowden, J., & Neemann, K. (2019). Blood stream infections and antibiotic utilization in pediatric leukemia patients with febrile neutropenia. Journal of Pediatric Hematology/Oncology, 41(4), 251-255. doi:10.1097/MPH.0000000000001279
  60. Scarsi, K. K., Cramer, Y. S., Rosenkranz, S. L., Aweeka, F., Berzins, B., Coombs, R. W., . . . AIDS Clinical Trials Group A5316 Study Team. (2019). Antiretroviral therapy and vaginally administered contraceptive hormones: A three-arm, pharmacokinetic study. The Lancet HIV, 6(9), e601-e612. doi:10.1016/S2352-3018(19)30155-9
  61. Schmitt, S., Macintyre, A. T., Bleasdale, S. C., Ritter, J. T., Nelson, S. B., Berbari, E. F., . . . McQuillen, D. P. (2019). Early infectious diseases specialty intervention is associated with shorter hospital stays and lower readmission rates: A retrospective cohort study. Clinical Infectious Diseases, 68(2), 239-246. doi:10.1093/cid/ciy494
  62. Schreier, T., Sherer, R., Sayles, H., Jacobsen, D. M., Swindells, S., & Bares, S. H. (2019). US human immunodeficiency virus (HIV) practitioners’ recommendations regarding condomless sex in the era of HIV pre-exposure prophylaxis and treatment as prevention. Open Forum Infectious Diseases, 6(3) doi:10.1093/ofid/ofz082
  63. Schully, K. L., Young, C. C., Mayo, M., Connolly, A. L., Rigas, V., Spall, A., . . . Currie, B. J. (2019). Next-generation diagnostics for melioidosis: Evaluation of a prototype i-STAT cartridge to detect burkholderia pseudomallei biomarkers. Clinical Infectious Diseases, 69(3), 421-427. doi:10.1093/cid/ciy929
  64. Shillcutt, S.K., Md,Ms, Fase, Arnzen, A., Md, & Cawcutt, K.,Md, Ms. (2019). Bridging the gender gap in critical care practice. International Anesthesiology Clinics, 57(2), 132-143. doi:10.1097/AIA.0000000000000223
  65. Spector, N. D., Asante, P. A., Marcelin, J. R., Poorman, J. A., Larson, A. R., Salles, A., . . . Silver, J. K. (2019). Women in pediatrics: Progress, barriers, and opportunities for equity, diversity, and inclusion. Pediatrics, 144(5) doi:10.1542/peds.2019-2149
  66. Stohs, E., Chow, V. A., Liu, C., Bourassa, L., Miles-Jay, A., Knight, J., . . . Pergam, S. A. (2019). Limited utility of outpatient surveillance blood cultures in hematopoietic cell transplant recipients on high-dose steroids for treatment of acute graft-versus-host-disease. Biology of Blood and Marrow Transplantation, 25(6), 1247-1252. doi:10.1016/j.bbmt.2019.01.031
  67. Sweeney, D. A., & Kalil, A. C. (2019). Why don’t we have more inhaled antibiotics to treat ventilator-associated pneumonia? Clinical Microbiology and Infection, 25(10), 1195-1199. doi:10.1016/j.cmi.2019.04.018
  68. Swindells, S., Ramchandani, R., Gupta, A., Benson, C. A., Leon-Cruz, J., Mwelase, N., . . . Chaisson, R. E. (2019). One month of rifapentine plus isoniazid to prevent HIV-related tuberculosis. New England Journal of Medicine, 380(11), 1001-1011. doi:10.1056/NEJMoa1806808
  69. Tan, E. M., Agarwal, S. K., Marcelin, J. R., & Virk, A. (2019). Rabies pre-exposure prophylaxis: A 10-year experience of vaccination in international travelers. Travel Medicine and Infectious Disease, 28, 102-103. doi:10.1016/j.tmaid.2018.07.003
  70. Tan, E. M., Marcelin, J. R., & Virk, A. (2019). Pre-travel counseling for immunocompromised travelers: A 12-year single-center retrospective review. Infection, Disease and Health, 24(1), 13-22. doi:10.1016/j.idh.2018.09.083
  71. Timsit, J. -., Sonneville, R., Kalil, A. C., Bassetti, M., Ferrer, R., Jaber, S., . . . Van Delden, C. (2019). Diagnostic and therapeutic approach to infectious diseases in solid organ transplant recipients. Intensive Care Medicine, 45(5), 573-591. doi:10.1007/s00134-019-05597-y
  72. Weld, E. D., Rana, M. S., Dallas, R. H., Camacho-Gonzalez, A. F., Ryscavage, P., Gaur, A. H., . . . Agwu, A. L. (2019). Interest of youth living with HIV in long-acting antiretrovirals. Journal of Acquired Immune Deficiency Syndromes, 80(2), 190-197. doi:10.1097/QAI.0000000000001896
  73. Zhou, C., Bhinderwala, F., Lehman, M. K., Thomas, V. C., Chaudhari, S. S., Yamada, K. J., . . . Fey, P. D. (2019). Urease is an essential component of the acid response network of staphylococcus aureus and is required for a persistent murine kidney infection. PLoS Pathogens, 15(1) doi:10.1371/journal.ppat.1007538
  74. Zimmer, A. J., & Freifeld, A. G. (2019). Optimal management of neutropenic fever in patients with cancer. Journal of Oncology Practice, 15(1), 19-24. doi:10.1200/JOP.18.00269

Evaluating Next-Generation Melioidosis Diagnostics

In addition to being one of our ID physicians, Dr. James Lawler serves as the Director or International Programs and Innovation at the Global Center for Health Security, a center that will focus on training federal personnel to manage highly infectious diseases, and Director of Clinical and Biodefense Research at the National Strategic Research Institute.  His interest in global health extends to his research, and we’re excited to feature his recently published an article in Clinical Infectious Diseases titled, “Next Generation Diagnostics for Melioidosis: Evaluation of a Prototype i-STAT Cartridge to Detect Burkholderia pseudomallei Biomarkers.”

Dr. Lawler summarizes the article and its findings:

Melioidosis is the most common cause of community acquired pneumonia and sepsis in many areas of South East Asia and Northern Australia. It is a significant cause of mortality and highlights the challenges of managing drug resistant infections in resource-limited regions, where more expensive broad-spectrum antibiotic therapy is prohibitively expensive for widespread use. Melioidosis is also a threat for US service members deploying to endemic regions.

A new sensitive, rapid, and affordable diagnostic test could dramatically improve our ability to deliver directed therapy for melioidosis. We think the proof of concept study with the iSTAT-based assay shows that such a test is possible. It also makes the case for a platform to support rapid fielding of point-of-care diagnostic assays for multiple pathogens, which could be a major leap forward in managing emerging infectious diseases.

You can read more about this work here.


 

PharmToExamTable: What do we know about Etravirine for HIV?

Recently, several of our HIV pharmacist colleagues in our Division of Infectious Diseases at UNMC/Nebraska Medicine, published an invited review in Clinical Pharmacokinetics entitled: Clinical Pharmacokinetics and Pharmacodynamics of Etravirine: An Updated Review.  The first author, Dr. Josh Havens PharmD, wrote this summary describing the review article.

What prompted the review?

This was an invited review, but there was only one previously completed shortly after etravirine’s FDA approval in 2009.

What do we know about the role of etravirine in ART regimens today?

Etravirine was initially brought to market as an additional agent to be used in conjunction with ritonavir-boosted darunavir in patients who were on failing regimens.  In the phase III, DUET-1 and -2 trials, the addition of etravirine to an optimized background regimen resulted in significantly greater improvements in HIV viral suppression.

In the US, etravirine’s use has declined secondary to the advent of integrase strand transfer inhibitors and etravirine’s twice daily dosing frequency.  Further, etravirine exhibits significant potential for bi-directional drug-drug interactions with other antiretrovirals as well as concomitant medications.  In other countries, specifically in Europe, etravirine has been used with once-daily dosing.  In pharmacokinetic studies, etravirine once-daily did not significantly differ from twice daily dosing by systemic exposure (AUC), but resulted in slightly higher max concentations (Cmax) and slightly lower trough concentrations (Cmin).

Etravirine has also been studied in small populations of antiretroviral naïve patients with variable results.  In comparison to DHHS guideline recommended antiretroviral regimens, etravirine use in naïve populations was less favorable by efficacy measures.  As a result, we still see etravirine’s use in the same way it was initially approved.  Once-daily dosing may be favorable in some patients to improve adherence granted that therapeutic drug monitoring may be available to verify sufficient etravirine plasma concentrations. Additionally, etravirine is now approved for use in children down to 2 years old with weight based dosing (BID only) and offers an additional agent in the form of a dissolvable tablet for use in this population.

What are the high-level take-aways about how/when to use etravirine?

Europe uses therapeutic drug monitoring more readily for ART than the US and thus uses once daily etravirine more frequently.  Given our stance on refraining from its use in naïve populations with a regimen such as ETR + F/TAF, as was done in the UNC study (78% VS rates at week 48), we feel the most likely patient that would use etravirine would be someone with some resistance and the risk of using once daily etravirine in this type of patient would likely be greater than its benefit.

What is the biggest gap in the science/knowledge about the role of etravirine in ART?

Further studies of etravirine use once daily in both adults and children may be warranted.  Given the efficacy of INI’s, we don’t feel that ETR has a place in naïve regimens.

Read the full study here: Havens, J.P., Podany, A.T., Scarsi, K.K. et al. Clin Pharmacokinet (2019). https://doi.org/10.1007/s40262-019-00830-9

Unpacking the new IDSA Community-Acquired Pneumonia guidelines

We are always excited to have our ID fellows provide guest blog posts. Second year ID fellow Dr. Lindsey Rearigh (follow her on Twitter @LRearigh) was recently on her Antimicrobial Stewardship rotation and reviewed the latest published guidelines for Community-Acquired Pneumonia (CAP). 

The American Thoracic Society (ATS) and Infectious Diseases Society of America (IDSA) recently released updated community-acquired pneumonia (CAP) guidelines. The first immediate implication is the healthcare-associated pneumonia (HCAP) definition is gone for good. IDSA had previously retired the term in the 2016 hospital-acquired pneumonia/ventilator-acquired pneumonia (HAP/VAP) guidelines.

HCAP was previously defined as patients with any one of the following risk factors: residence in a nursing home or other long-term care facility, hospitalization for >/= 2 days in the last 90 days, receipt of home infusion therapy, chronic dialysis, home wound care or a family member with a known antibiotic-resistant pathogen. This category would help guide empiric antibiotic therapy (before an organism is known), which could include treatment of methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas aeruginosa, and other multi-drug resistant pathogens.

In these new guidelines, clinicians are now recommended to empirically treat for MRSA or P. aeruginosa in adults with CAP only if locally validated risk factors for either are present. The most consistently strong individual risk factors for MRSA/P. aeruginosa include previous lower respiratory tract infection (LRTI) with MRSA or P. aeruginosa, hospitalization within last 90 days, or if the patient had received intravenous (IV) antibiotics within that time-frame. If empiric MRSA or P. aeruginosa therapy is started, the guidelines recommend de-escalation at 48hrs if cultures remain negative.

Traditional pathogens that previously accounted for CAP included Streptococcus pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae, Staphylococcus aureus, Legionella species, Chlamydia pneumoniae and Moraxella catarrhalis. Now with the implementation of vaccinations, viral pathogens are thought to be more prominent causes of CAP. Streptococcus pneumoniae is still a major contributor, although declined from 90-95% to 5-15% in recent studies.

Other main updates fall into the realm of diagnostic stewardship. The guidelines do not recommend obtaining sputum and blood cultures in the outpatient or inpatient setting, except only in cases of severe CAP (admission to the ICU or intubated), or if the patient is being empirically treated for MRSA or P. aeruginosa.

Procalcitonin has previously been used to help guide clinicians in the initiation of antibiotics in LRTI, but there were concerns of varied sensitivity of the test (range 38-91%) might miss patients with bacterial causes. The guidelines recommend empiric antibiotic therapy for presumed CAP regardless of initial serum procalcitonin.

Given the rising incidence and prevalence of viral causes of CAP, more research is needed to accurately identify clinical scenarios where antibiotic therapy can be safely withheld. Overall, treatment recommendations have not significantly changed except for the de-emphasis on macrolide monotherapy, particularly in areas where macrolide resistance was >/= 25% (which is pretty much everywhere in the US).

Five days of therapy is recommended to be adequate given the patient has reached clinical stability, including normalization of vital signs, ability to eat, and returned to baseline mental status.

If you are looking for a longer play-by-play summary of the new guidelines on Twitter, including a robust discussion of the mention of ceftaroline for CAP, click here for a thorough assessment by @ASPphysician, Dr. Andrew Morris.

Following up on pharmacist-led HIV pre-exposure prophylaxis

Earlier this year we featured a study by UNMC ID Drs. Sara Bares and Susan Swindells: “Midwest pharmacists’ familiarity, experience, and willingness to provide pre-exposure prophylaxis (PrEP) for HIV.”  We’re excited to share an update on their work building inter-professional relationships to increase PrEP education and use in Nebraska that was recently published in Open Forum Infectious Diseases: “Acceptability and feasibility of a pharmacist-led HIV pre-exposure prophylaxis (PrEP) program in the Midwestern United States.”

We spoke with first author Dr. Joshua Havens, UNMC ID HIV Program Clinical Pharmacist, about this recent publication.

What is the current work about?

The uptake of HIV pre-exposure prophylaxis (PrEP) is generally highest within large urban cities on the Western and Eastern coasts of the US.  Parts of the Midwest and the South are underserved in many ways but especially for PrEP access.  A provider paradox exists in determining the optimal setting where PrEP provision should take place (i.e. HIV provider, primary care clinic, STI clinic, etc).  It would seem that the primary care setting may be the first access point for PrEP provision of high-risk individuals, but many primary care providers are uncomfortable with providing PrEP for various reasons including increased daily patient loads, discomfort with HIV antiretrovirals, stigma, etc.  Further, patients have reported that they do not feel comfortable with discussing their sexual activity with their primary care provider.

Our study investigated the feasibility of pharmacists as collaborative HIV pre-exposure prophylaxis (PrEP) providers in several different settings (HIV clinic, primary care clinic, and a community pharmacy).  We aimed to capture the number of patients that chose to participate in the study, their retention in care over a year, patient satisfaction with the program, and the pharmacist’s acceptability with the program.

What were some of your key findings?

Our study enrolled 60 patients over 6 months most of which were Caucasian, gay or bisexual men with some sort of insurance coverage. Sexually transmitted infections (STI) were present in 23% of the population at baseline. The majority of the patients chose to participate in the study with nearly all enrolling at either the HIV clinic or community pharmacy settings (only 5 patients participated at a primary care site). Over the time course of the study, retention in PrEP care at all study sites fell. Overall, there was a high rate of patient satisfaction with the pharmacist-led program. Additionally, the pharmacist providers found the program to be acceptable.

The community pharmacy site for the study offered same day appointments in a private setting. All of the point of care screening and testing (HIV, creatinine, syphilis) was done by the pharmacist provider and the STI specimen collections (urine, pharyngeal, rectal) were self-collected by the patients after education was provided. All of these were free of charge during the study period and couriered delivery and processing of STI specimens were completed at a central laboratory with any incident STI’s communicated back to the study team to arrange for subsequent treatment. All of these processes pose as logistical challenges if the community pharmacy model were to be duplicated. Specifically, there is no point of care tesing for either Hepatitis B serology or rapid plasma regain (RPR). As a result, the initiation of PrEP in the community pharmacy would be challenging and the may be more appropriate for follow-up PrEP care. Further, the logistical challenges of STI specimen collection, processing, and treatment would present more challenges at the community pharmacy setting. Thus, these issues would need to be abated prior to implementing a pharmacist-led PrEP program in the community pharmacy setting.

What are some future directions for this work?

Larger scale research studies exploring ways to alleviate the logistical challenges noted in our study, PrEP persistence, and sustainability within the pharmacist-led PrEP model would help to strengthen its utility.

You can read more about this work here.

 


 

Fellowship MATCH DAY: Congratulations to our 2020 ID Fellows!

Every year our ID division is excited to welcome numerous fellowship applicants during the summer and fall months. Match Day is the culmination of these applicants’ hard work and our collective opportunities to demonstrate what we have to offer each other.  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 this year we expanded our our fellowship program, accepting three first-year fellows for the first time. We are thrilled that Drs. Casey Zelus, Laura Selby and Jonathan Ryder chose UNMC to embark on this path to becoming ID physicians. Congratulations, and we look forward to welcoming you in July 2020!

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

Learn more about the UNMC ID fellowship here and here.

Thanks and Gratitude

This time of year is a time for reflection, gratitude, and appreciation of the blessings we have, and we are grateful for the opportunity to share our thanks from all of us at UNMC ID. 

We want to thank all of our blog subscribers, those who forward our blog on to others, and all of our Twitter followers who support and share our content.

We want to thank the generous donors to our UNMCID #SHEARoes Race Against Resistance campaign (shout out to Tara Palmore who donated even after the race was over, thank you!), which raised over $2000 and won second place in the overall race.

We want to thank our Department Chair Dr. Debra Romberger, Division Chief Dr. Mark Rupp, and COM Dean Dr. Bradley Brittigan, for their ongoing support and encouragement for our Digital Innovation & Social Media Strategy team

We want to thank every individual, group, or conference who has invited our Digital Innovation & Social Media Strategy team (Drs. Cawcutt and Marcelin) to speak and share in this digital revolution

We want to thank our faculty, fellows, residents, students and advanced practitioners for their tireless work countless hours taking care of our patients in the hospital and in our clinics

We want to thank our ID pharmacists who have been instrumental in getting key initiatives off the ground, like our outpatient parenteral antibiotic treatment program and troubleshoot when we have antibiotic shortages.

We want to thank our ID nurses who have been the glue that keeps our clinics working

We want to thank our division/clinic administrators and administrative assistants for keeping the nonclinical work on track, and generally keeping us afloat

We want to thank our trainees for allowing us the privilege of teaching them this, and every year

We want to thank our statisticians and research assistants for working so closely with us on research that has brought us again to be the 2nd most productive division in the department of Internal Medicine at UNMC

We want to thank our patients in the hospitals and clinics for the privilege to treat them and in most cases, journey with them to complete resolution of their illnesses.

We want to thank our families who have supported all of us in our medical careers

THANK YOU, THANK YOU, THANK YOU, and keep following us for more amazing work in the future!

Antimicrobial Resistance is a Global Problem: Notes from the World Health Summit

From the World Health Summit, Berlin: Panel on Antimicrobial Resistance (AMR), October 27, 2019.

The 2019 World Health Summit (#WHS2019) opened with a panel discussion about the accelerating problem of global antimicrobial resistance (AMR). Dr. Peter Beyer, an intellectual property law expert working with the WHO on global health applications, led a panel of international experts to discuss current challenges of AMR – mostly focusing on what is widely recognized as a systemic market failure for R&D for new antimicrobials.

A number of international organizations, including the WHO and the UK Government, have issued reports citing the threat of AMR and issuing strong calls for action. (The CDC recently released their updated Antibiotic Resistant Threat Report earlier this November). The WHS panel began its conversation reviewing several recent reports of outbreaks of virtually untreatable bacterial infections. These reports highlight the current state of global emerging AMR. Many experts fear that we are approaching a tipping point in the 80-year “Antibiotic Era” in medicine and moving into a post-antibiotic era where definitive cures for bacterial (and other pathogen) infections are no longer a given.

A central theme of the WHS discussion was the alarmingly small pipeline of candidate antimicrobial therapeutics. Dr. Beyer relayed a current assessment by WHO that estimated in the range of 50 novel antimicrobials in the development pipeline across the entire pharmaceutical industry. This was contrasted with the thousands of candidate anti-cancer drugs currently in development. The lone industry representative on the panel, Julia Spencer from Merck, acknowledged the sentiments of the entire panel that the current economic market for antimicrobials coupled with the high development costs create an insurmountable disincentive for the capital and opportunity cost investments necessary to create new drugs under our present-day model of pharmaceutical R&D.

Panel members acknowledged the critical need for policy and regulation to reduce inappropriate antimicrobial use and advocated for more programs dedicated to improved infection prevention and control practices and antimicrobial stewardship. These interventions are particularly relevant for low and middle-income countries, and they represent a foundational element of actions to combat AMR.

Much of the discussion focused on the need for innovation, both in the technological space (where rapid, accessible, and affordable diagnostics could dramatically reduce inappropriate use of antimicrobials) and in the collaboration, finance, and market spaces. Dr. Elmar Nimmesgern, the head of the G20 initiative Global AMR R&D Hub, discussed opportunities to improve international collaboration and joint public-private efforts in antimicrobial development.

Some of the most interesting ideas came from the representative of the European Investment Bank, Felicitas Riedl. The Bank is exploring new financial instruments that could be used to incentivize investment in new antimicrobial candidates. The role of “impact investment” is acutely promising as a new trend where traditional venture capital mechanisms are used to achieve lower returns on investment in exchange for social impact that is important to investors. Variations on this theme, for example where impact investors may take “first loss” risk in investments, promise to expand dramatically the available capital for specific products or diseases.

The audience for the AMR panel was intently engaged, and the session ended with many hands still raised with questions and comments. The interest level from this international gathering of global health experts illustrates the importance of AMR in global health– what was termed “a silent pandemic” by one of the panelists. Dr. Lothar Wieler, President of Germany’s Robert Koch Institute ended the session on an optimistic note. He proposed that while similar to climate change in complexity and potential impact, AMR differs in that it is “100% anthropogenic” and therefore also resolvable by human action.

Although technically arguable – microorganisms have been producing and evolving to evade antimicrobial compounds for over a billion years – his point is relevant in directing immediate action that can counter this growing threat to global health security.

This content was written by Dr. James Lawler, Director, International Programs and Innovation, Global Center for Health Security and Director, Clinical and Biodefense Research, National Strategic Research Institute

Nebraska Medicine receives IDSA Antimicrobial Stewardship Center of Excellence Designation

In 2018, the Infectious Diseases Society of America (IDSA) began recognizing “Antimicrobial Stewardship Centers of Excellence” at hospitals that meet or exceed best practice standards. 

We are pleased to announce that Nebraska Medicine has recently been designated as an Antimicrobial Stewardship Center of Excellence effective October 2019. 

As we celebrate #AntibioticAwarenessWeek for 2019, we are reminded of the importance of antimicrobial stewardship as antimicrobial resistance is one of the most urgent global health threats. Everyone has a role to play in improving antibiotic use to help fight antibiotic resistance, and at University of Nebraska Medicine/Nebraska Medicine, we take that role seriously. 

The antimicrobial stewardship program (ASP) at Nebraska Medicine has been considered a leader in the field since becoming active and launching our website to guide clinicians on best practices in 2004. In fact, our ASP is one of thirteen hospitals highlighted by the Centers for Disease Control & Prevention (CDC) as examples of successful hospital antimicrobial stewardship programs. This has been increasingly demonstrated through institutional clinical care excellence, regional promotion of stewardship through programmatic support and training, research scholarship, and universal outreach through website and digital media resources.

The goal of the program is to optimize antimicrobial use, limit the spread of antibiotic resistance, and reduce adverse events of antibiotics such as C. difficile. Our ASP, now consisting of three physician directors and two pharmacist coordinators, is a multi-disciplinary collaboration between the UNMC Division of Infectious Diseases, Nebraska Medicine Departments of Pharmaceutical and Nutrition Care, and Infection Control and Hospital Epidemiology. The Nebraska Medicine ASP shares expertise with the Nebraska biocontainment unit the Davis Center for Global Health Security.

The program promotes standardization in patient care and high-reliability processes for clinical practice while taking into account patient-specific factors in the treatment of infection. Leveraging this experience and national recognition, the Nebraska Medicine ASP has been able to acquire multiple external grants in the last several years. The program also works with the Nebraska Department of Health and Human Services in securing funding annually from the CDC contracted with Nebraska Medicine for antimicrobial stewardship outreach in the state, through the Nebraska Antimicrobial Assessment and Promotion Program (ASAP).

We are grateful to the leadership of Nebraska Medicine, especially Dr. James Linder, CEO of Nebraska Medicine, Dr. Julie Fedderson, Chief Patient Safety and Compliance Officer, and Pharmacy leadership Lori Murante and Colleen Malashock for their support of the Nebraska Medicine ASP which was instrumental in attaining this Center of Excellence designation. We would also like to thank the members of our Antimicrobial Stewardship Program team (Salman Ashraf MD, Bryan Alexander PharmD, Scott Bergman PharmD, Phil Chung PharmD, Richard Hankins MD, Jasmine Marcelin MD, Erica Stohs MD, Trevor Van Schooneveld MD, Andrew Watkins PharmD), and our ID Division Chief Dr. Mark Rupp (who has led and been involved with the Nebraska Medicine ASP from the beginning), for all of their hard work in building our program at Nebraska Medicine.

Antimicrobial Stewardship efforts in the state of Nebraska

Content provided courtesy Dr. Salman Ashraf: Associate Medical Director, Nebraska Antimicrobial Stewardship Assessment and Promotion Program (ASAP) & Medical Director, Nebraska Infection Control Assessment and Promotion Program (ICAP)

CDC’s most recent (2019) report on Antibiotic Resistance Threats in the United States describes 2.8 million infections due to antibiotic resistant organisms in the US resulting in over 35,000 deaths annually. The Division of Infectious Diseases at University of Nebraska Medical Center (UNMC) and Nebraska Medicine (NM) is collaborating with Nebraska DHHS Healthcare-Associated Infections/Antimicrobial Resistance (HAI/AR) program via a CDC grant to decrease the prevalence of antibiotic resistance throughout Nebraska, through the Nebraska Antimicrobial Stewardship Assessment and Promotion Program (ASAP).

Some notable activities of Nebraska ASAP initiative include:

  • Assisting over 30 healthcare facilities in the state in developing or improving their antimicrobial stewardship program
  • Creating a website focused on promoting ASP in healthcare facilities by providing tools and templates specific to the different healthcare settings. Since its inception in August 2017, the Nebraska ASAP website has been visited by over 12000 users both nationally and internationally and has earned the reputation of a national resource for facilities looking into developing or improving their ASP.
  • Organizing Antimicrobial Stewardship Summits for the state of Nebraska in 2018 and 2019 to provide education to over 250 ASP program professional, and four smaller sessions were held in different cities to reach out to those who were not able to attend the main summit.
  • Establishing the Nebraska ASAP YouTube Channel in February 2018 hosting all of the educational videos developed by the team, with over 20,000 views so far.   
  • Sharing our experience with healthcare community at various national meetings. (Available at https://asap.nebraskamed.com/about/selected-publications-and-presentations/)
  • Collaborating with Nebraska Medicine ASP to reduce antibiotic prescribing in outpatient clinics for acute bronchitis by 10%.
  • Launching a free online educational training on management of acute respiratory infections in outpatient setting which includes a presentation on communication strategies with patients. [CME credits available until 2020]
  • Initiating a collaborative project to decrease Clostridioides difficile infections in acute and long-term care facilities in the state.

As ASAP team members, UNMC/NM subject matter experts are supporting DHHS HAI/AR team’s fight against antimicrobial resistance. In addition to the ASAP activities, Nebraska DHHS HAI/AR team has launched several other initiatives focused on promoting appropriate antimicrobial use in the state. The DHHS HAI/AR team is committed to the CDC AMR challenge and have developed an antimicrobial susceptibility registry that can detect resistant organisms early so facilities can be assisted in containing the spread of multi-drug resistant organisms. The DHHS HAI/AR program also works closely with relevant stakeholders in the state such as Great Plains QIN/QIO, various healthcare associations, Nebraska Pharmacist association and other healthcare systems and organizations to achieve the common goal of promoting appropriate antibiotic prescribing and decrease antimicrobial resistance. They are also collaborating with Nebraska One Health to prevent misuse of antibiotics in livestock industry and agriculture.

Source: Antibiotic Resistance & Patient Safety Portal

The statewide efforts of DHHS HAI/AR program including Nebraska ASAP along with the amazing work done by our partner organizations, healthcare facilities and healthcare professionals have had positive impact on antimicrobial stewardship programs and antimicrobial resistance in Nebraska. Our MRSA bacteremia and C. difficile rates are 58% and 17%,  lower than the national baseline, respectively. The number of hospitals meeting all 7 CDC-recommended core elements of antimicrobial stewardship program have been on the rise in the last few years with 81% of the hospitals reporting to NHSN meeting all core elements in 2018 as compared to 31% in 2015.

While these findings are very encouraging there is still opportunity for improvement. Nebraska is still in the Top 10 rates of outpatient antibiotic prescribing and is significantly above the national average of 821 prescriptions per 1000 population.  An encouraging finding has been a recent decline to 986 prescriptions per 1,000 population in 2017 which was the first time the rate had dropped below 1000. We are committed to build on this success and are planning to roll out new initiatives focused on improving outpatient antibiotic prescribing practices.

In a nutshell, the unique model of public health department (NE DHHS HAI/AR program) and academia (UNMC/NM) partnership has facilitated antimicrobial stewardship efforts in Nebraska. This model has been very effective in making antimicrobial stewardship experts available to resource limited healthcare settings (such as critical access hospitals and long-term care facilities), which otherwise lack access to such expertise. Other states may also benefit from developing such partnerships in order to fight antimicrobial resistance and raising awareness of the risk of inappropriate antibiotic use.

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