Division of Infectious Diseases

Going Viral with West Nile

As we get further into the summer, we are yet again nearing West Nile Virus season, and there are starting to be a few cases reported nationwide. Our senior ID fellow Dr. Lindsey Rearigh wrote an article outlining what to expect with West Nile Virus, how it is transmitted, diagnosed, and treated.

West Nile Virus (WNV) is a mosquito born illness that made its way to the United States in 1999. The majority of cases are reported in the late summer, peaking from mid- August to September. Although WNV infections have been seen in all the contiguous United States, Nebraska is commonly at the epicenter for cases each year. In fact, Nebraska led the 2018 seasons with 251 total cases reported at the end of the year, including 124 neuroinvasive cases.

In general, birds harbor the virus and transmit the virus to mosquitos after the mosquitos has feed on the infected bird. WNV is most commonly spread to humans by the bite of a mosquito although can rarely be spread through blood transfusions and organ transplantation as well. WNV has not been demonstrated to spread directly from human to human via touch, saliva or other bodily fluids.

Symptoms range from asymptomatic to fevers and neurologic manifestations including meningitis, encephalitis and even flaccid paralysis. About 80% of people affected will be asymptomatic with only about one in 150 cases manifesting as neuroinvasive disease. Symptom onset is seen approximately 2 to 6 days following mosquito exposure, but can be seen up to 2 weeks after a bite in the immunocompromised population. If symptomatic, the elderly are generally more severely affected with a demonstrated increased overall incidence of neuroinvasive disease peaking for those greater than seventy years old.

Diagnosis is typically made via serologic testing for immunoglobulins in the blood. If neuroinvasive disease is suspected cerebral spinal fluid (CSF) should be collected and tested for the immunoglobulins as well. IgM for WNV is usually detectable within 3 to 8 days from illness onset and can stay positive up to 30 to 90 days after initially detected, sometimes longer. IgG for WNV will persist for even longer than IgM even up to years after initially positive, meaning testing positive for IgG alone would not be sufficient evidence to diagnosis an acute infection either in the blood or in the CSF.

Treatment is aimed at symptomatic care with therapies such as high dose steroids and plasmapheresis demonstrating variable improvement in patient outcomes. Time to complete recovery is variable from weeks to months in some cases, and can even leave some permanent neurological affects in the patients most severely affected. There is no vaccination available, so education on prevention is of the utmost importance. Avoidance is key, staying indoors at dawn and dusk when mosquito activity is high and if you are outdoors during those times, wearing long pants and sleeves are recommended. Insect repellant approved by the EPA is also important in efforts to avoid mosquito bites and in general is recommended to be worn over clothing for maximal effect.

Want to find out exactly how many cases of WNV have been reported across the country? Check out the statistics here and here.

The CDC also has a comprehensive resource for more information on WNV.

New Faculty Spotlight – Dr. Nicolas Cortes-Penfield

Tell us about the position you are starting?

I’m joining the Infectious Diseases Division as an Assistant Professor of Medicine and Medical Director of UNMC’s Outpatient Parenteral Antimicrobial Therapy (OPAT) program. My clinical practice will be primarily devoted to seeing patients on the Orthopedic Infectious Diseases hospital service, meaning I’ll work with orthopedic surgeons at Nebraska Medicine and Ortho Nebraska to treat patients who have infections involving bones, joints, and implanted orthopedic devices (e.g. artificial knees and hips). I will also see patients on the General Infectious Disease hospital service, which cares for hospitalized patients with a wide range of infections and symptoms suggesting infection. In the outpatient clinic, I will primarily be following up with patients seen by Orthopedic Infectious Diseases in the hospital to monitor and continue their treatment.

As the Medical Director of our OPAT program, I will help ensure that patients who need to continue antimicrobial therapy after leaving the hospital receive the drug(s) best suited for their individual situations. When patients leave the hospital we try to give antimicrobials by mouth instead of intravenously whenever possible, because oral antimicrobials are often equally effective, less bothersome to administer, less costly for our patients, and avoid the risks and discomfort of having an intravenous line at home. That said, some patients have infections with organisms that cannot be treated with oral antibiotics, or have particularly severe infections that may respond better to intravenous therapy. For these people, my job will be to help ensure they receive the correct dose and duration of intravenous antimicrobials, receive appropriate safety monitoring bloodwork while on therapy, and have their intravenous lines removed promptly after completing their courses of treatment.

Background:

I was born and raised in Austin, Texas and completed my undergraduate education at The University of Texas at Austin. After graduating from UT-Austin, I went on to complete medical school, residency in Internal Medicine, and clinical and research fellowships in Infectious Diseases at the Baylor College of Medicine in Houston, Texas. In 2019 I brought my family to Omaha to join the Division of Infectious Diseases at the University of Nebraska Medical Center.

Why UNMC?

I knew that I wanted to stay in academic medicine and build a career focused on research and medical education. Interviewing at UNMC, what struck me most was the friendly and enthusiastic demeanor of all of my prospective colleagues. It was clear to me that the other junior faculty in the ID section felt supported in their varied career pursuits – clinical service, research, education, administration, etc – and were satisfied with their work/life balance. I also saw the Orthopedic Infectious Diseases position as a wonderful opportunity to develop expertise in a new, important, and rapidly growing niche within the field of Infectious Diseases.

Something interesting about me not related to medicine: I am a classically-trained saxophonist and recorded with the UT Saxophone Choir in college. I’m fascinated by the microorganisms that live all around us and on weekends can often be found tinkering with them via baking, home brewing, working in our backyard garden or pond or compost pile, etcetera.

UNMC Highlights Women in Science

As a medical student, I feel fortunate to be at UNMC, which values and supports women in medicine. One of the greatest examples of this empowerment championed is a program held this year called “UNMC’s Women in Science: Our Voices, Our Stories.” This event – sponsored by the McGoogan Library of Medicine, the Women’s Mentoring Group, and the UNMC Office of Faculty Development – consisted of a panel of impressive women at UNMC who shared their advice for seeking mentorship, identifying and taking advantage of opportunities, and advocating for oneself. The presenters included:

Jasmine Marcelin, M.D., assistant professor, infectious diseases, associate medical director, Antimicrobial Stewardship Program, UNMC Division of Infectious Diseases
Amber Donnelly, Ph.D., professor and director of cytotechnology education, UNMC College of Allied Health Professions
Ashley Wysong, M.D., chair of the UNMC Department of Dermatology

We are so proud that Dr. Marcelin participated in this event! Dr. Marcelin’s story of finding mentors who inspired her to follow in their footsteps particularly resonated with me. I have benefited so much from mentors who have taken time to talk to me about their careers, guide me through the complexities of getting to medical school, and help me become the woman I am now. Being surrounded by strong and thoughtful women has given me living examples of who I can be in the future.

You can watch the panel presentation here.

Pharm2Exam Table: What is persistent MRSA bacteremia and how is it treated?

The following is a clinical review written by Ashleigh Grammar, PharmD, a recent graduate of the UNMC College of Pharmacy, and supervised by Scott Bergman PharmD FIDSA, Clinical Pharmacy Coordinator of Nebraska Medicine Antimicrobial Stewardship Program (@bergmanscott)

What is persistent MRSA bacteremia and how is it treated?

Methicillin-resistant Staphyloccous aureus (MRSA) (photo credit: CDC Public Health Image Library) is a bacteria that can cause a wide variety of infections, including skin or soft tissue infections and bloodstream infections (bacteremia). The Centers for Disease Control (CDC) categorize MRSA as a serious threat (1). Although vancomycin has been a reliable antibiotic to treat MRSA for decades, severe infections from it are still difficult to cure. Current MRSA bacteremia practice guidelines by the Infectious Disease Society of America (IDSA) recommend the use of vancomycin or daptomycin as first-line treatment options for bacteremia (2). Concern arises, however, when bacteremia continues despite the use of these agents. IDSA defines persistent MRSA bacteremia as blood cultures that remain positive after 7 days of effective therapy (2). A study conducted by Cosgrove et al found mortality rates as high as 60% from MRSA bacteremia. Changes in therapy or combination therapy may be necessary despite the limited data (3).

An important step in persistent MRSA bacteremia treatment is identifying all possible sources of infection and obtaining source control through drainage or surgical debridement (3). The IDSA guidelines do not define an optimal treatment regimen for persistent bacteremia. An assessment of the patient’s clinical status around day 7 of therapy is reasonable and should help determine if a change in therapy is warranted. If first-line therapy fails, IDSA guidelines recommend a change in therapy rather than adding an additional agent. Recommendations include high-dose daptomycin at 10 mg/kg daily, if susceptible, in combination with another agent. The second agent could include gentamicin, rifampin, linezolid, sulfamethoxazole-trimethoprim, or a beta-lactam. If there is reduced susceptibility to vancomycin or daptomycin, guidelines suggest sulfamethoxazole-trimethoprim, linezolid, or televancin. These agents could be used alone or in combination with another antibiotic (2). A preferred regimen for persistent bacteremia, however, has yet to be established as most data is only available from case reports or series.

Daptomycin is a cyclic lipopeptide antibiotic that exhibits bactericidal activity against Gram-positive bacteria by inserting its lipophilic tail into the bacterial cell membrane which causes rapid depolarization. In vitro data suggests a synergistic relationship between daptomycin and other antibiotics providing an advantage in persistent MRSA bacteremia. The addition of a beta-lactam to daptomycin improves daptomycin binding to the cell membrane leading to an increase in net cell membrane surface charge and ultimately cell death. A “see-saw effect” also occurs when daptomycin is in combination with an antistaphylococcal beta-lactam where a reduction in daptomycin susceptibility provides an increase in antistaphylococcal susceptibility (3). One case series of 7 patients that were treated with daptomycin 8-10 mg/kg daily plus either nafcillin or oxacillin 2 grams every 4 hours, after failing vancomycin, had blood sterilization within 24-48 hours (4). Adding an antistaphylococcal beta-lactam to daptomycin is a reasonable option when treating persistent MRSA bacteremia.

Similar to the antistaphylococcal penicillins, ceftaroline has also demonstrated a synergistic relationship when added to daptomycin. Ceftaroline, however, provides further benefit by its natural activity against MRSA, vancomycin resistant strains, and daptomycin non-susceptible Staphylococcus aureus. A multi-centered, 26 patient case series reported 96% of patients had clear blood cultures in an average of 2 days after initiation of daptomycin 6-10 mg/kg daily plus ceftaroline 400-600 mg every 8 to 12 hours (5). A recent clinical study of MRSA bacteremia was terminated early due to a significant difference in the mortality rate of daptomycin plus ceftaroline (0%) compared to standard monotherapy (26%), which was mainly vancomycin. Although more data is needed, daptomycin plus ceftaroline has promising results and is an attractive option for salvage therapy in persistent bacteremia.

Another potential option for persistent bacteremia is the addition of sulfamethoxazole-trimethoprim. Combination therapy of daptomycin and sulfamethoxazole-trimethoprim has demonstrated in vitro synergy by increased inhibition of folate synthesis, although the exact mechanism is unknown. The combination did show greater bactericidal activity than either agent alone (7). Two case reports acknowledged successful treatment of a daptomycin non-susceptible bacteremia with daptomycin 10 mg/kg daily plus sulfamethoxazole-trimethoprim 8 mg/kg daily divided every 8 hours (8). In addition, a case series of 26 patients with MRSA bacteremia caused by bone and joint infections identified 24 out of 26 patients that had microbiological eradication in an average of 2.5 days after combination therapy with daptomycin and sulfamethoxazole-trimethoprim (9). This series suggests a potential benefit of this combination in patients that specifically have persistent MRSA bacteremia due to a bone or joint infection.

Although linezolid is an option for S. aureus bacteremia, it is not FDA approved and is often not the preferred agent due to its bacteriostatic activity and large volume of distribution. Combination therapies that add linezolid, however, have shown some benefit in persistent bacteremia. In vitro data has shown a combination of linezolid with daptomycin was more effective than either agent alone.10 Few clinical data have shown this benefit. Two studies demonstrated a 30 day mortality benefit of a linezolid based-regimen over adding another agent to vancomcin (11,12). Although there is a risk of toxicities associated with a prolonged duration of therapy, linezolid based regimens could be used for salvage therapy in persistent bacteremia.

Lastly, rifampin in combination with daptomycin for persistent bacteremia potentially provides additional benefit due to the ability of rifampin to target biofilm. It should be noted that addition of rifampin for bacteremia with endocarditis is not routinely considered because of rapid development of rifampin resistance by circulating S. aureus. Patients with bacteremia due to an infected prosthetic device or bone infections may have more success with this regimen (3). A case series of 12 patients with osteomyelitis or other joint infections showed clinical cure in 10 of the patients that received high dose daptomycin plus rifampin 300-600 mg daily (13). These cases provide another option in salvage therapy for those patients that have an infection with biofilm.

Conclusion

Many combination antibiotic regimens have been shown to be successful in patients that have MRSA bacteremia lasting more than 7 days. Daptomycin-based combinations seem promising. However, the lack of randomized controlled trials and comparative studies has made choosing the most appropriate regimen difficult. The patient’s clinical condition, ability to obtain source control, and results of susceptibility testing should determine when and if a modification to the standard antibiotic therapy is indicated. Because of the significant burden of persistent MRSA bacteremia, antibiotic therapy is warranted for at least 6 weeks. Although a combination regimen is likely not necessary for the full course of therapy, timing of antibiotic de-escalations is also not well studied. Eradication of infection, source control and improvement in the patient’s clinical condition can provide insight as to when de-escalation may be appropriate.

References

1. Centers for Disease Control and Prevention. Antibiotic resistance threats in the United States, 2013. http://www.cdc.gov/drugresistance/threat-report-2013/index.html. Accessed February 16, 2019.

2. Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin‐resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis. 2011;52:1‐38.

3. Lewis PO, Heil EL, Covert KL, Cluck DB. Treatment strategies for persistent methicillin-resistant staphylococcus aureus bacteraemia. J Clin Pharm Ther. 2018;43(5):614-625.

4. Dhand A, Bayer AS, Pogliano J, et al. Use of antistaphylococcal β‐lactams to increase daptomycin activity in eradicating persistent bacteremia due to methicillin‐resistant Staphylococcus aureus: role of enhanced daptomycin binding. Clin Infect Dis. 2011;53:158‐163.

5. Sakoulas G, Moise PA, Casapao AM, et al. Antimicrobial salvage therapy for persistent staphylococcal bacteremia using daptomycin plus ceftaroline. Clin Ther. 2014;36:1317‐1333.

6. Geriak M, Haddad F, Rizvi K, et al. Clinical data on daptomycin plus ceftaroline versus standard of care monotherapy in the treatment of methicillin-resistant Staphylococcus aureus bacteremia. Antimicrob Agents Chemother. 2019 [ePub ahead of Print]

7. Dhand, Abhay et al. Daptomycin in combination with other antibiotics for the treatment of complicated methicillin-resistant Staphylococcus aureus bacteremia. Clin Ther. 2014; 36:1303-1316.

8. Avery LM, Steed ME, Woodruff AE, et al. Daptomycin non‐susceptible vancomycin‐intermediate Staphylococcus aureus vertebral osteomyelitis cases complicated by bacteremia treated with high‐dose daptomycin and trimethoprim‐sulfamethoxazole. Antimicrob Agents Chemother. 2012;56:5990‐5993.

9. Claeys KC, Smith JR, Casapao AM, et al. Impact of the combination of daptomycin and trimethoprim‐sulfamethoxazole on clinical outcomes in methicillin‐resistant Staphylococcus aureus infections. Antimicrob Agents Chemother. 2015;59:1969‐1976.

10. Parra-Ruiz J, Bravo-Molina A, Peña-Monje A, et al; Activity of linezolid and high-dose daptomycin, alone or in combination, in an in vitro model of Staphylococcus aureus biofilm. Journal of Antimicrobial Chemotherapy. 2012; 67(11):2682–2685.

11. Jang HC, Kim SH, Kim KH, et al. Salvage treatment for persistent methicillin‐resistant Staphylococcus aureus bacteremia: efficacy of linezolid with or without carbapenem. Clin Infect Dis. 2009;49:395‐40.

12. Park HJ, Kim SH, Kim MJ, et al. Efficacy of linezolid‐based salvage therapy compared with glycopeptide‐based therapy in patients with persistent methicillin‐resistant Staphylococcus aureus bacteremia. J Infect. 2012;65:505‐512.

13. Rose WE, Berti AD, Hatch JB, Maki DG. Relationship of in vitro synergy and treatment outcome with daptomycin plus rifampin in patients with invasive methicillin‐resistant Staphylococcus aureus infections. Antimicrob Agents Chemother. 2013;57:3450‐3452.

Placing PICCs for Antibiotics – Potential Undue Risks May Outweight Benefits

PICC placement is common practice for intravenous (IV) antibiotic needs, however, we may be inadvertently placing certain patients at higher risks for complications. A recent study by Paje et al assessed the frequency of PICC placement among patients with CKD stage 3b or greater, a practice discordant with current guidelines. This prospective study included data from over 20,000 adult patients across 52 hospitals participating in the Michigan Hospital Medicine Safety Consortium between 2013 and 2016. The most common indication for PICC placement was for IV antibiotics (37.6%). Of patients with PICCs, 23.1% had CKD stage 3b or greater, with increased likelihood of PICC placement in the setting of CKD within the ICU as compared to the wards (32.1% vs 18.9%, respectively). Further, most PICC lines placed in patients with CKD were removed prior to hospital discharge (67.2%), with 25.8% of these lines having an indwell time of less than 5 days. 17.8% of all PICCs developed complications, with higher rates among those in the ICU and those with CKD. This study is incredibly important as it highlights the need to assess potential risks of placing a PICC, in addition to the need for IV antibiotics, particularly among those with CKD. The high rate of PICC placement among CKD patients limits their future potential for AV fistula placement, the lowest risk hemodialysis access for CLABSI and other complications. Further, the short duration of indwell time in PICCs suggests potential alternative IV access, or potential treatment options, could have been pursued. There is great opportunity for the ID community to improve vascular access device choice, in concordance with current guidelines, among CKD patients requiring antibiotics.

Content originally posted in the IDSA Journal club. Written by Dr. Kelly Cawcutt.

Dr. Susan Swindells to lead new TB prevention clinical trial

We are very proud to have Dr. Susan Swindells as a part of our division. A nationally and internationally renowned HIV clinical researcher, Dr. Swindells is a Professor of Internal Medicine-Infectious Diseases at University of Nebraska Medical Center. For many years she has led the Specialty Care Center in providing extraordinary care to patients with HIV in Omaha.

Simultaneously, Dr. Swindells has also led several groundbreaking clinical trials investigating HIV treatment and management of tuberculosis in people with HIV. Earlier this year, Dr. Swindells was the lead author on a study published in the New England Journal of Medicine, that found “a 1-month regimen of rifapentine plus isoniazid was noninferior to 9 months of isoniazid alone for preventing tuberculosis in HIV-infected patients“.

Now, Dr. Swindells will be one of four scientists leading as protocol chair for a new Phase 3, international, multi-site clinical trial evaluating drugs to be used to prevent multidrug-resistant tuberculosis (MDR-TB), which affects many people with HIV globally.

Dr. Kim Scarsi PharmD is a nationally and internationally recognized HIV Pharmacist, and UNMC ID Faculty member. Dr. Scarsi was named as the protocol pharmacologist for the study. Dr. Scarsi was recently recognized by the AIDS Clinical Trials Group (ACTG) with the Constance B Wofsy Woman’s Health Award “in Recognition of Scientific Contributions to Research in HIV-Infected Women and Embodiment of Qualities Exemplified by Dr. Wofsy“.

The study, called PHOENIx MDR-TB, is funded by the NIH (including the AIDS Clinical Trials Group and the International Maternal Pediatric Adolescent AIDS Clinical Trials Network), the Eunice Kennedy Shriver National Institute of Child Health and Human Development, and the trial drug delamanid, will be donated by the manufacturer, Otsuka Pharmaceutical Co., Ltd. of Tokyo.

Learn more about this new study that Dr. Swindells will be leading here.

More about MDR-TB here.

A Message from Our ID Fellowship Leaders

Fellowship application season is nearing and as the leaders of our ID fellowship, we wanted to highlight some of the exciting aspects of our program. Our program and our division are growing. We began in 2011 with 2 fellows, grew to 4 in 2017, and are planning to expand to six fellows by 2021. We plan to match 3 fellows this application season. Our faculty also continues to grow, as we now have 23 physician faculty with diverse expertise. Dr. Trevor Van Schooneveld has been the Program Director since the program was created, and we recently appointed an Associate Program Director, Dr. Andrea Zimmer. Dr. Zimmer is also the director of the Oncology ID program, and she completed her ID fellowship at Vanderbilt University, followed by a transplant ID fellowship at Mayo Clinic.

Drs. Hankins and Karnatak spent time in the biocontainment unit

Fellows at UNMC enjoy a robust clinical experience that includes not only the typically complex patients seen at a tertiary referral center, but also includes extensive experience caring for immunosuppressed patients. In addition to our General ID service, we have two separate immunocompromised services that care for oncology and solid organ transplant patients. In the last year we have added an orthopedic infectious diseases rotation where fellows gain experience managing these complex patients and work with faculty who have extensive experience in this area. We have also expanded our ambulatory offerings with the creation of a non-tuberculous mycobacteria (NTM) clinic and a travel clinic. The faculty at UNMC are nationally recognized experts in their field, and are also very approachable and devoted to the education and success of trainees. They have created extensive educational opportunities, covering topics from opportunistic infections in solid organ and hematopoietic stem recipients to emerging global pathogens and biopreparedness. Fellows gain knowledge in HIV/AIDS management working in our multidisciplinary HIV clinic which cares for over 1200 people with HIV.

As new career opportunities develop for ID physicians, we have worked to provide our fellows with the skills to engage in these fields. UNMC ID fellows receive extensive experience in the area of infection control and antimicrobial stewardship. UNMC also offers the opportunity to stay for an option third year to further develop a research portfolio or pursue additional clinical expertise in subspecialty areas.

Dr. McCreery presenting his research

An important part of fellowship is developing skills in interpreting and performing research, and we provide our fellows with six months of mentored research experience centered on their career goals. A research committee assists fellows in mentor identification and project development. Fellows also participate in a week-long UNMC sponsored research training program, and typically present their work at national conferences like IDWeek and SHEA.

Our goal as program directors is to provide fellows with an educational experience that provides them with skills and knowledge to make them successful in whatever career path they choose. The opportunities available to ID physicians continue to expand and we hope you will consider UNMC ID. If you are interested in more information, please feel free to visit our website and/or contact us.

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

EMET Student Profile – Samantha Cox, M1

Meet Samantha Cox, a new M1 student in our HIV Enhanced Medical Education Track!

Tell us a little about yourself

I moved to Omaha with my family from Saskatoon, Saskatchewan, when I was in elementary school and attended high school at Duchesne Academy. I completed my Bachelor’s degree in French and Biology at College of Saint Benedict/Saint John’s University in Minnesota. Shortly after graduating from university, I decided to pursue a career in medicine and began taking pre-requisite courses at UNO while working as a medical scribe in the Nebraska Medicine Emergency Department. I completed a Master’s degree in Medical Anatomy from UNMC before beginning medical school this past fall.

Why did you decide to come to medical school at UNMC?

I chose to come to UNMC for medical school largely thanks to the physicians I worked with in the Emergency Department – their willingness to teach me and give me a glimpse into the world of medicine showed me what a great place UNMC would be to continue learning from amazing faculty from all departments and specialties. This was reaffirmed by the professors I interacted with while completing my Master’s degree. The moment I found out I was accepted into UNMC, I knew exactly where I would be for the next four years. I am incredibly grateful for the mentorship and encouragement I’ve already received and for the friendships I have made with my peers during my first year of medical school.

Could you tell us more about the HIV EMET program? What drew you to it?

Broadly, the EMET programs are an opportunity for medical students to pursue an area of interest in more depth than is covered in the standard curriculum and to receive invaluable mentorship from the faculty members who are in charge of each program. The Comprehensive HIV EMET will allow me to learn more about the care of patients living with HIV over the course of almost 4 years through a longitudinal project, clinical experience, and faculty guidance. My initial interest in HIV was sparked when I began volunteering at the Nebraska AIDS Project (NAP) when I moved back to Omaha; my interest grew after learning more about HIV and meeting the incredible HIV physicians this past fall. It became evident that I could approach the topic from the perspective of women’s issues, biomedical research, socioeconomic determinants of health, LGBTQ issues, public health, medical history, health policy, and so on and so forth! No matter what field of medicine I pursue, I will care for and interact with patients with HIV. I am excited to continue learning about and being an advocate for HIV patients through this EMET.

What is something you enjoy outside of medicine?

I enjoy getting outside as much as I can especially now that the weather is getting nicer. I worked at summer camps for about a decade before medical school and still enjoy getting out to lead a high ropes course whenever I can. I love traveling and learning about the cultures and wildlife in different areas of the world – I am going to Australia this summer and am indescribably excited to see the Great Barrier Reef and Daintree Rainforest.

We wish Samantha the best of luck over the next several years during his journey with us as part of the HIV EMET! More information about the EMET program can be found here.

Inpatient Diarrheal Illness…Don’t Flush your Money: Save it with Diagnostic Stewardship!

Recently, a multidisciplinary team at UNMC published a diagnostic stewardship study in Infection Control & Hospital Epidemiology (ICHE) entitled: Hardwiring diagnostic stewardship using electronic ordering restrictions for gastrointestinal pathogen testing, that prompted a press release from The Society for Healthcare Epidemiology of America (SHEA), and a feature on an upcoming ICHE podcast episode. Drs. Jasmine Marcelin and Trevor Van Schooneveld are the lead and senior authors on this study.

What is the study about?

Antimicrobial stewardship has really morphed from just being about antibiotic prescribing, to a more comprehensive strategy including diagnostic testing and collaboration with the microbiology laboratory. Our antimicrobial stewardship program at University of Nebraska Medical Center is heavily invested in diagnostic stewardship and the gastrointestinal pathogen panel (GIPP) was the focus of this latest project. The hospital implemented the use of the GI Pathogen panel in 2016, a quick and sensitive, but costly test that detects 22 common organisms causing diarrheal illness. Many studies using this test have found it useful to detect a wide range of community-associated organisms, but that it is not as helpful if patients have been hospitalized for more than 3 days, or have had a previously negative test. After implementing the test (replacing most traditional stool cultures) in 2016, it was used frequently and repeatedly, including in patients hospitalized even longer than 5 days.

There is a clinical effectiveness team at UNMC (including physicians, lab clinicians, pharmacists, nurses and other leaders) at the hospital that looks at things like this to see where we can be more effective at providing high-value, cost conscious care to our hospitalized patients. The GI pathogen panel test is not cheap, and it was being used frequently, so this was a good target for the CE team to tackle. Collaborating with the microbiology lab, we used our hospital electronic health record (EHR) to provide best practice alerts when people tried to order the test, and if someone tried to order it inappropriately (which we designated as >72hrs post admission or duplicate test), there was a hard stop that prevented the test from being signed and completed. If people felt very strongly that the test needed to be done after the hard stop, they could call the microbiology laboratory director to discuss overriding the stop (that did not occur very often).

What did the study find?

In the fifteen months before the hard stop was activated, we found that 21.5 percent of the GIPP tests ordered were inappropriate. In the 15 months after implementing the hard stop in the EHR, only 4.9 percent were inappropriate (P<0.001). The study also included a cost analysis for this intervention. When considering only the orders prevented by the hard stop (30% reduction), there was an actual savings of $67,000 over that post-intervention 15 months. However, if considering all of the potential orders which were prevented by the best practice alerts AND the actual hard stop preventions, there was a 46% reduction in inappropriate testing and potential savings of $168,000, even after accounting for the cost of alternative testing! That is enough to fully fund an ID pharmacist or at least partially fund an ID physician for a hospital’s Antimicrobial Stewardship team.

Why is this study interesting?

The study will be useful for any clinicians who may order microbiologic testing for diarrheal illness for hospitalized patients – primary and specialist physicians, microbiologists and laboratory directors, medical trainees, and advanced practice providers. Additionally, hospital administrators and quality improvement individuals will be interested in this study given the significant cost savings associated with this intervention. When this work was presented at IDWeek2018, many people were looking for simple interventions like this that saved hospitals money, as examples to demonstrate to their C-suites the value of funding Antimicrobial Stewardship. This study is interesting because it shows a relatively simple intervention can have an impactful result. It demonstrates that that when it comes to diarrheal illnesses in the hospital, asking physicians to reconsider if the testing is appropriate through hardwired alerts saves money without compromising quality of care.

What about future research questions?

The most important takeaway from this study is that we can improve the efficiency of the care we deliver by hardwiring criteria for appropriate test ordering and diagnostic stewardship into the electronic health record, and that it is something relatively easy to do. Some things that were not studied, but would have been helpful if we collected information on include: length of stay or antibiotic use for diarrheal illness. This would have had allowed the opportunity to evaluate the potential relationship of these outcome metrics with the hard stop. That would not only further support our assertion that the hard stop would not compromise quality of care, but if we could demonstrate shorter length of stay or fewer unnecessary antibiotic prescriptions for this indication, we could go even further to state that this intervention enhances quality of care. Another area of interest would be applying this concept to other rapid diagnostic testing. Currently, other available multiplex tests like the GI pathogen panel include the meningitis panel, upper respiratory and newer lower respiratory panel tests; if we can figure out how to use these tests responsibly and not abuse them, we could further improve high-value, high-efficiency and cost-conscious care.

Citation

Marcelin, J., Brewer, C., Beachy, M., Lyden, E., Winterboer, T., Murphy, C., . . . Van Schooneveld, T. (2019). Hardwiring diagnostic stewardship using electronic ordering restrictions for gastrointestinal pathogen testing. Infection Control & Hospital Epidemiology, 40(6), 668-673. doi:10.1017/ice.2019.78

Everyone Should be Tested for HIV

Today is National HIV Testing Day, and one of the most fulfilling conversations to have with persons living with HIV (PLWH) is to share that since the 1980’s, we have made significant progress in the management of the AIDS epidemic. FDA approval of 27 antiretrovirals and 20 fixed dose combination antiretrovirals, increased HIV testing campaigns and funding for HIV care through the Ryan White Comprehensive AIDS Resource Emergency (CARE) Act have made it possible for millions of persons with HIV to live fulfilling lives. Notwithstanding these amazing movements, eliminating HIV remains a moving target as stigma and socioeconomic, racial, age and gender disparities result in inequalities of diagnosis, linkage to and retention in care.

In 2006, the Centers for Disease Control and Prevention (CDC) recommended universal HIV screening, which was endorsed by the United States Preventive Services Taskforce (USPSTF) in 2013. Despite these recommendations, 1 in 7 persons living with HIV (PLWH) in the United States are unaware of their diagnosis. When stratified by age, young people between the ages of 13-24 account for 22% of all new HIV diagnoses in the U.S., but 44% of PLWH in this age group are unaware of their diagnosis (the highest percentage among all age groups).

HIV testing is available at multiple locations. You can ask your primary care clinician to test you for HIV, but did you know that you can get tested for free or low cost at multiple locations near you? These can be local nonprofits like the Nebraska AIDS Project (NAP), your County Health Department like the (Douglas County STD Clinic). Getting tested for HIV can be quick, easy and confidential – go to bit.ly/NHTD2017 and enter your zip code to find an HIV testing location near you. Our Specialty Care Clinic works closely with the Douglas County STD Clinic and NAP. We treat PLWH diagnosed with HIV at these locations and provide pre-exposure prophylaxis (PrEP) for patients who are at risk.

The HIV Care Continuum demonstrates our progress and areas for improvement towards our goal of eliminating HIV. While 85% of persons living with HIV (PLWH) are aware of their diagnosis, less than 50% of these people have achieved viral suppression. PLWH who are not virally suppressed are at risk of transmitting the virus to others, subsequently repeating the cycle of infection. Therefore successful campaigns to end HIV must not only focus on diagnosis and treatment, but also prevention. HIV treatment as prevention for PLWH and Pre-exposure prophylaxis (PrEP) for persons without HIV (but are at risk for becoming infected) are very powerful prevention tools that require retention in care. We need to test more people for HIV so that 15% of undiagnosed PLWH are brought into care, but a greater challenge beyond that lies in our ability to retain PLWH engagement in care.

How can YOU help to end the AIDS epidemic? Get tested. Encourage your friends and partners to get tested. If you test positive, get into care with an HIV clinician, and STAY in care. If you are a clinician, screen your patients for HIV, regardless of perceived risk; offer high risk patients PrEP, and commit to keep your patients engaged in care.