Division of Infectious Diseases

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.

Propagation of Misinformation – Lessons From the 2019 Ebola Outbreak

This month, two concerning stories about the ongoing epidemic of Ebola virus disease (Ebola for short) in Africa grabbed our attention. On Monday, several social media sites circulated posts about Congolese refugees who had crossed the border from Mexico to Texas and tested positive for Ebola. The various posts circulated widely enough that they were picked up by mainstream media outlets, and Texas health officials eventually had to issue statements to refute the claims. Then on Tuesday, health authorities in Uganda confirmed the first trans-border spread of the outbreak from its source in eastern Democratic Republic of the Congo (DRC) in the form of a five-year-old child and several family members.

Both reports were alarming: the first for its falsehood and propagation of dangerous mythology surrounding emerging infectious disease threats; and the second for its confirmation that this current Ebola outbreak, now burning for over nine months and achieving the status of the second-largest in recorded history, shows no signs of abating. As infectious disease and public health professionals, we feel there are powerful lessons to be learned from each.

Misinformation may be one of the greatest public health threats we face today. As the 21st century ages into adulthood, we run the risk of walking back the tremendous achievements made by public health in the 20th century. From 1900 through the dawn of the new millennium, public health actions such as sanitation and hygiene, vaccines, and disease surveillance and control measures virtually eliminated the worst childhood diseases from the United States, completely eradicated the scourge of smallpox, and increased American life expectancy by 30 years. Yet today we face burgeoning outbreaks of vaccine-preventable disease, such as measles, fueled by baseless speculation regarding the safety of the very vaccines that we have used effectively for a generation. Public trust in established institutions of knowledge and expertise is eroding as discourse over science becomes increasingly politicized; fertile ground for ideological or political zealots to propagate their own false narratives.

The Congolese refugee story is one such example where common myths about disease were used for political purpose, presumably to stoke fear and distrust of refugees and immigrants. While certainly not a new meme, fear of disease-carrying immigrants continues to distort our perception of infectious disease risk and distract from the most important interventions we need to take to protect ourselves.  While we should increase our health screening services for undocumented persons arriving at our border, that is not where our vulnerabilities to emerging infectious diseases lie. In fiscal year 2018, Customs and Border Protection (CBP) apprehended 404,142 people crossing into the U.S. illegally, whereas in any average day, CBP processes over one million passengers and pedestrians entering the U.S. through legal points of entry. This includes over 340,000 international air travelers. The point is, if a disease outbreak occurs somewhere in the world, it is likely to eventually end up here, and not via refugees or illegal immigrants. And in our modern economy that depends on free movement of people and goods across the globe, trying to reduce this risk by limiting such traffic would mean a cure worse than the disease. By the way, the worst pandemic of the 20th century, the 1918 Influenza that killed over 50 million people worldwide, appears to have originated in Kansas.  Misinformation about immigrants does not provide the protection we need against emerging disease threats.

Indeed, it is misinformation and fractures in the public’s trust of authorities that drives the current outbreak in eastern DRC. Despite lessons learned from 2014, emphasis on early detection, enhanced treatment, safe and dignified burial practices, and a new vaccine, the epidemic has claimed over 1,400 lives, with no end in sight. Among the local population, rumors about the outbreak and response abound. Some people believe the outbreak is a government ruse to control political opposition, and some believe that the Ebola treatment units are harvesting organs. The result is families that are afraid to identify ill relatives, villages that refuse to admit public health teams, and even mobs that commit violence against health workers.  Now that the outbreak has spread across the border with Uganda, cases are only six hours by road from the urban capital of Kampala and the international airport in Entebbe. The risk of acceleration and spread increases. The events in DRC and Uganda should serve as a warning that infectious diseases are a continuing threat, and our global public health tools are still inadequate. As Bill Gates has said, in the fight against emerging pandemic diseases, we are “bringing a knife to a bazooka fight.”

So, what can we do to help the struggle against emerging infections? First, we can fight misinformation and promote messages from our public health and scientific experts. The Centers for Disease Control and Prevention (CDC) website is a good place to start. Second, we can adequately fund our public health infrastructure that we rely on for surveillance, detection, and containment efforts. Third, we can support international collaboration in emerging infection preparedness and response, remembering that these diseases do not respect borders and combatting them is a collective effort. Finally, we can make new investments in innovation for pandemic defense – not only in new drugs and vaccines, but also in improved systems for early detection and optimized clinical care in public health emergencies. At UNMC and Nebraska medicine, we lead the world in training, research, and clinical care for highly dangerous pathogens, and we will continue to work tirelessly to develop new tools in our constant struggle against pandemic threats. Let’s all pitch in and be part of the solution.

Original editorial posted in the Omaha World Herald on June 23, 2019. Read it here.

For more education on how we lead global education, please check out: https://netec.org/

Read a New York Times Piece on this topic here.

Content written by James V. Lawler, MD MPH FIDSA with insights from Jasmine Marcelin, MD, Kelly Cawcutt, MD MS FACP, Angela Hewlett, MD MS FIDSA

 


 

A Day in the Life of Central Venous Access Devices

This post comes courtesy of Dr. Mark Rupp, who recently published a study in the Journal of Infusion Nursing about outpatient maintenance practices for central venous access devices (CVADs)!

Our patients are increasingly receiving intravenous therapy at home via indwelling CVADs. However, limited data exist regarding patients’ experiences with outpatient CVADs. Regina Nailon is the lead author on a recently published paper in the Journal of infusion Nursing detailing the patient experience with home infusion therapy. In this project, patients maintained a 14-day diary that detailed the location, frequency, and purpose of CVAD access episodes and who performed CVAD care.

Across all of the patient’s, 77% of CVAD care was provided in the patient’s home compared with other sites (infusion centers, doctor’s offices, etc.). CVAD care was provided by the patient themselves (48%), a family member/caregiver (25%), or an infusion nurse (27%). An occlusion rate of 9.57 per thousand device days was noted. No central line associated bloodstream infections were observed.

This study nicely documents the extent of self-care and family member care for outpatients with indwelling CVADs and the potential for care practice variation that increases the risk for complications in the home setting. These findings support efforts aimed at standardizing the education and processes of care for patients with CVADs in the home setting.

You can read the full article here.


 

Congratulations to our graduating ID Fellows!

On Tuesday June 4, 2019, the Infectious Diseases Division gathered to celebrate two outstanding fellows, Drs. Raj Karnatak and Richard Hankins. Both are graduating and moving on to amazing next steps.

In 2017, our ID fellowship program was expanded to 2 fellows per year and both Dr. Hankins and Dr. Karnatak welcomed the opportunity to experience the program growth in live action.  Since then, we have filled our fellowship, currently with four fellows (they were joined in 2018 by Drs. Lindsey Rearigh and Randy McCreery).

Our Infectious Diseases faculty were honored to help Drs. Karnatak and Hankins grow and develop their infectious diseases knowledge, leadership and team management skills, and most importantly, to expand their skills in delivering compassionate patient care. We are fortunate that neither is going too far away!

Dr. Hankins is staying on faculty as an Instructor of Medicine, where he will be obtaining his Masters of Clinical & Translational Science, taking on the role of Associate Medical Director of Infection Prevention & Hospital Epidemiology, and continuing teaching as an attending on the General Infectious Diseases service.

Dr. Karnatak will be transitioning to the UNMC Critical Care department, where he will be completing a third year of fellowship in Critical Care Medicine.

We wish them all the best in their journeys, and hope to keep sharing their news along the way!


 

Tiffany Kalin, APRN-NP on Why I Love ID

Why I love ID and UNMC:

I wanted to work an UNMC/NM because of the positive experiences/education that I gained while working within the system previously (2007-2016). I truly enjoyed and am looking forward to again working in such a large operation with so many different experiences/education opportunities that are truly specific to UNMC/NM.  I am excited about ID because of the knowledge/experiences I have gained over the past 3 years while working in this specialty in a different practice. I have very much enjoyed the challenge of learning/seeing something new each and every day.

Something about me unrelated to my work:

I married my “high school sweetheart” and we now have 2 happy, healthy little girls (5 y/o and 3 y/o) who definitely keep us busy and on our toes.


 

Preparing for Measles – What You Need to Know

Measles is one of the most contagious infections and is acute respiratory viral infection currently causing an outbreak of infection through the United States. Measles was first described hundreds of years ago and became a reportable infection in the US in 1912. In 1963, the first vaccine for measles became available. Efforts focused on measles elimination starting in the late 1970’s and with increased vaccination rates, measles was declared eliminated in the US in 2000.

Illustrator: Alissa Eckert CDC/ Allison M. Maiuri, MPH, CHES

What’s the Big Deal?

As of May 17, 880 cases of measles have been confirmed in the US this year making this outbreak the largest in the US since 1994 (before elimination in 2000). The number of cases continues to rise and thus far, 24 states have reported at least 1 measles case. Thus far, Nebraska has had a confirmed case of measles, but certainly the risk remains present as neighboring states (including Iowa, Missouri, and Colorado) have reported measles.

https://www.cdc.gov/measles/cases-outbreaks.html

How did this happen?

The risk for spread of measles has existed despite US elimination as the infection can be secondary to imported cases from travel as globally, measles has not been eliminated. The risk of transition has been augmented with the increased number of parents opting to not vaccinate their children against measles (via the MMR vaccine; see more about the vaccine below), thus there are increased opportunities for nonimmune, unvaccinated persons to develop infection and subsequently spread measles. Up to 90% of nonimmune people with a close exposure to measles will develop the infection. Measles is very contagious and can spread through the air. People with measles can infect others even before the classic rash appears, increasing the possibility of spreading the infection unknowingly.

Clinical Presentation

After exposure to the measles virus, symptoms usually appear between 7 and 14 days, however, may still develop for up to 21 days.

Measles usually presents with high fever, malaise and the 3 C’s: cough, coryza (runny nose) and conjunctivitis (red and watering eyes). Two to three days after symptoms arise, tiny white spots may appear inside the mouth, known as Koplick spots. Three to five days after onset, the classic rash of measles breaks out starting as flat red spots starting on the head and face and extending downward over the rest of the body. These spots may connect to create large patches of red. When the rash appears, it may high temperatures ( even over 105 degrees F) may arise.  (images can be found here: https://www.cdc.gov/measles/about/photos.html)  Measles is contagious for 4 days before the onset of the rash to 4 days after it develops.

Complications: Measles can be very serious, resulting in hospitalization in approximately 1 in 4 patients and even death (in 1-2 of every 1000 infected children). Additional complications include: bronchitis and/or pneumonia, otitis media, diarrhea and acute encephalitis. The acute encephalitis can cause permanent brain damage at the time of infection, and those with measles can also suffer from subacute sclerosing panencephalitis (SSPE) 7 to 10 years after their initial infection. SSPE a degenerative disease of the central nervous system that is fatal, but rare.

Diagnosis: The test of choice is a PCR test before day 9, after that , serology testing is more effective. This remains a reportable disease, so testing will need to go through local public health laboratories and departments.

Treatment: There is no specific treatment to cure measles. For those who are not immune, or have weakened immune systems, vaccines and infusions of immunoglobulins may be used to prevent measles, or at least decrease the severity of infection.

Prevention Spread of Disease:

Transmission: Measles is one of the most contagious of all infectious diseases; up to 9 out of 10 susceptible persons with close contact to a measles patient will develop measles. The virus is transmitted by airborne spread, therefore in clinics or hospitals, if you present with symptoms (or care a healthcare worker caring for them) N95 masks should be used. If not available, a surgical mask should be used. Measles virus can remain in the air for up to two hours after an infected person leaves.

Post-exposure Prophylaxis

If you have been exposed to measles, if you cannot show you have evidence of immunity against measles via documentation of vaccine or age. If these are no readily available, post-exposure prophylaxis with the vaccine (within 72 hours of exposure for healthy individuals) or immune globulin infusions (within 6 days of exposure). Of note, both of these should not be given for a single exposure event.

Outside of the healthcare setting, after receiving the MMR vaccine for a known exposure, people can return to school or work. For healthcare workers without evidence of immunity, from 5 to 21 days post-exposure they should be excluded from work.

Vaccine Specifics:

Measles vaccine is usually combined with mumps and rubella (MMR), or with mumps, rubella and varicella (MMRV).

Everyone should be assessed for immunity via documentation MMR/MMRV vaccinations or if adults are born during or after 1957 (before this assumed to have immunity UNLESS they are a healthcare worker, then immunity should be confirmed or vaccination considered).

Children – should have 2 doses of vaccine. 1 between age 12-15 months and 1 between 4-6 years.

Adults born during or after 1957 ( or currently under age 63): should have at least one documented dose of vaccine with the exception of the following, who should have a 2nd dose:

  • Postsecondary educational students
  • International travelers
  • Healthcare personnel
  • Persons with HIV and a CD4 count ≥ 200 cells/μl for at least 6 months
  • Household or close personal contacts of immunocompromised persons with no evidence of immunity.

Stay Informed:

https://www.cdc.gov/features/measles/

https://www.cdc.gov/measles/resources/parents-caregivers.html.

https://www.cdc.gov/vaccines/parents/parent-questions.html.

https://www.cdc.gov/vaccines/parents/diseases/child/measles.html.

https://www.cdc.gov/measles/index.html

https://www.who.int/immunization/diseases/measles/en/

https://www.paho.org/hq/index.php?option=com_topics&view=article&id=255&Itemid=40899&lang=en

Latest updates for Nebraska can be found here:  http://dhhs.ne.gov/Pages/Health-Alert-Network.aspx


 

UNMC IDSHEAROES Enter the Race Against Resistance – Read Their Top Ten Reasons

Life-threatening infections caused by antimicrobial resistant organisms, commonly referred to as ‘superbugs’ have taken the media by storm. MRSA, VRE, MDRO, KPC, CRE, CDI – all acronyms that put fear in our hearts that one day, we will have run out of treatment options. That one day, our patients will die from infections that we once could cure.

Sadly, what was once a threat, is predicted to be a reality by 2050. Certain experts predict that these ‘superbugs’ will be the most common cause of death globally in 2050. That is truly terrifying.

What can we do?

We can fight back with science. The Society for Healthcare Epidemiology of America (SHEA) is sponsoring the Race Against Resistance for the 4th year. Money raised is used to fund educational scholarships involved in treating, and researching, ways to prevent the 2050 predictions from coming true. This is a chance to take a stand against ‘superbugs’, to support those fighting against them today, to help change the future.

So, who is racing?

Dr. Kelly Cawcutt and Dr. Jasmine Marcelin, are faculty physicians within UNMC’s Division of Infectious Diseases and have leadership roles in Infection Prevention and Antimicrobial Stewardship, respectively. They also serve as Co-Directors for Digital Innovation & Social Media Strategy for the ID Division. Together, they are the UNMC IDSHEAroes – two social media Co-Directors, trying to do some good.

Here are their TOP TEN reasons for racing:

10 – To beat Dr. Hilary Babcock, who won last year.

9 –  Because honestly, it’s a pretty catchy title & team name.

8 –  To remind everyone that antibiotics cannot treat a ‘cold’ or the flu. Or measles.

7 – To inspire our younger colleagues in medicine that anyone can help make a difference.

6 – To focus on healthy & wellness in a profession that has been struggling with burnout.

5 – To help SHEA and our racing teammates raise more money this year than EVER before

4 – To raise awareness of ‘superbugs’ & antimicrobial resistance by publicly sharing the Race Against Resistance.

3 – To provide the funds that train the next generation in Infection Prevention & Antimicrobial Stewardship.

2– To honor those who fought the fight against resistance before us, and the ones we have lost along the way.

1 – To never lose another patient to an infection we cannot treat.

How are we racing?

With physical wellbeing through exercise! Dr. Cawcutt is recovering from a partial knee reconstruction and will be #RacingInRehab to gain independent ambulation. Dr. Marcelin is#RacingForWellness by focusing on active exercise every day as a reminder that we cannot provide excellent care for others, if we do not care for ourselves first.

If you are interested in supporting the UNMC SHEAROES in the Race Against Resistance, you can donate here.


 

Do you really need to test the poo? Diagnostic stewardship for (outpatient) diarrheal illness

Rapid molecular testing has changed the landscape of diagnostic approaches to many infectious disease syndromes, including diarrheal illnesses. These panels typically have the capacity to diagnose multiple organisms in one test. The FilmArray gastrointestinal pathogen panel (BioFire) tests 22 stool pathogens. Despite the impact of improved clinical efficiency, these tests are often expensive, especially in the outpatient setting, but the convenience of a comprehensive testing panel can lead to unnecessary testing.

Recent IDSA guidelines on management of diarrheal illness only recommends rapid diagnostic testing in patients who are immunocompromised or those with fever, severe diarrhea, abdominal pain, bloody stools. Clark et al. sought to validate these recommendations in the outpatient setting by evaluating the yield of the molecular testing, and clinical outcomes.  In this retrospective study, 629 patients were included in the analysis, and over two-thirds of patients had a duration of diarrhea greater than 14 days.

Given the possibility of asynchronous testing without face-to-face encounter, physical exam findings were not included in assessment, only documentation of patient-reported abdominal pain. Only 20% of the specimens actually had pathogens detected, and were clinically relevant in only 5% of patients (19/107 in immunocompromised patients vs 14/522 immunocompetent patients, p<0.001).

The authors validated that the IDSA guideline-based criteria had a sensitivity of 97% (95% CI 84.2-99.9), specificity of 33.9% (95% CI: 30.1-37.8), negative predictive value of 99.5% (95% CI: 97.3-100.0), and a positive predictive value of 7.5% (95% CI: 5.2-10.4). They found that application of these testing criteria would have avoided testing in 32% of patients, and avoided unnecessary antibiotics) in 23% of patients.

The authors concluded that duration—based criteria for testing stool is not warranted, however given the higher prevalence of clinically relevant pathogens in immunocompromised patients (who may demonstrate fewer systemic symptoms), broadly testing in this patient population is reasonable. C. difficile was not included in this study, and guidelines recommend two-step testing for C. difficile infections (rather than single-step PCR, as would be the case for this panel).

The retrospective nature and absence of clear physical exam findings limit the findings. Nevertheless, this study emphasizes the opportunity for diagnostic stewardship to decrease inappropriate testing without significant clinical penalty, and identifies immunocompromised patients as a valuable subgroup where less restricted use of this test for diarrhea is reasonable.

Citation: Stephen D Clark, Michael Sidlak, Amy J Mathers, Melinda Poulter, James A Platts-Mills, Clinical yield of a molecular diagnostic panel for enteric pathogens in adult outpatients with diarrhea and validation of guidelines-based criteria for testing, Open Forum Infectious Diseases, ofz162, https://doi.org/10.1093/ofid/ofz162


 

 

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