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CRE or not CRE: A Question of Risky Business and Notes from the Field

The following was originally posted by Dr. Marcelin to the August 2018 SHEA Journal Club 

Carbapenem-resistant Enterobacteriaceae (CRE) are not as prevalent in the United States as they are in the Eastern Hemisphere; however travel within our global village means creates opportunity for movement of these organisms to our region.  The following is a review of two studies on risk predictors for CRE and three “Notes from the field” investigations from the CDC.

 The Rapid Prediction of Carbapenem Resistance in Patients With Klebsiella pneumoniae Bacteremia Using Electronic Medical Record Data. Timothy Sullivan et al.   Open Forum Infectious Diseases, Volume 5, Issue 5, 1 May 2018

In this study, the authors created a model to predict the likelihood of carbapenem resistance (as defined by imipenem MIC ≥2μg/mL) in Klebsiella pneumoniae bacteremia. 613 individual cases of K. pneumoniae bacteremia occurred over a 4 year period, with a 10% imipenem-resistance rate. Logistic regression was used for the initial model development, which was subsequently re-validated using additional statistical methods.  The model included the following; colonization with imipenem-resistant Klebsiella pneumoniae, hospital location (ICU/med-surg vs low-risk units), age (>60yrs), total oral or intravenous antibiotic days of therapy (in the past 2 years) and inpatient days (in the past 5 years). The model correctly predicted imipenem resistance in 73% of cases, with a specificity of 59%; positive predictive value of 16% and negative predictive value of 95%. All culture data present in the EMR were available to the model, eliminating manual searches when making decisions about empiric therapy. The negative predictive value is high, but lack of generalizability could limit the clinical utility.

Using Patient Risk Factors to Identify Whether Carbapenem-Resistant Enterobacteriaceae Infections Are Caused by Carbapenemase-Producing Organisms Patricia Simmer et. al  Open Forum Infectious Diseases, Volume 5, Issue 5, 1 May 2018

In this brief report, authors identified risk factors for having a CP-CRE (as compared to non-CP-CRE). Their retrospective, single-institution cohort included 96 hospitalized individuals who had CRE over a one-year period, with an incidence of CRE that year of 4%. CP-CRE isolates (predominantly K. pneumoniae) were identified in 47% of the patients. They found that CP-CRE isolates were more commonly identified in patients with recent international healthcare exposure within six months (27% vs 2%; odds ratio [OR], 18.18; 95% confidence interval [CI], 2.26–46.53); and patients who were recently transferred from a post-acute care facility (31% vs 12%; OR, 3.39; 95% CI, 1.17–9.78). Considering the prevalence of CP-CRE in regions outside the United States, should we be more intentional about asking travel history when patients are being admitted to the hospital?

The following snippets are Notes from the Field published in MMWR with new information about CRE organisms:

Verona Integron-Encoded Metallo-Beta-Lactamase–Producing Pseudomonas aeruginosa Outbreak in a Long-Term Acute Care Hospital — Orange County, Florida, 2017/MMWR Danielle Rankin, MPH et. al

The first VIM-producing Pseudomonas aeruginosa in Florida was detected in an outbreak of colonized patients at a long-term acute care hospital in Orange County. One patient was first identified in July 2017, followed by six additional patients identified in the subsequent months at the same facility. Only 2 isolates were closely related.

Carbapenemase-Producing Carbapenem-Resistant Enterobacteriaceae from Less Common Enterobacteriaceae Genera — United States, 2014–2017/MMWR Maroya S. Walters, PhD et. al

CRE Surveillance by the Minnesota Department of Health revealed 20 CP-CRE from less common Enterobacteriaceae genera (i.e. not Klebsiella spp., Enterobacter spp. or E. coli). 7 IMP-producing Providencia rettgeri and 6 KPC-producing Citrobacter freundii predominated. Most patients with these isolates were currently hospitalized; two were previously hospitalized internationally in the last year.

Notes from the Field: Domestically Acquired Verona Integron-Mediated Metallo-β-Lactamase-Producing Enterobacteriaceae — Indiana, 2016–2017/MMWR DJ Shannon, MPH et. al

There is a question of possible regional emergence of VIM-producing CRE, with 7 patients & 9 isolates reported in Indiana between 2016-2017. One patient had three different VIM-CRE organisms isolated; all patients had prior overnight local hospitalizations and none had prior international travel within the past 6 months.


 

What’s all the buzz about West Nile Virus?

This summer, we have seen several cases of West Nile infection, prompting many questions related to the infection.

So, what’s all the buzz about West Nile? Drs. Jasmine Marcelin and Kelly Cawcutt compiled some answers to Frequently Asked Questions about West Nile.

What is West Nile Virus?  West Nile Virus is spread via mosquito bites.  Mosquitos get the virus by biting infected birds.  In North America, the virus causes disease seasonally from summer through fall, with peak infections occurring in August and September.  

Where can you get it? West Nile cases have been reported in all of the continental US states in the past, and most thus far in 2018. This year, as of CDC’s September 4 report, the leading states with cases of West Nile were North Dakota, Nebraska and South Dakota, respectively.

Who gets it? Anyone can get West Nile Virus. Besides mosquito bites, it has been spread through blood transfusions, organ donation, vertically from mother to fetus and via breast milk. Patients over age 60 are higher risk for developing infection, including serious complications.

What are the symptoms/signs of West Nile Virus infections? Most patients will not develop symptoms of infection, with only about 20% of patients falling ill. Symptomatic infection may include fever, muscle aches, headache, weakness or other nonspecific symptoms of a viral illness. According to the CDC, approximately 1 in 150 patients will develop severe, potentially fatal, infections from West Nile Virus.

Are we seeing more cases than usual this year? West Nile Virus infections vary year-to-year, but yes, there are more confirmed cases in Douglas County this year compared to last year (7 confirmed cases in 2017). In Nebraska, we already have seen more cases thus far than the entire season last year (79 cases and 4 deaths already compared to 68 cases and 2 deaths last year), but the season is not over.  Over the past several years, there are many seasons with much higher rates of infection in the state.

Is there more neuroinvasive disease than in the past? Neuroinvasive disease (e.g., meningitis, encephalitis, or acute flaccid paralysis) occurred in about 46% of West Nile Virus infections over the past 18 years of surveillance. In the state of Nebraska, 42of the 79 cases of West Nile Virus infections this year have been classified as neuroinvasive. Nationally, of the 231 cases of West Nile Virus infections reported nationally to the CDC to date, 55% have been neuroinvasive cases. However, we are just at the peak of the season and will likely see more cases that are not neuroinvasive as the season progresses.

How do I test for it? Should I re-test? In general, diagnosis of West Nile Virus requires testing blood for antibodies to the virus. IgM antibodies present indicate a current or recent infection. If a person has neurologic symptoms (concerning for neuroinvasive disease), lumbar puncture is recommended with testing of the cerebrospinal fluid for West Nile IgM. If the initial IgM test is negative but suspicion for West Nile Virus is high, the antibody test should be repeated in 10 days (Convalescent testing), particularly if symptoms persist.

What is the treatment? The best treatment is time.There is no specific medication to treat infections due to West Nile Virus. Patients with this infection usually require symptomatic management, like fluids, supplemental oxygen, etc. Other treatments like antivirals, intravenous immunoglobulin (IVIG), or plasma exchange have not been proven to be beneficial.

Can it be prevented? There is no vaccine for West Nile Virus.  You can prevent West Nile infection by preventing mosquito bites. Use long sleeves, pants and insect repellents such as DEET or Picardin. Check out the EPA repellent information to help choose the best option here: https://www.epa.gov/insect-repellents/find-repellent-right-you

References:
https://www.cdc.gov/westnile/index.html 
https://www.cdc.gov/westnile/statsmaps/preliminarymapsdata2018/disease-cases-state-2018.html


 

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Are we ready for an outbreak?

It has been said that ‘an outbreak anywhere is a risk everywhere’.   At any given time, there are multiple concurrent outbreaks of highly hazardous communicable diseases, and the ease of global travel creates the risk of rapid spread of diseases around the world.  The Nebraska Biocontainment Unit (NBU) closely and continuously monitors these outbreaks, since the NBU could be called upon to care for patients who are infected with diseases like Ebola and Middle East Respiratory Syndrome Coronavirus (MERS-CoV).

The current outbreak of Ebola is located in the Northeast part of the Democratic Republic of Congo (DRC), close to the borders of Rwanda and Uganda. This area is a known conflict zone, with significant cross-border movement.  As of September 2, there were 118 people with confirmed or suspected Ebola virus disease, and 77 deaths.  Contact tracing and vaccination efforts are underway, and experimental therapeutic agents have been administered in an attempt to control the outbreak.   This is the 10th Ebola outbreak in the DRC.

There is also an ongoing outbreak of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) in the Arabian Peninsula.  Although most cases have occurred in Saudi Arabia, multiple other countries have been affected.  Imported cases have also occurred, including a single traveler arriving in South Korea that resulted in 186 secondary cases.  Most recently, an ill traveler presented for care in the United Kingdom and was found to be infected with MERS-CoV.

These outbreaks are only a small sample of the infectious diseases that are occurring in the world today.  The Nebraska Biocontainment Unit maintains the highest degree of preparedness, including ongoing staff training, drills and exercises.  NBU team members are continually leading and participating in the training and education of other healthcare centers in the United States and around the world.  If we receive the call to care for patients with highly hazardous communicable diseases, we are ready.

Content courtesy Dr. Angela Hewlett, Director of the Nebraska Biocontainment Unit

New Faculty Spotlight – Daniel Cramer, MSN, APRN, FNP-C

We are thrilled to have another member of our UNMC ID team. Read on to learn a little more about Daniel Cramer, who is joining our new Orthopedic Infectious Diseases team.

Why did you choose to stay at UNMC?

UNMC is home for me!  I completed my undergraduate degree here, as well as my graduate degree.  I previously was a staff nurse at Nebraska Medicine for about 5 years and the connections and friendships I have formed at UNMC and Nebraska Medicine are what keeps me here.  Beyond the connections and friendships, the commitment to extraordinary patient care and cutting-edge medicine is also a huge draw for me as well.

What makes you excited about working in ID?

I have always had a passion for infectious disease medicine from the start of my educational journey!  My first undergraduate degree was to be microbiology at Nebraska Wesleyan before I decided to pursue a career as a nurse practitioner.  I knew my dream job was to be in infectious disease when I did a two-month rotation at the specialty care clinic and I told myself after that rotation that I would steer my career towards infectious disease!  I love that having a career in infectious disease allows me to participate in cutting edge research, as well as providing excellent patient centered care.

Tell us something about yourself that is unrelated to medicine?

Something about myself that is unrelated to medicine is that I absolutely love supporting the arts in Omaha!  I am a member of the Young Arts Patrons, as well as a                                                     new season ticket holder to the Omaha symphony!


 

UNMC ID’s Dr. Diana Florescu wins DANCE FOR A CHANCE

Back in May, we were thrilled to announce that Dr. Florescu was participating in YES Dance for a Chance

Dance for a Chance raises awareness and money for Youth Emergency Services (YES) and the homeless youth of Omaha. There are hundreds of homeless youth in Omaha. Some of them have been emotionally, physically, or sexually abused, making it unsafe for them to return home, while others are facing health, mental health, or substance abuse issues. At the end of the competition, there will be 3 winners – the team with the most votes (money), the team with the best dance, and most importantly, the homeless youth of Omaha. More information can be found here.

Dr. Florescu awed the crowd and won best dance,all while raising over $6000 for YES! She would like to also extend thanks to her dance partner, Derek Pasqualetto from Vintage Ballroom as her dance instructor, partner and for his graciousness in volunteering his time for this fantastic cause.

We are so proud of Dr. Florescu for sharing her talent of dance with the community for such a great cause. Thank you to all who supported Dr. Florescu, YES, Omaha and all endeavors to continue to provide a safe, healthy and welcoming community for everyone in the Omaha area and beyond!

 

 

 


 

Clinical Pearls From Case Conference: Focus on CNS Infections

At Case Conference on August 16, Drs. Hankins and McCreery presented excellent cases of viral CNS infections combined with a great review of pertinent literature.  Here are the key clinical pearls from their presentations.

Dr. McCreery on viral and bacterial meningitis:

  1. Empiric dexamethasone appears to be beneficial in S. Pneumoniae and H. Influenza meningitis but should be stopped if found to have viral meningitis or meningitis caused by other bacteria.
  2. The addition of an aminoglycoside in the treatment of Listeria bacteremia and neurolisteriosis was associated with improved mortality in the MONALISA study – France (OR 0.60 (0.38-0.94) p 0.024) n = 679.  When neurolisteriosis was examined (n=-252 cases), some with bacteremia and some without, the addition of an aminoglycoside was not reported to have been associated with improved outcomes.
  3. Mild HSV-2 meningitis likely does not require treatment, however there may be some benefit among immunocompromised patients related to preventing neurologic sequelea.
  4. Suppressive valacyclovir after HSV-2 meningitis was associated with increased recurrence after cessation.
  5. Data is lacking regarding the utility of suppressive valacyclovir therapy in the treatment of non-genital HSV-2 infection during pregnancy

Randy McCreery MD, UNMC 1st Year ID fellow.

Dr. Hankins on Influenza Encephalitis:

  1. Diagnosis of exclusion in patients with altered level of consciousness and a positive influenza antigen or PCR.
  2. Most often occurs in 24-48 hours after febrile incident.
  3. 95% of patients with influenza encephalitis are younger than 21 years old.
  4. Associated with bilateral thalamic necrosis on MRI.
  5. Guidelines suggest that oseltamivir may be beneficial.  Other studies suggest that methylprednisolone pulse therapy may be beneficial.

Richard Hankins, MD
2nd Year ID Fellow

 

 

 

 

 

 

 


 

 

At UNMC, ID fellows learn HIV from the experts

Over the course of their training, fellows in the UNMC’s Division of Infectious Diseases will receive dedicated clinical and didactic training in the area of HIV alongside faculty with expertise in the HIV clinical care and research.

Clinical Training: Fellows will have their continuity clinic at UNMC’s HIV clinic one half day each week. The UNMC HIV Program is a regional leader in HIV care and fellows will have the opportunity to care for patients of diverse backgrounds alongside a multidisciplinary team.

While most of the clinical training occurs in the outpatient setting, there are often a few patients with HIV in the hospital at any given time and fellows will have the opportunity to learn the inpatient aspects of HIV care when they rotate on the general ID consult service.

Curriculum: Additionally, fellows have the opportunity to participate in a biweekly HIV Roundtable series, the didactic component of the HIV curriculum. The HIV Roundtable series is a 2-year curriculum in which both core HIV topics are taught by the faculty along with the fellow and more advanced topics are covered by the faculty and guest lecturers with content expertise. The Roundtable lectures are case-based and employ active learning methods in order to optimize fellow engagement and retention.

Research: Fellows interested in a career in HIV clinical or translational research may be given the opportunity to spend more time in the outpatient clinic, spearhead HIV-related educational programs, and participate in HIV-related research.

Leadership: Our fellows have the opportunity to work with clinic Director Dr. Susan Swindells, who has national and international recognition for her expertise in treatment of persons living with HIV and those co-infected with tuberculosis. Dr. Sara Bares is the HIV curriculum director for the fellowship and Nebraska AIDS Education & Training Center Director and has received recognition for her interdisciplinary educational achievements and HIV research.

Learn more about the UNMC Infectious Disease fellowship here. We look forward to reviewing your fellowship application!

Content provided courtesy Dr. Sara Bares


 

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Are you a Pharmacist interested in an Infectious Diseases Clinical Practice? UNMC ID has the perfect job for you!

The Department of Pharmaceutical and Nutrition Care at Nebraska Medicine and the Division of Infectious Diseases at the University of Nebraska Medical Center (UNMC) are recruiting for a full-time clinical pharmacist to expand the Antimicrobial Stewardship Program and develop an Outpatient Parenteral Antimicrobial Therapy (OPAT) program in collaboration with a new Orthopedic Infectious Diseases service line.

This is a unique position that allows a candidate to step into the well-established Antimicrobial Stewardship program at an academic health science center and strengthen services across the health-system, focusing on transitions of care. Interested candidates are encouraged to visit the nationally-recognized Nebraska Medicine Antimicrobial Stewardship website to learn more about the program.

The successful candidate will work closely with the pharmacy coordinator and physicians responsible for the antimicrobial stewardship and hospital epidemiology programs. The candidate’s teaching requirements will include being a preceptor for the recently approved post-graduate year 2 infectious pharmacy residency along with instructing medical students, residents and fellows on the infectious diseases consult services.

Participation in additional rotations for infectious diseases and antimicrobial stewardship with the 9 PGY1 residents and 6 other PGY2 residents at Nebraska Medicine is encouraged.  Provision of didactic lectures and facilitation of pharmacotherapy laboratory activities are also available on campus at the UNMC College of Pharmacy.

The candidate must possess a PharmD and a PGY2 residency or fellowship training/equivalent experience in Infectious Diseases, and be eligible for pharmacy practice licensure in Nebraska. The successful candidate will contribute to documenting how their activities result in improved clinical outcomes and utilization of anti-infective therapy throughout Nebraska Medicine. Presentation and publication of these findings are encouraged.

Numerous interdisciplinary collaborative research opportunities exist with investigators throughout UNMC. The program is supported by a robust decision support software and information technology system.

Salary will be commensurate with qualifications and experience. A generous benefit program is available through Nebraska Medicine.

Applications will be accepted until the position is filled. Submit an application online with curriculum vitae, and list of references.

Inquiries can also be sent to:
Scott Bergman, Pharm.D., Pharmacy Coordinator – Antimicrobial Stewardship, scbergman@nebraskamed.com and Trevor Vanschooneveld, M.D., Medical Director – Antimicrobial Stewardship, Associate Professor – Infectious Diseases, tvanscho@unmc.edu.

Travels, Bones and Bugs, Oh My! ID fellows will see it all at UNMC

At UNMC ID we are fortunate to have some very unique experiences for fellows to explore their interests in our various aspects of our specialty. We are also fortunate to have experts and leaders at the helm, leading fellows through these experiences toward their ultimate career choices. One of these leaders is Dr. Angela Hewlett (pictured on the right in the personal protective equipment below), who directs the Orthopedic Infectious Disease service, Biocontainment Unit and the Travel Clinic. Learn more about these experiences below.

Ortho ID service –  Fellows will learn how to manage complicated bone and joint infections on the inpatient Ortho ID service, as well as participate in Ortho ID outpatient clinic.  Patients in the Ortho ID clinic are seen collaboratively with the Orthopedic surgeons, and the clinic is located within the Orthopedics clinic.  The Ortho ID service is a true multidisciplinary effort, and Ortho ID physicians work closely with Orthopedic surgeons to achieve the best outcomes for patients with complicated bone and joint infections.

Biocontainment Unit –  Opportunities exist for Fellows in the Nebraska Biocontainment Unit (NBU), which is one of only a few units in the United States capable of caring for patients with highly hazardous communicable diseases.  The NBU team cared for 3 patients with Ebola Virus Disease in 2014, and has many ongoing efforts to enhance biopreparedness.   Fellows have the opportunity to work directly with the Medical Director of the unit, observe and participate in activities in biopreparedness, and possibly participate in patient care activities if the NBU is activated.

Travel Clinic – Fellows have the opportunity to participate in the UNMC Travel clinic, where patients with planned travel are evaluated to assess and mitigate risk of travel-related diseases.

Learn more about the UNMC Infectious Disease Fellowship here.

Content provided courtesy Dr. Angela Hewlett


 

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Acing the Interview: Top Tips For Fellowship Interviews

As faculty, we have the amazing opportunity to both mentor and interview residents applying for fellowship in Infectious Diseases, and we have seen it all. From the great, well-prepared interviewee to the one who had the institutional information completely incorrect. We wish we could mentor every resident in person, but since that is not possible, we decided to do the next best thing and offer our tips and tricks to acing the ID (or any other) interview! Tips and tricks are in no particular order. 

  • Be yourself and relax.
  • Articulate why you are interested in this fellowship program, what your ID interests are and where you think you would like your career to go (even if you acknowledge that might change or be a little vague at this time).
  • Have an idea of how the program works and ask specific questions to help deepen that knowledge regarding the education you will receive. What are the strengths, weakness and unique aspects of the program you want to know more about?
  • Remember that you are interviewing the fellowship program as much as they are interviewing you. Do your research and come prepared with questions about everything from how the fellowship will prepare you for your career as an ID physician to where you will park.
    • Need suggestions on how to curate your list of questions?
      • Look up the program and Division on their website.
      • It is helpful to know a little about the faculty you are interviewing with, so if you get a schedule ahead of time find out what their clinical/research interests are and ask them about it – you can check out their publications on PubMed or Google Scholar to focus questions on specific topics.  If you don’t get a schedule ahead of time, ask them what their interests are or what their role is during your interview.
      •  Formulate questions important to you about the program, the institution and the local area regarding resources, lifestyle and more.
  • Be prepared to talk about your successes and the challenges you have encountered. For example, if you have an unexpected break in training, use that as example to illustrate what you learned from that experience. We do not expect perfection, but value honesty and clarity.
  • If you have something on your application that might be viewed negatively (academic difficulties, etc.) take the initiative and explain how you have overcome it and why you are a good candidate now before we have to ask you about it.
  • Consider a “highlight” reel handout for faculty on an updates to your CV since you submitted your application in ERAS. This can be incredibly beneficial if you have had a new publication, presentation or other activities demonstrating your interest in ID and future potential as a fellow.
  • Be friendly and treat everyone, including program coordinators and other office personnel kindly and with respect. Your interview starts from the moment some first meets you (a current fellow, administrative assistant or staff) and ends when you say goodbye to the last person. ALL opinions count. If you are rude to anyone, trust us, we will find out.
  • Be truthful and be yourself. Don’t answer questions with what you think the interviewer wants to hear (e.g. don’t say you want to do academic medicine if you are interested in private practice). This is the only way for both you and the program to determine whether or not you are truly a good fit.
  • Tell us something interesting about yourself, even if it doesn’t relate to ID.  It is important to be well-rounded, and hearing about hobbies, experiences and interests helps keep the interview conversation fun and flowing.
  • Thank the faculty for their time; the emails and cards with a personal comment regarding a specific detail of the interview are both appreciated and noticed.

Multiple ID faculty contributed to this list and thus the credit goes to the entire UNMC Division.


 

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