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Summary of 8 Antibiotic Myths for Infectious Disease Clinicians (Part 2)

Antibiotic usage frequently has rapidly changing recommendations. This summary reviews myths 5-8 of the top 8 antibiotic myths facing clinicians.

Written by Savona Bateman (left)
UNMC PharmD Candidate 2024

Reviewed by Jenna Preusker (right), PharmD, BCPS, BCIDP
Nebraska ASAP Pharmacy Coordinator

McCreary E, Johnson M, Jones T, et al. Antibiotic Myths for the Infectious Diseases Clinician, Clinical Infectious Diseases, Volume 77, Issue 8, 15 October 2023, 1120–1125, https://doi.org/10.1093/cid/ciad357

Myth 5: Trimethoprim-sulfamethoxazole should not be used for skin and soft tissue infections caused by Streptococcus pyogenes (Group A Strep)

Pustular skin and soft tissue infections are frequently caused by staphylococcal species, while non-pustular skin and soft tissue infections are most frequently caused by streptococcal species.  With the rise of Methicillin-Resistant Staphylococcus aureus, first-line treatments have changed from primarily cephalexin monotherapy to include a tetracycline or trimethoprim-sulfamethoxazole.

It is believed that trimethoprim-sulfamethoxazole is not active against S. pyogenes, so it is commonly prescribed in combination with a beta-lactam for empiric treatments of cellulitis. This misconception is mainly laboratory-based and is related to the media that was historically used to grow S. pyogenes in culture. S. pyogenes has the ability to use exogenous sources of thymidine when biosynthesis is blocked by trimethoprim-sulfamethoxazole. When cultured on thymidine-containing agar media, this gives the false impression of resistance. Currently recommended thymidine-depleted media eliminates this issue. When tested appropriately, all S. pyogenes isolates in North America are susceptible to trimethoprim-sulfamethoxazole with a MIC ≤ 0.12 ug/ml.  Further support from a randomized control trial indicated a rate of cure of uncomplicated skin and soft tissue infections using trimethoprim-sulfamethoxazole to be 88.2%. 

Fact: This support, in addition to the low prevalence of S. pyogenes isolated skin and soft tissue infections, allows for the use of trimethoprim-sulfamethoxazole monotherapy for uncomplicated skin and soft tissue infections.

Miller  LG,  Daum  RS,  Creech  CB,  et  al.  Clindamycin  versus  trimethoprim- sulfamethoxazole  for  uncomplicated  skin  infections.  N  Engl  J  Med  2015;  372: 1093–103.

Myth 6: Oral Fosfomycin should be used as a first-line treatment for uncomplicated cystitis

IDSA guidelines recommend fosfomycin as a first-line treatment option for uncomplicated cystitis, but efficacy data for fosfomycin are conflicting.1 A 2019 trial found nitrofurantoin had improved outcomes compared to fosfomycin at 28 days (70% vs 58%) for treatment of uncomplicated cystitis for 5 days.2 Fosfomycin requires glucose-6-phosphate (G6P) to have activity against bacteria as the G6P induces transport into the bacterial cell.3 G6P is not present in human urine, calling into question if fosfomycin is reliably active at the site of infection. From this perspective, MIC and breakpoints may be higher than in vitro activity with supplemented G6P suggests. Furthermore, fosfomycin is not typically included on susceptibility panels, so the microbiology lab must take extra steps to provide clinicians with susceptibility information. From a resistance standpoint, increased fosfomycin use has been connected to increases in fosfomycin-resistant, extended-spectrum β-lactamase-producing Escherichia coli.4 Treatment practices are currently being evaluated to determine the reliability of fosfomycin and the accuracy of susceptibility markers. 

Fact: If fosfomycin is utilized for uncomplicated cystitis, patients should be carefully assessed for cure.

1. Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis 2011; 52: e103–20.

2. Huttner  A,  Kowalczyk  A,  Turjeman  A,  et  al.  Effect  of  5-day  nitrofurantoin  vs single-dose  fosfomycin  on  clinical  resolution  of  uncomplicated  lower  urinary tract infection in women: a randomized clinical trial. JAMA  2018;  319:1781–9.

3. G.A. Detter, H. Knothe, B. Schönenbach, G. Plage, Comparative study of fosfomycin activity in Mueller–Hinton media and in tissues, Journal of Antimicrobial Chemotherapy, Volume 11, Issue 6, June 1983, Pages 517–524, https://doi.org/10.1093/jac/11.6.517

4. Falagas ME, Athanasaki F, Voulgaris GL, Triarides NA, Vardakas KZ. Resistance to fosfomycin: mechanisms, frequency and clinical consequences. Int J Antimicrob Agents 2019; 53:22–8.

Myth 7: Rifampin or Gentamicin are required for combination treatment in the setting of Prosthetic valve endocarditis caused by Staphylococcus species

The IDSA recommends the addition of rifampin or gentamicin in treatment guidelines for Staphylococcus species prosthetic valve endocarditis. This, in part, may be due to the high morbidity and mortality of the infection.  A study done by Cosgrove et al. did not show a benefit in the treatment when gentamicin was added and instead found increased renal injury.1 A study completed by Le Bot et al. on the addition of rifampin to treatment of prosthetic valve endocarditis did not show a difference in mortality at 1 year and instead found an increased length of hospital stay.2

Fact: Overall, the benefit of the addition of rifampin or gentamicin to the treatment of staphylococcal prosthetic valve endocarditis needs to be further evaluated. The problems introduced by drug interactions and toxicities outweigh the utility of these antibiotics in endocarditis. 

1. Cosgrove SE, Vigliani GA, Fowler VG Jr, et al. Initial low-dose gentamicin for Staphylococcus aureus bacteremia and endocarditis is nephrotoxic. Clin Infect Dis 2009; 48:713–21

2. Le Bot A, Lecomte R, Gazeau P, et al. Is rifampin use associated with better out-come in staphylococcal prosthetic valve endocarditis? A multicenter retrospective study. Clin Infect  Dis 2021; 72:e249–55.

Myth 8: Doxycycline is contraindicated in patients who are pregnant or <8 years of age

The tetracycline class effect includes warnings for maternal hepatotoxicity, inhibition of bone growth, and tooth discoloration when used in pediatric patients <8 years of age.  Doxycycline was developed later and differs from tetracycline with improved activity, decreased calcium binding, and fewer adverse effects but still remains under the same “class effect” warnings.  This label understandably causes hesitancy in providers even when doxycycline is recommended as a first-line treatment.

Doxycycline is used as a first-line treatment for Rocky Mountain spotted fever and other tick-borne illnesses, which can be fatal in young children. Multiple studies have shown no increase in risk of teratogenicity and limited risk of teeth staining in courses less than 21 days.1 The data overall suggests that the benefits far outweigh the risks of using doxycycline in patients who are pregnant or <8 years old.  Further data is needed to determine long-term outcomes for other adverse effects, such as bone growth inhibition from doxycycline use.

Fact: In the cases of serious infections without equivalently efficacious treatment alternatives, such as rickettsial diseases, the benefits of using doxycycline outweigh the risks for pediatric patients.

1. Cross R, Ling C, Day NP, McGready R, Paris DH. Revisiting doxycycline in pregnancy and early childhood–time to rebuild its reputation? Expert Opin Drug Saf 2016;  15:367–82.

Summary of 8 Antibiotic Myths for Infectious Disease Clinicians (Part 1)

Antibiotic usage frequently has rapidly changing recommendations. This summary reviews the first 4 of the top 8 antibiotic myths facing clinicians. Check back to the next post for the remaining antibiotic-prescribing myths!

Written by Savona Bateman (left)
UNMC PharmD Candidate 2024

Reviewed by Jenna Preusker (right), PharmD, BCPS, BCIDP
Nebraska ASAP Pharmacy Coordinator

McCreary E, Johnson M, Jones T, et al. Antibiotic Myths for the Infectious Diseases Clinician, Clinical Infectious Diseases, Volume 77, Issue 8, 15 October 2023, 1120–1125, https://doi.org/10.1093/cid/ciad357

Myth 1: Cefazolin should be avoided for central nervous system infections

Tertiary medical references commonly state that cefazolin should not be used for meningitis because it does not adequately attain high enough concentrations in the cerebrospinal fluid (CSF) to be effective for central nervous system infections. This statement came from two main studies in the 1970s. The first study in 1973 used another first-generation cephalosporin called cephalothin, and findings were extrapolated to cefazolin.1 Another study done in 1976 showed low cefazolin concentrations in CSF after only a single administration of a 1-gram dose intravenously.2

However, studies on cefazolin and CSF concentrations were not abandoned completely. A few years later, another study found the concentration of cefazolin in CSF after one administration of a 2-gram dose was actually higher than the concentration of one administration of a 2-gram dose of nafcillin, a drug we commonly rely on to treat meningitis. Since then, multiple other studies supported this idea that the concentration of cefazolin in the CSF may be higher and more effective than previously reported. Importantly, the studies indicated that concentrations of cefazolin reaching the CSF are above the recommended breakpoints for Staphylococcus aureus and Enterobacterales.4 Further data is needed to ensure optimal dosing, but some experts recommend high doses of 2 grams administered intravenously every 6 hours or a continuous infusion of 8 to 10 grams daily.

Fact: Overall, cefazolin administered at higher doses may be considered as an option for CNS infection treatment with proper susceptibilities.

  1. Mangi RJ, Kundargi RS, Quintiliani R, Andriole VT. Development of meningitis during cephalothin  therapy. Ann Intern Med 1973;  78:347–51.
  2. Bassaris HP, Quintiliani R, Maderazo EG, Tilton RC, Nightingale CH. Pharmacokinetics and penetration characteristics of cefazolin into human spinal fluid. Curr Ther Res Clin Exp 1976; 19:110–20.
  3. Frame  PT, Watanakunakorn  C, McLaurin  RL, et al. Penetration  of  nafcillin,  methicillin,  and  cefazolin  into  human  brain  tissue.  Neurosurgery  1983;12:142–7.
  4. Clinical  and  Laboratory  Standards  Institute  (CLSI).  Performance  standards  for antimicrobial  susceptibility  testing,  31st  ed.  CLSI  document  M100.  Wayne,  PA:CLSI, 2021.

Myth 2: Linezolid should be avoided in patients taking Selective Serotonin Reuptake Inhibitors

Linezolid is an antibiotic commonly used for multidrug-resistant gram-positive bacterial infections. Linezolid is a nonselective inhibitor of monoamine oxidase which can reduce the breakdown of serotonin. This process leads to a potential increased risk of serotonin syndrome (SS) in patients taking other serotonergic drugs.1

One study of over 4,000 patients taking serotonergic agents found a low incidence of SS overall and no significant increase in frequency in patients taking linezolid.2 This was further supported by additional studies evaluating individual antidepressants and linezolid combinations. The scatterplot below shows the relationship between the proportion of SS reports (on the x-axis) and the mean number of DDIs (on the y-axis) for each serotonergic agent.3

Fact: Overall, serotonin syndrome is exceedingly rare even when linezolid is combined with serotonergic agents. If linezolid is needed as the preferred antibiotic, the risk/benefit profile in patients receiving serotonergic drugs is acceptable.

1. US FDA drug safety communication: updated in-formation about the drug interaction between linezolid (Zyvox) and serotonergic psychiatric  medications.  Available  at:  www.fda.gov/Drugs/DrugSafety/ucm276251.htm. Accessed 25 September  2022.

2. Butterfield JM, Lawrence KR, Reisman A, et al. Comparison  of  serotonin  toxicity  with  concomitant  use  of  either  linezolid  or comparators and serotonergic agents: an analysis of phase III and IV randomized clinical trial data. J Antimicrob Chemother 2012; 67:494–502.

3. Gatti M, Raschi E, De Ponti F. Serotonin syndrome by drug interactions with linezolid: clues from pharmacovigilance-pharmacokinetic/pharmacodynamic analysis. Eur J Clin Pharmacol. 2021;77(2):233-239. doi:10.1007/s00228-020-02990-1

Myth 3: Linezolid dosing regimens do not need renal dose adjustment

According to the package insert for linezolid, the dosing regimen is 600 mg twice daily administered IV or orally with no indicated adjustment for renal dysfunction. The initial clinical trials and uses of linezolid in short courses had low incidences of thrombocytopenia at <3%.  However, a study in 2019 suggested a higher risk of thrombocytopenia at 27% incidence with a 13.8% incidence of severe thrombocytopenia. Interestingly, it was found that an increased linezolid exposure was associated with thrombocytopenia. The frequency of thrombocytopenia was higher in patients with a renal dysfunction (eGFR <60 ml/min/1.73m) at 42.9% compared to patients without renal dysfunction at 16.8%.1 This information leads to an expert recommendation of a reduced dose of linezolid for renal dysfunction so as to reduce the incidence of thrombocytopenia. 

Fact: The current expert recommendation is to reduce the linezolid dose to 300 mg administered IV or orally twice daily in patients with an eGFR <60 ml/min/1.73m.2  

1. Crass RL, Cojutti PG, Pai MP, Pea F. Reappraisal of linezolid dosing in renal impairment to improve safety. Antimicrob Agents Chemother. 2019;63(8):e00605-19. doi:10.1128/AAC.00605-19

2. Abdul-Aziz  MH,  Alffenaar  JC,  Bassetti  M,  et  al.  Antimicrobial  therapeutic  drug monitoring  in  critically  ill  adult  patients:  a  position  paper.  Intensive  Care  Med 2020;  46:1127–53.

Myth 4: Clindamycin is recommended as a first-line treatment for surgical site infection prophylaxis in patients with penicillin allergies

Cefazolin is typically the first-line choice for surgical prophylaxis but is often avoided in patients with a penicillin allergy due to historical references that quote potential cross-reactivity of 5-10%.1 In these cases, clindamycin has been a common alternative choice for patients with penicillin allergies since it does not share any structural similarities with beta-lactam antibiotics. However, the 5-10% cross-reactivity with cefazolin is likely overstated, as the side chain of cefazolin is not similar to any other beta-lactam, including other cephalosporins. A meta-analysis found that incidence of allergy to both penicillin and cefazolin was 0.7%.2 Importantly, a 2023 study indicated a lower frequency of surgical site infections when cefazolin was used prophylactically compared to clindamycin.3

In 2022, Nebraska Medicine implemented a systemwide change that suppressed alerts for non-IgE-mediated penicillin allergies in the electronic medical record upon cephalosporin prescribing. In individuals with penicillin allergy, preoperative cefazolin prescribing increased from 49.6% to 74.3% (P < .01).5

Fact: The Joint Task Force on Practice Parameters recommends cefazolin as a first-line antibiotic for surgical prophylaxis in patients with penicillin allergies.4

  1. Herbert ME, Brewster GS, Lanctot-Herbert M. Medical myth: ten percent of patients who are allergic to penicillin will have serious reactions if exposed to cephalosporins. West J Med 2000; 172:341
  2. Sousa-Pinto B, Blumenthal KG, Courtney L, et al. Assessment of the frequency of dual allergy to penicillins and cefazolin: a systematic review and meta-analysis. JAMA Surg 2021; 156:e210021.
  3. Norvell MR, Porter M, Ricco MH, et al. Cefazolin vs. second-line antibiotics for surgical site infection prevention after total joint arthroplasty among patients with a beta-lactam allergy [manuscript published online ahead of print 24 April 2023]. Open Forum Infect Dis 2023. doi:10.1093/ofid/ofad224
  4. Khan DA, Banerji A, Blumenthal KG, et al. Drug allergy: a 2022 practice parameter update. J Allergy Clin Immunol 2022; 150:1333–93.
  5. Bogus, A., McGinnis, K., May, S., Stohs, E., Schooneveld, T., & Bergman, S. Perioperative cefazolin prescribing rates following suppression of alerts for non-IgE-mediated penicillin allergies. Antimicrobial Stewardship & Healthcare Epidemiology, 3(S2), S98-S99. doi:10.1017/ash.2023.369

Penicillin Allergy Risk Low? Challenge with PO!

This post is part of a shared series for U.S. Antibiotic Awareness Week between the Nebraska Antimicrobial Stewardship Assessment and Promotion Program (ASAP), the Infection Control Assessment and Promotion Program (ICAP), and the University of Nebraska Medical Center Division for Infectious Diseases. Check out the other posts on the ASAP webpage and social media accounts.

Post reviewed by Erica Stohs, MD, MPH, University of Nebraska

More evidence supports proceeding directly to an oral penicillin challenge in patients who are low risk for penicillin allergy. This review highlights two studies using allergy history-taking to determine eligibility for direct oral penicillin challenge.

In the PALACE randomized clinical trial, investigators selected participants reporting low-risk penicillin allergies via PEN-FAST tool in this multicenter, non-inferiority, randomized clinical trial to undergo direct oral challenge (intervention) or skin-testing followed by oral challenge if the skin test is negative (control; standard-of-care). PEN-FAST is a short questionnaire validated to assess risk for penicillin allergy in patients reporting such an allergy; those deemed “low” and “very low” risk of a positive allergy test were eligible. A total of 382 outpatient adults across 6 medical centers in Australia, US and Canada were randomized. One patient in each group (0.5%) had a positive oral penicillin challenge (primary outcome); both were treated successfully with oral antihistamines. The trial met their non-inferiority margin of 5%. There was no difference in delayed immune reactions up to 5 days. These findings offer clinicians without the time or resources to implement penicillin skin testing as a safe alternative to skin-testing, which may be easily adaptable to inpatient settings. 

In an observational, quasi-experimental study at a non-teaching community medical center in New Jersey, investigators created a medication allergy history interview questionnaire and a medication allergy assessment algorithm to classify patients as low vs moderate vs high risk of allergy. Low risk patients could undergo oral beta-lactam challenge, moderate risk patients were referred for skin testing, and high-risk patients continued avoidance. The objective of this intervention was to increase allergy history documentation in the electronic medical record and increase beta-lactam use. One-hundred eighty-four patients in the pre-intervention period was December 2018 to April 2019 were compared to 208 in the January-April 2021 post-intervention period. Using interrupted time-series analyses, they found that documentation of complete allergy histories increased by nearly 20%, and beta-lactam use increased by 9.3 days of therapy per 1000 days-present. This study emphasized that non-teaching, community hospitals can successfully implement beta-lactam allergy interventions and inspired greater confidence among their clinicians in proceeding to direct oral challenge in low-risk individuals. 

Reference:  

Copaescu AM, Vogrin S, James F, et al. Efficacy of a Clinical Decision Rule to Enable Direct Oral Challenge in Patients With Low-Risk Penicillin Allergy: The PALACE Randomized Clinical Trial. JAMA Intern Med.2023;183(9):944–952. doi:10.1001/jamainternmed.2023.2986

Trubiano JA, Vogrin S, Chua KYL, et al. Development and Validation of a Penicillin Allergy Clinical Decision Rule. JAMA Intern Med. 2020;180(5):745–752. doi:10.1001/jamainternmed.2020.0403

Vyas, L., Raja, K., Morrison, S., Beggs, D., Attalla, M., Patel, M., & Philips, M. (2023). Beta-lactam comprehensive allergy management program in a community medical center. Antimicrobial Stewardship & Healthcare Epidemiology,3(1), E189. doi:10.1017/ash.2023.461

Article Submitted by Jenna Preusker, PharmD, Nebraska ASAP

Research Digest: Advancing Transplant ID

Research Digest is a periodic installment that recognizes the world-class clinical research performed right here at UNMC ID. Today, we review three articles covering the infectious complications of organ transplants. As always, check out the linked full articles for more details.

Dr. Zimmer, co-author of this review on GVHD-related bacterial pneumonia.

In the first article featured, co-authored by Dr. Andrea Zimmer, the post-organ transplant causes of bacterial pneumonia are outlined, particularly in regard to the chronic graft-versus-host disease (GVHD) population. GVHD is a systemic inflammatory response to organ transplantation where immune cells in the transplanted organ begin to attack the host. A severe complication of transplantation, treatment often necessitates long-term immunosuppression, which opens the door for opportunistic pathogens to cause disease. This review covers chronic GVHD and bacterial pneumonia pathophysiology and a host of specific causative pathogens including Mycobacterium tuberculosis, Legionnaires’ Disease, Nocardia, and Pseudomonas aeruginosa as well as preventative and treatment considerations. Read more here for the full details on this devastating transplant complication.

Dr. Abbas, the lead author of this article on WNv infections in transplant patients.

The second article, authored by Dr. Anum Abbas as well as Adia Sikyta, Dr. Diana Fluoresce, and others from the UNMC community, explores West Nile virus (WNv) infections following solid organ transplant. While WNv infection in immunocompetent individuals is typically asymptomatic or results in a mild fever, infection in immunocompromized solid organ transplant recipients can be much more severe, leading to neurological damage in some cases. Further, this patient population is at increased risk, with higher rates of infection than the general population. This study examined the medical records of solid organ transplant recipients at UNMC between 2010 and 2018, finding 8 patients with documented WNv infection. The majority of these patients previously received a kidney transplant and all presented with either meningitis, encephalitis, or both. The article explores the treatment, recovery, and outcome of these patients and compares this to the existing literature. Read on here for more information.

Dr. Stohs, lead author of this paper outline the utility of antimicrobial stewardship in the post-transplant patient population.

Lastly, Dr. Erica Stohs recently authored an article outlining the importance of antimicrobial stewardship in the care of solid organ transplant recipients. The article explains that antimicrobial stewardship is needed to combat rising antimicrobial resistance and associated adverse events (such as C. difficile infection) in this patient population. The paper explores, in great detail, exactly what can be done to combat these infectious transplant comorbidities, how to monitor progress, what works, and what likely doesn’t. The major take-aways were:

  • Clinicians can target C. difficile infections in transplant recipients through diagnostic testing stewardship and comparative trials of therapeutic and prophylactic agents.
  • Renal transplant recipients do not benefit from treatment of asymptomatic bacteriuria when greater than 2 months from transplant.
  • Solid organ transplant recipients benefit from antibiotic allergy delabeling, allowing receipt of narrowed, targeted antibiotics.

Read the full story here.

Research Digest: Antimicrobial Advances (Part 2)

Research Digest is a periodic installment that recognizes the world-class clinical research performed right here at UNMC ID. Last time, we reviewed two articles covering advances in antibiotic and antimicrobial medications. This week, we feature three more articles from UNMC exploring the pharmaceutical treatment of different infectious diseases with wide-reaching implications. As always, check out the linked full articles for more details.

Dr. Kimberly Scarsi, one of the co-authors of this article

The first article, titled Pharmacogenetic interactions of efavirenz or rifampin and isoniazid with levonorgestrel emergency contraception during treatment of HIV or tuberculosis and co-authored by UNMC College of Pharmacy’s Michelle Pham, Anthony Podany, and Kimberly Scarsi, explores the interaction of isoniazid, rifampin, and efavirenz on the effectiveness of levonorgestrel as an emergency contraceptive. Some of these drugs alter the activity of detoxifying enzymes in the liver, potentially reducing the plasma concentrations of hormonal contraceptives. While this effect is avoided by administering higher levonorgestrel dosages, certain genetic mutations common in the general population also affect these enzymes and may further complicate compensatory treatment regimens. Indeed, this study found that individuals who possess CYP2B6 poor metabolizer genotypes displayed exacerbated efavirenz-levonorgestrel interactions, making this effect more difficult to overcome. In contrast, NAT2 slow acetylator genotypes reduced the interaction, underscoring that genetic variability can profoundly alter the efficacy and effective treatment dosages of many medications. Read the full story here.

Dr. Molly Miller, lead author of this article in Open Forum Infectious Diseases

The second article, co-authored by many members of UNMC ID and Pharmacy, including Molly Miller,  Trevor Van Schooneveld,  Erica Stohs, Jasmine Marcelin,  Bryan Alexander,  Andrew Watkins,  Hannah Creager, and Scott Bergman, aimed to assess whether the implementation of multiplex PCR panels for pneumonia diagnosis impacted antibiotic de-escalation. This is crucial as earlier identification of causative organisms could result in a more rapid adjustment to the narrowest effective antibiotic regimen, potentially limiting the generation of antibiotic resistance to broad-spectrum antimicrobials. Conversely, the increased sensitivity of this technique to detect organisms could have the opposite effect, as clinicians treat PCR results which may not end up clinically significant. The group did not detect a difference in antibiotic use before or after implementation of the PCR pneumonia panel in this pilot study; however, this work lays the groundwork to further evaluate a significant real-world impact on antibiotic de-escalation in ICU patients treated for pneumonia. Read the article here.

Dr. Andre Kalil, author of this comment piece on antiviral therapy

The last article, written by Dr. Andre Kalil and published in The Lancet: Respiratory Medicine, reviews the effectiveness of Remdesivir in the treatment of patients hospitalized for COVID-19. Remdesivir is a viral RNA polymerase inhibitor with a complicated recommended treatment history throughout the pandemic. Kalil reviews the wealth of data supporting the use of this drug in hospitalized COVID patients, namely a faster time to recovery, shorter length of hospital stay, decreased progression to mechanical ventilation, and lower mortality. Nonetheless, many published guidelines over the past few years showed little agreement with each other, and none recommended expanded use of this treatment, a trend aided by shortages of drug production as well as research decisions that favored analysis of many different patient situations over a generalized analysis of efficacy among hospitalized patients, limiting the power of these studies. Dr. Kalil explores the history of Remdesivir use over the past few years, the potential missteps along the way, and lessons we can learn for future treatment of viral illnesses with life-saving antiviral medications. Read the whole story here.

Dr. Swindells Awarded with Lifetime Achievement Award at IDWeek

Dr. Susan Swindells, clinician, researcher, and recipient of the 2023 Alexander Fleming Award for Lifetime Achievement

Last week was IDWeek, which brought many members of UNMC ID to Boston, Massachusetts, to learn and share all things ID. In addition, select individuals are honored by the Infectious Diseases Society of America (IDSA) for outstanding contributions to the field. This year, Dr. Swindells was recognized for her significant contributions to ID research, service, and clinical practice with the Alexander Fleming Award for Lifetime Achievement.

In giving this award, the IDSA president, Dr. Carlos del Rio, commented, “Dr. Swindells’ tireless efforts and leadership have led to clinical research successes that truly make a difference in the lives of persons living with HIV globally. We applaud her decades of mentorship and contributions to the field…”

Dr. Rupp also praised the news, saying, “Dr. Swindells is a skilled and compassionate clinician, a gifted scientist and a generous mentor and educator. Not only has Dr. Swindells been a local leader for HIV care, but she is also internationally recognized for her work in the treatment of tuberculosis and opportunistic infections associated with HIV/AIDS. Furthermore, Dr. Swindells served admirably during the COVID-19 pandemic and helped to craft the US national guidelines regarding evaluation and treatment of infection due to SARS CoV-2. The UNMC ID Division could not be more pleased or proud.”

Congratulations, Dr. Swindells! This award is a huge achievement and much deserved. Your contribution to UNMC and the ID field at large has been nothing short of extraordinary. Thank you for all you do!

For more details, check out the IDSA award announcement as well as this recent article in UNMC Today celebrating this achievement.

New Fellow Friday: Welcome, Dr. Stephen Cooper

We are excited to welcome Dr. Stephen Cooper as a new fellow in our Infectious Diseases program! Dr. Cooper joins us following the completion of an internal medicine residency in Omaha at Creighton University. Read on to learn a little more about him.

Tell us about the position you are starting.

I am excited to undergo a fellowship in infectious diseases at the University of Nebraska Medical Center. I look forward to learning more about the world of infectious diseases, everything from microorganism resistance mechanisms to politely asking primary teams to remove central lines.

Why did you choose to come to work at UNMC?

I realized during my M3 year as I was writing another patient biography that I belonged with the infectious disease doctors of the world. I’ve always wanted to see and learn as much as possible and was excited by the opportunities present at UNMC. We have a phenomenal ID team here with world-renowned physicians and expert teams in subspecialty areas of ID like orthopedics, transplant, and hematology/oncology ID. 

What makes you excited about working in ID?

There isn’t really a good way to say I like infectious diseases without sounding like a weird bacteriaphile. It doesn’t help that our ears perk up when a patient’s cultures grow an organism that the primary team can’t pronounce. I find infectious diseases fascinating but mainly derive satisfaction from ridding people of the effects that come from harboring said mutinous organisms. The field of ID is so broad because any organ can have an infection in it. I love that I get to keep wearing my internal medicine hat when thinking about patients and yet have the sole job of eradicating infections. As physicians, we deal with a lot of chronic issues, and it is really rewarding to be able to cure someone of an infectious process.  

Tell us something about yourself that is unrelated to medicine

I am a husband and father of two of the most wonderful children on the planet, unbiased opinion. I enjoy pretty much every sport known to mankind from your classics like basketball and football to your backyard games like Bareither Ball and Can Jam. I was a decathlete in college and have always enjoyed being active, much to the chagrin of my sinew. On a typical day off you can find me throwing some disc at Seymour park or biking around Omaha. 

New Fellow Friday: Welcome, Dr. Tyler Rosengren!

We are excited to welcome Dr. Tyler Rosengren as a new fellow in our Infectious Diseases program! Dr. Rosengren joins us following the completion of an internal medicine residency in Mason City, Iowa at MercyOne North Iowa. Read on to learn a little more about him.

Tell us about the position you are starting.

Here at UNMC, I am starting an Infectious Disease fellowship to continue following an interest I have had in microbes that I have had since early in my career.

Why did you choose to come to work at UNMC?

Growing up outside of Omaha, UNMC is where I have had a lot of my personal medical care in the past. As I progressed through my education, this hospital system became one that I looked at in a different light and wanted to become a part of. The added benefit of having family not far from the city is a bonus, but the UNMC Infectious Disease program itself is not only fantastic on its own, but it has some national recognition for things such as its antimicrobial stewardship guidelines and its role in the Ebola cases some years back.

What makes you excited about working in ID?

ID is an interesting field of medicine where not only are you treating the patient, but their disease process itself. There is another organism(s) that you are actually trying to treat that is causing all of the patient’s problems. This means that as new microbes and viruses are found, we have new organisms to treat. This, coupled with the difficulty in treating ever-evolving organisms, leads to a field that is constantly having to shift and adjust its thought process and standard of care. This constant evolution is what makes me interested in the field as a whole.

Tell us something about yourself that is unrelated to medicine

Outside of medicine, I have my wife and son whom I spend most of my time. We do have a pet rabbit as well. I have an odd conglomeration of hobbies from video games and reading fantasy stories to going on trips, trying new restaurants, and starting home projects. My attention span for any one project/hobby can be fairly limited by the amount of free time I have, so sometimes I end up bouncing between things not infrequently trying to do multiple things all at once.

UNMC ID Recognizes Advanced Practice Provider Appreciation Week!

The UNMC Infectious Diseases Division recognizes the talented and dedicated group of Advanced Practice Providers (APPs) that deliver excellent and compassionate clinical care for our patients.  We are appreciative and feel privileged to work with you.  Thank you for all that you do – every day!

Here at UNMC ID, we have 5 service lines that rely on these crucial team members (pictured above in order from left to right):

Community ID:

Amber Klaasmeyer, APRN-NP; Michelle Rude, APRN-NP

HIV/SCC:

Dan Cramer, APRN-NP; Ann Fitzgerald, APRN-NP; Nikki Regan, APRN-NP; Christine Tran, APRN-NP

Oncology ID:

Whitney Knuth, APRN-NP; Sarah Schober, PA-C; Jolene Tijerina, APRN-NP 

Orthopedic ID:

Sarah Maher, APRN-NP; Kimberly Rhodes, APRN-NP

Solid Organ Transplant ID:

Cassandra Day, PA-C; Jen Hrbek, APRN-NP; Adia Sikyta, APRN-NP 

    

New Faculty Spotlight: Dr. Mackenzie Keintz

Dr. Mackenzie Keintz is no stranger to UNMC ID as a third-year ID fellow, but she is joining UNMC ID faculty as a clinical instructor. She is also the associate medical director of Nebraska ICAP’s Project First Line, which enhances the ID training of frontline healthcare workers. Read on to learn more about Dr. Keintz. Congratulations, Mackenzie!

Tell us a little about your background in medicine.

I was born in a small town in northern Wisconsin. I went to the University of Wisconsin-Madison for my undergraduate degree. The major I had chosen my freshman year at UW-Madison was discontinued leading me to select Medical Microbiology and Immunology, which ended up being very fortunate as it led me to my decision to become an infectious disease physician.  I went to St. George’s University in Grenada, West Indies for medical school. I lived in Grenada for two years before moving to Atlanta, GA for my clinical rotations. I came to UNMC in 2018 for my internal medicine residency and completed my training in infectious disease here as well! 

Tell us about your new position.

I am joining the Division of Infectious Disease faculty as a clinical instructor and third-year fellow. I am also the associate medical director of Project First Line through our Nebraska ICAP program and associate medical director of the Nebraska ASAP program. I will see patients on the General Infectious Disease service both at main campus and at Bellevue. I will also take care of patients living with HIV in clinic. 

I am pursuing a third year of fellowship to further my training in antimicrobial stewardship or using antibiotics wisely. I am particularly interested in antibiotic prescribing in the outpatient setting. Over the next year, I will be working with UNMC providers in the outpatient setting to improve antibiotic prescribing. In my role in Nebraska ASAP, I will utilize those skills to improve outpatient antibiotic prescribing across the entire state of Nebraska! I also am very interested in medical education. Through my role with Project First Line, I have been working on educating frontline healthcare workers, including CNAs, RNs, and environmental service workers, in infection control practices. These trainings help keep all our of colleagues safe while they provide care for our patients. 

Why did you want to work at UNMC?

I was drawn to UNMC during residency interviews due to the friendly collegial culture. I knew that I wanted to return to the Midwest after living abroad and in the southern US for a couple of years. UNMC has a nationally recognized division of infectious diseases. Even as an internal medicine resident, I was welcomed into the ID division, leading to excellent mentorship experiences throughout training. After finishing training, I knew I wanted to stay at an academic medical center. UNMC has everything I was looking for in terms of clinical, stewardship, and medical educational opportunities. 

What about ID makes you excited?

Clinically, the thing I like most about ID is the puzzle. Sometimes, that is in the form of a diagnostic mystery, while other times, it comes in the form of management strategy. I like being able to piece together what is the most efficient and effective antibiotic combination I can create for a given infection. I also enjoy that I get to learn really interesting things about my patients. I get to hear about their travel, pets, and passions, which not only helps me to understand their infection risk but also them on a deeper level. 

I am also very excited about antimicrobial stewardship. I love being able to help my colleagues in other areas of medicine take care of patients better. Antimicrobial resistance is a problem that continues to grow so it is very important to utilize our antibiotics thoughtfully to preserve their function in the future. 

Tell us something interesting about yourself unrelated to medicine.

In addition to my interest in microbes, I have an interest in growing rare plants. The prize of my collection right now is a Monstera Albo (pictured right)!

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