Division of Infectious Diseases

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


 

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


 

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.


 

 

Transplant Infectious Diseases Program

University of Nebraska Medical Center – Omaha, NE

The University of Nebraska Medical Center (UNMC) is excited to announce the recruitment of a faculty position in Transplant-ID in the Division of Infectious Diseases, Department of Internal Medicine. Successful candidates will hold an academic appointment at the assistant or associate professor level and will be employed by UNMC and Nebraska Medicine. Candidates should be Board Eligible/Certified in Infectious Diseases.

A generous compensation package with salary commensurate with experience will be offered. Candidates should have an enthusiasm for patient care, teaching, and clinical research. Generous protected time and support are available in order to conduct collaborative clinical research and achieve the goals of the program.

Opportunity Highlights:

  • Join established Board Certified ID Physicians fully dedicated to Transplant patients, Advanced Practice Providers, and Research Team
  • Participate in diverse translational research program that encompasses both diagnostic and therapeutic aspects of the Transplant ID patient population
  • Participate in teaching of medical students, residents, and ID fellows on the Transplant ID consult service

The applicant will also participate in the clinical, teaching, and research programs of the Infectious Diseases Division – a vibrant and growing division made up of 20 ID faculty. The interested applicant is encouraged to learn more about UNMC ID at: https://www.unmc.edu/intmed/divisions/id/index.html and the UNMC ID blog:  https://blog.unmc.edu/infectious-disease/feed/.

Interested candidates should submit a letter of interest and CV to:

Mark Rupp, MD

Chief, Division of Infectious Diseases

University of Nebraska Medical Center

985400 Nebraska Medical Center

Omaha, NE 68198-9400

Email: merupp@unmc.edu


 

Ceftazidime-avibactam resistance in carbapenem-resistant Enterobacteriaceae: what’s next on the horizon?

Ceftazidime-Avibactam

Ceftazidime-avibactam is approved by the Food & Drug Administration (FDA) for treatment of complicated intra-abdominal and urinary tract infections, and has activity against carbapenem-resistant Enterobacteriaceae (CRE). Data regarding its real-world application and potential pitfalls is still emerging, and this review illustrates some experiences with use and emerging resistance to ceftazidime-avibactam.

The authors of the first paper in this review “Pneumonia and Renal Replacement Therapy Are Risk Factors for Ceftazidime-Avibactam Treatment Failures and Resistance among Patients with Carbapenem-Resistant Enterobacteriaceae Infections” reported their single center, retrospective experience of treatment outcomes of ceftazidime-avibactam for CRE infections. Among 77 patients receiving this antibiotic, 30-day and 90-day survival outperformed the predicted survival, at 81% and 62% respectively. Fifty-five percent of patients achieved clinical success, and on a multivariable analysis, the presence of pneumonia (OR 4.78, CI 1.03-22.2, p=0.046) and need for renal replacement therapy (RRT) (OR 3.09, CI 1.03-9.34, p=0.045) were independent risk factors for treatment failure.   Ten percent of patients developed resistance to ceftazidime/avibactam; all were KPC-3 subtypes. RRT independently predicted risk for development of resistance among patients who developed microbiologic failure (OR 26.67, CI 2.24-317.1, p=0.009). Poorer outcome in patients with pneumonia is troubling given that of the 77 patients, 43% had pneumonia. The pharmacokinetics/pharmacodynamics of this antibiotic in critically ill patients with nosocomial pneumonia needs further evaluation. Optimal dosing of ceftazidime-avibactam in RRT still needs to be determined, as it is possible that those patients did not achieve adequate serum drug concentrations to be effective.

In the second article, the authors reported a case of emergence of resistance to colistin by a KPC producing K. pneumoniae causing a bloodstream infection while the patient was on treatment with colistin. The patient’s isolate demonstrated decreased susceptibility to ceftazidime-avibactam (MIC 4ug/mL), despite being naïve to it. He was treated with meropenem, tigecycline and colistin combination therapy, but his bloodstream infection relapsed after 8 days of treatment. The second isolate was typed and found to be clonally related to the first but had developed colistin resistance. They hypothesized that, induced by induced by antibiotic pressure, the ST258 strain of KPC-K. pneumoniae that infected the patient was likely to have developed colistin resistance by random transposition of the mgrB gene sequence.

With CRE resistance to “last line” agents such as colistin, what is the next frontier for treatment of these infections? There are European reports of bacteriophage research for use in MDR infections, but there is a paucity of data demonstrating clinical effectiveness in large scale studies. The authors in the third brief report reported a case of treatment of an MDR Acinetobacter baumannii post-traumatic cerebritis with bacteriophage therapy. He had demonstrated susceptibility to colistin in vitro but did not improve clinically on a combination regimen of colistin/azithromycin/rifampin. The use of bacteriophage therapy was conducted under an emergency investigational new drug application. The isolate had to be screened to determine which phage had most virulence against it and was individualized for the specific bacterial isolate. The local craniotomy site infection appeared to heal but the patient did poorly and eventually care was withdrawn. The authors concluded that the patient’s death was not necessarily a result of phage failure; potential considerations included intravenous rather than local phage therapy, baseline critical illness with poor chance of recovery, and perhaps inadequate serum bacteriophage levels. Time and effort to individualize and administer bacteriophages means that significant research still remains to determine if and when this therapy would be useful in clinical care. Meanwhile, given the slow drug discovery pipeline, modification of our current use patterns and Antimicrobial Stewardship still remain the cornerstone strategies to prevent us from toppling off the proverbial cliff of antimicrobial resistance.

(Ceftazidime-Avibactam image credit: Vaccinationist – Own work, Public Domain)


 

Welcoming our new ID fellows – Focus on Dr. McCreery

Randy McCreery MD, UNMC 1st Year ID fellow.

We are thrilled to welcome Dr. Randy McCreery as a new fellow in our Infectious Diseases program! Read on to learn a little more about him…

Tell us about the position you are starting

I’m starting an Infectious Diseases fellowship at UNMC.  Appropriately, the fellowship is weighted toward general infectious diseases but surprisingly, the second most common rotation we have is research.  There is also ample time spent on transplant infectious diseases and oncology infectious diseases.  We also have the option of a third year to focus on building a portfolio in preparation for a career in academic medicine.

Tell us about your background

I’m the first doctor in my family.  I was born in the California’s San Joaquin Valley and spent most of my life there.  My fondest memories growing up were travelling around the state playing (and winning of course) soccer, going deep into the Sierra Nevadas on camping and fishing trips and spending time at my grandfather’s ranch (now a peach farm that I’m excited to say should produce its first crop this year).

Why UNMC?

UNMC is packed with excellent ID physicians and you’re only as good as who you surround yourself with.  It’s also just a good hospital to work at; maybe that’s the way it is everywhere in the Midwest, but everyone is reasonable and approachable no matter what specialty they are in.  People talk to each other and work as a team to get the job done, and that’s the type of place you want to be at.  Omaha is also a great place to raise kids and I have 3 of them.

What about ID makes you excited?

There is so much about ID that makes me excited.  I think I like curing things and a lot of infections, unlike so many other diseases, can be cured.  Of those that can’t be cured, many of them can be well controlled and it’s very satisfying to help a person control something that is constantly lurching in the background, ready to strike at any time if given the chance.

Tell us something about yourself UNRELATED to medicine

I’ve named a place in the world.  It’s not an official place registered with the US Government, but if you zoom in on Google Maps, and follow the Kings River into the Sierra Nevada’s just east of Fresno, you’ll find a string of fishing holes that I’ve named.  The names for these places were given to me by my father, and given to him by an old man who had been going there since he was a kid.  Some may have different names for these places, but if you go to Google Maps and type in “The Rope Hole, Lakeshore, CA”, you’ll find one of the places where I first learned to fish.  Catching fish on that river as a boy, was where I first experienced the feeling of independence and that I might, one day, be able to make it in this world on my own.  I love that place….. and I think of it often.

Learn more about the UNMC Infectious Diseases Fellowship here.


 

Intra-abdominal abscesses – do we REALLY need to know every organism in there?

This is a review of a recently published article.

Andrew Kozlov, Lorenzo Bean, Emilie V Hill, Lisa Zhao, Eric Li, Gary P Wang; Molecular Identification of Bacteria in Intra-abdominal Abscesses Using Deep Sequencing, Open Forum Infectious Diseases, Volume 5, Issue 2, 1 February 2018

Most intra-abdominal abscesses are polymicrobial. Sometimes aerobic organisms are identified from culture, but often anaerobic organisms do not grow on conventional culture media, especially when patients have received prior antibiotics. This knowledge often leads to broad-spectrum antibiotic therapy including anaerobic coverage.

The authors proposed that culture-independent 16S rRNA sequencing can be used to identify bacteria within intra-abdominal abscesses independent of culture data. They used de-identified clinical specimens from intraabdominal abscesses.  They obtained gram stain and culture of all specimens, and used 16s rRNA Illumina Sequencing to amplify a particular hypervariable bacterial region.

They included 26 samples with amplification products and deep sequenced them.  8 of these samples were gram stain and culture negative, and while these had lower microbial diversity, bacterial sequences revealed a predominance of streptococci, B. fragilis and gram positive anaerobic cocci.

In 5 of the samples, culture growth was monomicrobial. The deep sequencing found that even the samples with monomicrobial culture growth were in fact polymicrobial, with the dominant bacteria being the one identified on culture (in 3 of those 5), and recovery of anaerobic organisms was abundant.

An interesting clinical relevance of this: a perihepatic culture had monomicrobial growth of Coagulase-negative staphylococcus, but the sequencing revealed the dominant organism to in fact be Enterococcus faecium. This discrepancy would have significant clinical implications for choice of therapy, especially in the context of a potential vancomycin-resistant enterococcus. The polymicrobial culture samples on the other hand, were a mish-mash of organisms on sequencing; anaerobic cultures predominated, with minority aerobic organisms growing on culture.

The biggest limitation is that with the samples being de-identified, there is no patient-level antimicrobial history data to correlate and account for culture growth. We also don’t have treatment and outcomes data after the cultures were obtained, so it is not clear whether or not the targeted therapy for a monomicrobial abscess culture resulted in clinical cure; in which case, what difference does it make to know about these other organisms?

Knowledge of the complete biodiversity of organisms within an abscess may result in narrowed therapy, however it could also result in prolonged broad spectrum therapy, as prescribers try to chase all of the organisms identified on PCR. Ultimately, proposing this as a culture-independent modality may be risky given the inability to perform antibiotic susceptibility testing on the result; but there may be some utility for this in situations where cultures are negative.

Welcoming our new ID fellows – Focus on Dr. Rearigh

Lindsey Rearigh DO, UNMC First Year ID Fellow

We are excited to welcome Dr. Lindsey Rearigh as a new fellow in our Infectious Diseases program! Read on to learn a little more about her…

Tell us about the position you are starting

I am just starting my first year as an infectious disease fellow at UNMC. This is a 2-year program aimed at training its fellows in every area of infectious disease, from general ID to antibiotic stewardship, epidemiology and HIV.

Tell us about your background

I’m originally from Colorado, which is where most of my family still lives. I went to undergrad at Pfeiffer University in the tiny village of Misenheimer, NC where I played D2 lacrosse for four years. I then went to medical school at Edward Via College of Osteopathic Medicine (VCOM) in Spartanburg, SC and just completed my internal medicine residency at Mercy Medical Center in Des, Moines IA. I often say I have no true home because I have been bouncing around so much, but I enjoy learning about each new city and am excited to see how my two years in Omaha will turn out.

Why UNMC?

UNMC has an excellent reputation for ID training in the Midwest. The program touches on all areas of ID including rotations in general, oncology, ortho, and transplant. We also develop a strong base in HIV with weekly clinic time throughout the two years, as well as special opportunities for training in biopreparedness, antimicrobial stewardship and microbiology. It was important for me to choose a program that offered so many different opportunities so I can learn as much as I can during these two years to help better serve my future patients.

What about ID makes you excited?

ID is an amazingly diverse field that still utilizes every aspect of internal medicine training. I love that even though infectious disease is a specialty it still involves every organ system. I also get really excited about our patients and taking a really good history. We get to know our patients really well in this field because we are always asking questions about occupation, sex, travel, and pets. Some of the backstories that we get, even if it’s not related to why they are in our care, are very interesting. Often times getting to know these small details about our patients leads to better overall care and helps us overcome some barriers that may not have been addressed previously.

Tell us something about yourself unrelated to medicine

Outside of medicine, I enjoy pretty basic things like spending time with my family and friends, traveling and trying new things. I also really enjoy yoga. I find that it offers a nice balance to hectic call schedules, demanding patients and physician burnout. Yoga keeps me grounded in gratitude and focused on learning from everything. From new consults (even if in the middle of the night) to complex patients (even if not ID related) there is always something to learn. Wish me good luck on my journey over the next 2 years!

Learn more about the UNMC Infectious Diseases Fellowship here.


 

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