Division of Infectious Diseases

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.

ID Journal Club – BLASTing Inappropriate Allergies out of the EMR with Antimicrobial Stewardship

BLASTing Inappropriate Allergies out of the EMR with Antimicrobial Stewardship

The following is a review by one of our fellows Dr. Rajendra Karnatak from our last Journal Club, who discussed the article by Leis et al: Point-of-Care β-Lactam Allergy Skin Testing by Antimicrobial Stewardship Programs: A Pragmatic Multicenter Prospective Evaluation, Clinical Infectious Diseases, Volume 65, Issue 7, 1 October 2017, Pages 1059–1065.

There is mounting evidence suggesting patients with labelled allergy to beta-lactams often have worse outcomes, due to receiving second line, less efficacious, broader spectrum antimicrobial agents, and have increased mortality and length of stay. Broad spectrum antimicrobial agents also contribute to development of antimicrobial resistance. Evidence supports most patients with reported allergy to a beta-lactam can safely tolerate beta-lactams. The Infectious Disease Society of America (IDSA) and Society of Healthcare Epidemiology of America (SHEA) recommend that patients with reported beta lactam allergy should undergo beta lactam allergy skin testing. Beta-lactam allergic skin testing is an inexpensive method that can safely exclude type I hypersensitivity reaction with negative predictive value of 97-99%. Beta-lactam testing however, is generally performed by Allergy specialists, and data describing experiences with Antimicrobial Stewardship (ASP) -led allergy testing to de-label allergies is accumulating slowly.

Beta-Lactam Allergy Skin Testing (BLAST) is a multicenter, prospective study conducted in three centers in Toronto, Canada. In this study, the investigators evaluated the feasibility of point of care beta-lactam allergy skin testing as an ASP activity. There were 3 major objectives of this study: 1) Feasibility of point of care BLAST as an antimicrobial stewardship activity 2) Impact of BLAST on the use of beta-lactams and 3) Impact of BLAST on overall patient clinical outcomes.

At all 3 centers BLAST was performed by ASP teams consisting of an infectious disease physician and antimicrobial stewardship pharmacists. ASP teams at each hospital received drug safety training and hands on training sessions with an Allergist on how to perform and interpret BLAST. During the study period a total of 827 patients with reported allergy to beta-lactams were reviewed by ASP/ID service; in 76% of these patient’s beta lactams were considered preferred agents.

Based on the beta-lactam allergy history 50% of the patients received preferred beta-lactam agents during the baseline period. This number was increased to 60% during intervention period by careful evaluation by ASP team by history alone (P = .02). During the intervention period after implementation of BLAST, use of preferred beta lactam therapy further increased to 81% (P < .001). The authors concluded there were 4.5-folds higher odds of receiving preferred beta lactam therapy after implementation of BLAST without increase in side effects (95% CI, 2.4–8.2; P < .0001). During the intervention period use of agents with higher risk for C difficile infection such as fluoroquinolones and carbapenems decreased more than half (28% vs 13%; P < .0002) and penicillin use tripled (11% vs 32%; P < .0002).

Although this study was underpowered to evaluate overall clinical outcomes in term of mortality and cost between two groups, investigators were able to demonstrate feasibility of BLAST as an ASP activity. Potential for reducing the use of fluoroquinolones and carbapenems to more than half demonstrates need for a wider integration of BLAST in ASP.

Patients hospitalized in intensive care units (ICU) can have an 8-times higher likelihood of negative histamine control testing. Given that 25% of their patients were in the intensive care unit (ICU), it was surprising that this study described such a low percentage (4%) of histamine control-negative individuals. It would be interesting to know if the results are as beneficial in ICU settings with higher rates of negative controls, as this might potentially be a group of patients where targeted testing and use of beta-lactams appropriately may have more clinical impact.

Despite the fact that ASPs are being widely mandated in the United States, there is limited availability of expertise in Allergy and BLAST. Implementation of BLAST as a stewardship activity could provide a much-needed solution to this problem, and by including both academic and community hospitals in their study, the authors have demonstrated that it is feasible. Others have also demonstrated integration of BLAST into ASP, with involvement of pharmacists and ID fellows. Despite its benefits, BLAST is labor-intensive and needed an hour per intervention during this study. Therefore, resources to support BLAST as an ASP activity will need to be addressed before such changes can be implemented.

Editorial Food For Thought: The authors included community and academic hospitals, but all three hospitals are teaching institutions. In truly resource-limited settings like rural non-teaching hospitals, critical access hospitals or those in developing countries, is the benefit worth the expenditure of personnel, materials and time required for this to be successful? Given the improvement in use of beta-lactams with just more intensive allergy history-taking, is the cost-effective solution simply just doing a better job at allergy review? In many patients it is difficult to ascertain whether the “allergy” (even if real) could really be IgE-mediated, and in this case, BLAST seems to be an ideal solution. One clinical situation where we have clear evidence of differences in clinical outcomes with beta-lactams vs alternatives is S. aureus bacteremia; are these the targeted clinical syndromes where BLAST would be most cost-effective, especially in a resource-limited setting?

UNMC Medical Students…Community Champions, Global Volunteers

“Nebraska Goes Global” selected as finalists in American Medical Association Global Health Challenge, led by UNMC ID EMET Student

UNMC medical students Olivia Sonderman, Laura Newton, and Rohan Khazanchi have been selected as finalists in a national competition for future healthcare professionals interested in global health equity. Their team, “Nebraska Goes Global”, was selected as one of 10 finalists in the American Medical Association’s (AMA) 2018 Global Health Challenge for their submission advocating for evidence-based medical volunteerism and global health work that addresses social determinants of health.

The AMA Global Health Challenge is a competition for undergraduates, medical students, and residents sponsored by Timmy Global Health, a non-profit organization with community health partnerships domestically and internationally in underserved areas. Finalists were selected based on initial essay submissions; winners will be chosen based on a combination of judging and voting on the essays and videos. Contest winners will have the opportunity to work alongside Timmy Global Health in Ecuador, Guatemala, or the Dominican Republic to help provide high-quality health services to local underserved populations.

The UNMC students, led by M2 Team Leader Rohan Khazanchi (UNMC ID EMET student interested in Infectious Diseases) wanted to share a bit about themselves as they ask for your vote.

What drew each of you to competing in this global health competition, and to a broader interest in working with underserved communities? How do you foresee these interests developing throughout your career?

Olivia: During my studies at UNL, I became interested in underserved communities after volunteering at the People’s City Mission (PCM) free health clinic. While at PCM, I interacted with patients who fell through the cracks in our healthcare system, a system that I have always been able to access. Soon after, I began to recognize disparity in my hometown of Columbus, NE in patients living in rural areas who struggle to meet with urban specialists to manage their health problems. Furthermore, my major of Global Studies took me to Mumbai, India where I met patients diagnosed with epilepsy who faced a great deal of social stigma surrounding their disease.

In each setting, I was fortunate to encounter people working to help these communities: healthcare professionals and staff who volunteered their time, urban doctors making efforts to travel to rural communities, and non-profit organizations that fought to reverse social stigmas and increase access to care. I quickly realized how important and rewarding their work was and decided to pursue medicine to join in their efforts. After I complete my third year of medical school, I will take a leave of absence to pursue a one-year Masters in Health Policy at a different institution. I hope this training will prepare me to both critically examine existing health policy and create novel legislation that improves the care our global medical community can provide to its patients. This global health competition specifically interested me as a way to better understand how to effectively serve a community with a well-respected organization like Timmy Global Health.

Rohan: My interest in health disparities largely stems from the time I spent as an undergraduate in St. Louis. Following the shooting of Michael Brown in Ferguson, a neighborhood 10-15 minutes from where I lived at the time, I became acutely aware that St. Louis, like Omaha, is a city with historically ingrained divisions that create disparities in the social determinants of its citizens’ health. I was inspired by the widespread activism I saw around St. Louis and involved myself in a narrative-based music outreach program to help uplift the stories of young community members. I was also motivated to leverage my own leadership positions on campus to advocate for the mental health of students of color and LGBTQ+ students.

I spent time with a team of students and physicians working with a rural community in Honduras, through which I learned about the scope of global health disparities by hearing the stories of local patients and providers. By the end of college, I was inspired by the compassionate work of my peers and mentors and decided to apply to medical school to continue caring and advocating for underserved communities as a physician. These goals drew me to the HIV Enhanced Medical Education Track (EMET), through which I am working on a project characterizing the social, demographic, and clinical factors impacting changes in the outcomes of people living with HIV. Like Olivia and Laura, I was drawn to this competition to continue exploring these interests with Timmy Global Health, an organization that has well-established local partnerships and values high-quality, evidence-based care on a global scale.

Laura: Through volunteering at community organizations growing up, I became aware of differences in wealth, educational opportunities, and neighborhood resources between Omaha communities. During a college course in Ecuador which focused on social and political transformations, I gained a broader understanding of the global pervasiveness of inequalities, especially in health. In Minnesota where I attended college, I volunteered at a community health clinic teaching an exercise and nutrition class for Hispanic and Somali women struggling with obesity and diabetes. The hard work, persistence, and camaraderie of these women left me inspired and grateful for their friendship and the privilege to take part in their path to better health, and I felt drawn to a vocation in health care.

In medical school, I travelled twice with a group of UNMC students and faculty to Falmouth, Jamaica to provide medical care to that community and the surrounding villages. I was again struck by the injustice of inequities in health and access to medical care both between countries and within communities. I participate in UNMC’s Enhanced Medical Education Track for Underserved Health Care, which immerses students in community partnerships and prepares us to be leaders in advocacy for the unique health care needs of these populations, both inside and outside clinic walls. This global health competition appealed to me as an opportunity to explore with my fellow students the challenges of global health and witness firsthand how an organization such as Timmy Global Health provides high quality service to underserved populations.

Click this link to watch their video, read more about their mission to combat health disparities throughout their careers, and vote for their team DAILY until July 30th!

Content and photos provided courtesy Olivia Sonderman, Laura Newton, and Rohan Khazanchi

Applying for ID fellowship? Hear Why UNMC ID was the right choice for one of our current fellows!

Why UNMC ID Was Right for Me

As I took inventory of what I had here in Omaha (this is where I did my residency), no other program could beat the quality of training that I knew I would receive while also providing the quality of life that my family enjoys. While I get to work and learn from national experts in many common diseases (just review some of the IDSA guidelines), my daughter gets free cello lessons, takes ballet class, is going to a dual language elementary school and is one of 15 kids under the age of ten that I can hit from my porch with a football (we have an amazing neighborhood!). I received the kind of mentorship from the ID staff as a resident that all residents should receive, but unfortunately don’t. I know that type of attention and guidance will continue throughout my fellowship.

The program is extensive with mature divisions in general ID, oncology, transplant and HIV, in addition to other areas of accomplished specialization in orthopedics, bio-containment and my favorite area, antimicrobial stewardship (apologies to anyone I left out).

I think this is usually the case for ID staff anywhere, but it is true here as well. ID physicians are some of the happiest and most passionate doctors you will find and I knew that I would be working with those kind of people if I stayed here.

I could really just go on and on, Warren Buffet is my neighbor, the hospital is 5 minutes from my house, the hospital itself runs well, there are a ton of good restaurants, the college world series is a ton of fun. Simply put, anyone that sees this program will find depth, maturity, quality and kindness in the division of infectious diseases.

Content from Dr. McCreery.

Keeping Fourth of July full of Explosions in the Air (Not from Down There)

The following was written by Dr. Jasmine Marcelin and originally posted to the Physician’s Weekly Blog on July 3, 2018 in honor of the upcoming Independence Day holiday.

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Fourth of July. Independence Day. For most, a delightful holiday filled with fun, family, friends and most importantly, FOOD.

Independence Day is the most popular day to grill. Whether the plan for July 4th is grilling, picnics or checking out a hot dog eating contest, if you will be gathering around food, there’s a chance that food-borne illnesses will gather with you. You may not realize immediately that you have been exposed to a potential foodborne illness until days after your picnic. Here’s a list of potential offenders and how to keep them safe:

Potato/Egg Salad: Salmonella – causes vomiting, diarrhea, fever, cramps within 12-72hrs
Hot Dogs/Deli meat: Staphylococcus aureus – causes nausea, vomiting, diarrhea, cramps within 30 minutes-6 hours
Chicken: Campylobacter spp – causes bloody diarrhea/fever and stomach cramping within 2-5 days (Also Salmonella, as above for potato/egg salad)
Beef: Clostridium perfringens – causes acute diarrhea/stomach cramps within 6-24hrs
Burgers: Escherichia coli – causes diarrhea, stomach cramps, vomiting within 3-4 days
Shellfish: Vibrio – causes nausea, vomiting, watery diarrhea, fever within 1-4 days
Fresh Fruit/Vegetables: Cyclospora spp – causes watery diarrhea/cramps within a week
Cheeses: Listeria – causes fever, flu-like illness in pregnant women (can hurt the growing fetus too), and meningitis in elderly or immunocompromised persons

So how do you keep your 4th of July focused on fireworks instead of flatulence? The CDC encourages using the steps “Clean, Separate, Cook and Chill” to ensure proper food safety. Step 1 – Clean: Wash your hands, utensils and food handling surfaces often
Step 2 – Separate: Don’t cross-contaminate. Keep raw meat separate from other cooked or uncooked foods, separate your meats (i.e. keep your chicken separate from your pork and beef), and use separate cutting boards for each item
Step 3 – Cook: Always cook your food to the right internal temperature, and use a food thermometer. Consuming raw or partially uncooked meats increases your risk of foodborne illnesses. The CDC suggests these temperature recommendations for different types of foods:
• 145°F for whole cuts of beef, pork, veal, and lamb (then allow the meat to rest for 3 minutes before carving or eating)
• 160°F for ground meats, such as beef and pork
• 165°F for all poultry, including ground chicken and turkey
• 165°F for leftovers and casseroles
• 145°F for fresh ham (raw)
• 145°F for fin fish or cook until flesh is opaque

Step 4 – Chill: Refrigerate your food promptly, and at most within 2 hours (within 1 hour if outside temperature is above 90°F). After cooking, put the food back in the cool refrigerator and make sure it can keep temperatures below 40°F. Food left at room temperature for long periods invites bacteria to multiply rapidly, increasing likelihood of foodborne illnesses.

Remember, summer heat and humidity makes it difficult to keep food cold outdoors. If leaving your home to celebrate the Fourth, invest in a proper cooler and load it with ice to keep your meats cold before cooking. Use a separate cooler for drinks. Remember to fill up your grill gas tank or stack up on charcoal to ensure that food is grilled to the “Kill bacteria and keep them dead” temperature.

Most importantly, WASH YOUR HANDS before and after handling raw meat, before handling non-meat items, and before you sit down to enjoy the fruit of your grilling prowess. (Or at least use hand sanitizer!)

Check out these CDC websites for more food safety tips and information about symptoms and sources of foodborne illnesses.

We hope everyone enjoys their holiday, Happy Independence Day!

Ending the AIDS epidemic with 90-90-90…Have YOU been tested?

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

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

HIV testing is available at multiple locations. You can ask your primary care clinician to test you for HIV, but did you know that you can get tested for free or low cost at multiple locations near you? These can be local nonprofits like the Nebraska AIDS Project (NAP), your County Health Department like the (Douglas County STD Clinic). Getting tested for HIV can be quick, easy and confidential – go to bit.ly/NHTD2017 and enter your zip code to find an HIV testing location near you.

Our Specialty Care Clinic works closely with the Douglas County STD Clinic and NAP. We treat PLWH diagnosed with HIV at these locations and provide pre-exposure prophylaxis (PrEP) for patients who are at risk. Our nurse and case manager Precious Davis BSN, MSN has been very involved with reaching out to our community to spread the message of HIV testing. At an event in the Spring, Precious shared some of these statistics and information on treatment and stigma of HIV care in a poem (pictured here). At that event, 25 people were tested for HIV.

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

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

Jennifer O’Neill, RN, BSN on Why I Love ID

Why I Love ID:

” I love ID. In my role as a clinical research coordinator with the HIV team, I get the opportunity to provide very holistic, multidisciplinary care to our patients while working with the latest interventions and seeking to gain new information to advance the science of care. It is exciting to share those advances with patients, reflecting on how far we have come in a relatively short amount of time and knowing that we are helping to shape the management of the disease going forward. I truly feel privileged to work with such a gifted team focused on providing continuity of care in such a comprehensive way. “

-Jennifer O’Neill, RN, BSN

Learn more about ID at UNMC here.

When You Stop To Smell the Roses and Cannot Smell A Thing

The following was written by Dr. Kelly Cawcutt and originally posted to the Physician’s Weekly Blog on May 31, 2018. Dr. Cawcutt was inspired by a recent personal experience with an upper respiratory infection and its impact on her senses of smell and taste, and she shares how some infections can interfere with basic senses we often take for granted.

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It all started with allergies – or so I thought. We moved into a new house and there are all of these new plants, some more exotic, that were in full bloom when it started. The itchy watery eyes, the sneezes, the post-nasal drip..drip..drip. Too much? Nah, you hear (and see) worse over your Grand Rounds or Noon Lunch-and-Learn sessions.

But, I digress.

Then it got worse. Around 1 week later, the cough started. The body aches. The headaches. The sore throat. The “influenza-like illness,” or ILI, arrived with no apologies. I thought the virus had done its worst; then, as I made my morning coffee, Wacky Wednesday started. I could not smell it. It seemed strange, but I thought it was just congestion. I took a sip. Hot liquid, tasteless. I rummaged through my kitchen–smelling and tasting noxious things, testing my senses. Garlic? Nothing. Chili Lime seasoning? Nothing. Pepper, salt, ginger? All nothing.

I lost my sense of taste and smell.

The loss of smell (anosmia) and taste (ageusia) impact millions of adults in the United States, with distortions in smell being more common. The actual prevalence is likely underestimated, however, given that the primary method of diagnosis is self-reporting. The range of symptoms can go from impairment to total absence and to phantom sensory involvement—that’s right, smelling the roses when they are not there. Advanced age can be a cause for loss of both of these chemosensory agents, but there are many other potential causes, including sinus disease, ear diseases, trauma, neurologic diseases, and infections ranging from the sinuses to the oral cavity to upper respiratory infections and beyond. Interestingly, hepatitis C is also associated with altered perceptions of taste.

Of course, as an ID specialist, the infections are what catch my eye.
What infections can cause this? How does it happen?

Loss of smell from infection, or any kind of sinusitis, usually is due to the acute inflammation of the nose and sinuses impeding the olfactory nerves and system to respond appropriately.

For most infections, think the common cold or upper respiratory infections, it seems that the post-infection loss of smell is generally temporary due to the phenomenal plasticity of the olfactory system. In fact, after URI’s, 32-66% of patients will recover their sense of smell spontaneously. For those struggling, training your sniffer can carry significant advantages toward recovering with intentionally smelling various types of odors a few times per day to “retrain” the olfactory system. It’s physical therapy for the nose!

Taste carries similar risk factors, with URIs, oral infections, sinus infection,s and the unusual association of hepatitis with ageusia. Dysgeusia is more common that ageusia, and many of those who have alternations in taste will also report changes in their sense of smell. Pathophysiology is very similar—acute inflammation of the immediate nerves enroute back to the brain limit the sensation. Except with hepatitis C—there are several potential hypotheses out there on this one, but it is thought that the virus directly impacts the nervous system, resulting in symptoms.

All this being said, smell and taste can be a secondary impact of many common viral and bacterial infections of the head and neck. Treatment should be specific toward the underlying infection to start. Any infections that can cause mass or invasive lesions (aspergillus, mucormycosis, actinomyces) could also result in damage. Many patients will have full recovery, but for those who do not, referral to a specialist is in order for further evaluation and management.

As for me, my taste and smell started to recover slowly after about 48 hours. But, it did raise some awareness—without smell, I may miss the smell of my roses, but I would also not smell the smoke from a fire spreading outside or a gas leak from my stove. These are tangible risks that we should consider in patients with reported losses.

Tomorrow, I will try again to stop and smell the roses.

References

https://academic.oup.com/chemse/article/41/1/69/2365821

https://academic.oup.com/chemse/article/42/7/513/3844730

https://www.ncbi.nlm.nih.gov/books/NBK482152/

https://www.amjmed.com/article/S0002-9343(16)30177-2/fulltext

UNMC ID In The Trenches – Perspective From A Current ID Fellow

Dr. Karnatak, who is finishing his 1st year of ID fellowship, shares what ID fellowship is like here at UNMC:

UNMC ID fellowship is uniquely designed to create an individualized training path for fellows. During my fellowship interview, I believed this fellowship would support fellows to achieve their personal career aspirations, and now after completing my first year of fellowship, I know this is true. The UNMC ID faculty are both the reason for this support and are also the best part of the fellowship! Everyone in the division is very approachable and ready to help in every feasible way. The faculty take pride in teaching the fellows.

The, first year of fellowship provides excellent experience in general ID and introductory rotations to solid organ transplant infections and oncology infectious disease. Overall, two years of ID fellowship at UNMC also provides 6+ months of research experience and at least 4-6 months experience of immunocompromised infections (solid organ transplant and oncology ID). When I started my fellowship, I had very little research experience. At UNMC I was able get the opportunity to work with national leaders in ID. Research training is very well designed to train fellows in writing research proposals, IRB applications and independently doing your research projects. During my first year, I was able to co-author a manuscript and submit an abstract for a national ID meeting. I am close to finishing my first research project, and I have already started discussing about more research projects I will be doing during my second year of fellowship.

The Multidisciplinary HIV ambulatory continuity clinic provides excellent exposure to HIV care, which is critical for gaining confidence in managing patients with HIV. I started my fellowship with very little experience in HIV management. At the HIV continuity clinic, once you demonstrate understanding of basic HIV knowledge, you will be exposed to more complex issues in HIV care such as HIV resistance, therapy switch challenges, drug-drug interactions and more. The bimonthly HIV round-table discussion is an excellent place to discuss challenges in HIV care with the experts.

Omaha is a city is known for its pioneer history and cultural centers. People are welcoming and you will feel the authentic Midwestern hospitality. No matter where you come from there is always something for everyone to enjoy here in Omaha. I lived in New York city during my residency and I was amazed see the cultural diversity in Omaha. It’s a perfect balance of amenities of big city with less hassle. In Omaha, people are nice and will greet you, even if they don’t know you.

Overall UNMC ID fellowship provides opportunity to build a career in multitude of areas including clinical infectious diseases, infection control, antibimicrobial stewardship, ID-critical care, Transplant infectious diseases, Oncology infectious diseases and biopreparedness training. If this kind of diverse exposure excites you, UNMC ID fellowship would be a good fit. Join us!!

What happened at the first Nebraska Antimicrobial Stewardship Summit?

After almost a year of planning, the First Annual Nebraska Antimicrobial Stewardship Summit convened on Friday, June 1^st, 2018 in La Vista, NE. This conference is the first of its kind in Nebraska in which information on antimicrobial stewardship in various healthcare settings is the focus of the meeting. The conference center was abuzz with excitement as close to 270 healthcare professionals attended the Summit that included over 130 nurses, 80 pharmacists, and 30 providers. While the majority of the attendees were from Nebraska, healthcare professionals from neighboring states such as Iowa, Kansas, Missouri and South Dakota also attended the Summit.

Following a warm welcome from Dr. Maureen Tierney (Director of the HAI/AR Program, Nebraska DHHS), Dr. Srinivasan (Associate Director for Healthcare-Associated Infection Prevention Programs, CDC) gave an Update on National Antimicrobial Stewardship Activities in acute, long-term and ambulatory care settings. His concluding message was that the question now is not IF we need antimicrobial stewardship but WHAT is the most efficient and effective way to accomplish it because stewardship is more than just antibiotic resistance, it is a matter of patient safety.

The morning session continued with presentations from Dr. Diekema (Professor, University of Iowa Carver College of Medicine, pictured to the left) on the Role of the Laboratory in Antimicrobial Stewardship; Drs. Vivekanandan (Associate Professor of Medicine, Creighton University) and Horne (Assistant Professor of Medicine, Creighton University) on “Is Antibiotic Stewardship the Answer to C. difficile”; and Kate Tyner, RN, CIC (Nurse Coordinator, Nebraska ASAP and ICAP) on the “Role of the Infection Preventionist in Antimicrobial Stewardship”. The morning session concluded with a presentation from Drs. Tierney and Pedati (Medical Epidemiologist, Nebraska DHHS) on “Public Health Support for Antimicrobial Stewardship” in which they discussed the state MDRO outbreak detection and management protocols as well as the state antimicrobial susceptibility registry and antibiogram.

During lunch, Summit attendees had the opportunity for roundtable discussions with Summit speakers, Planning Committee members, and HAI Antimicrobial Stewardship Advisory Committee members during the Meet-the-Expert session. The goal of this activity was to promote networking and stimulate discussion on solutions to overcome antimicrobial stewardship challenges. Lively discussions ensued between antimicrobial stewardship experts and attendees over hoagies and subs! (Dr. Marcelin pictured with her table above)

Education in antimicrobial stewardship continues in the afternoon with breakout sessions in the Acute and Ambulatory Track and the Post-Acute and Long-Term Care Track at the Summit. Dr. Bergman (Pharmacy Coordinator, Antimicrobial Stewardship Program, Nebraska Medicine, pictured to the left) started the acute and ambulatory session with his presentation on “Regulatory Requirements for Hospitals and Outpatient Antimicrobial Stewardship”. This was followed by presentations from Dr. Van Schooneveld (Medical Director, Antimicrobial Stewardship Program, Nebraska Medicine) on “Antimicrobial Stewardship Interventions in Acute Care Hospitals”; Dr. Kuper (Senior Clinical Manager, Infectious Diseases, Vizient) on “Antibiotic Stewardship Metrics: How Do You Measure Up?”; and Drs. Marcelin (Associate Medical Director, Antimicrobial Stewardship Program, Nebraska Medicine) and Green Hines (Medical Director, Antimicrobial Stewardship Program, Children’s Hospital & Medical Center) on “Antimicrobial Stewardship in the Outpatient Setting (#OutptASP)”. The session was well attended and appreciated by Summit attendees.

Equally well attended is the post-acute and long-term care session that was opened with a presentation from Dr. Crnich (Chief of Medicine and Hospital Epidemiologist, Williams S. Middleton VA Hospital, pictured to the left) on “Regulatory Requirements for Post-Acute and Long-Term Care Antimicrobial Stewardship Programs”. This afternoon session continued with Dr. Ashraf (Co-Medical Director, Nebraska ASAP and Medical Director, Nebraska ICAP) speaking on “Antimicrobial Stewardship Implementation in Post-Acute and Long-Term Care Facilities”; Dr. Crnich on “Management of Common Infections in Long-Term Care Facilities”. The session concluded with a presentation from Tammi Schaffart, RN (Infection Control Nurse and QAPI Coordinator, Douglas County Health Center) and Dr. Ortmeier (Consultant Pharmacist Team Lead, Community Pharmacy Services) on the “Role of Nurses and Consultant Pharmacists in Antibiotic Stewardship in Post-Acute and Long-Term Care Facilities”.

When asked about take-home points on establishing antimicrobial stewardship programs in long-term care facilities, speakers from the Post-Acute/Long-Term Care Track shared their thoughts. Dr. Crnich said it takes a team to establish a stewardship program while Dr. Ashraf (pictured to the left) echoed a similar sentiment that no one is alone in this journey. Tammi emphasized to the many nurses in the audience the importance of documentation to show their efforts for the numerous clinical activities they performed in nursing facilities, including antimicrobial stewardship. Dr. Ortmeier stressed the importance of persistence and the need to continue to ‘keep at it’ for eventual success.

We genuinely appreciate the support Summit attendees expressed. It is our hope that this type of Summit will continue annually in the future and that new topics and updated contents in antimicrobial stewardship will be presented. Additionally, we hope to make many more connections with healthcare professionals in Nebraska and neighboring states to improve the care and safety of our patients and residents by improving prescribing of this precious resource, antimicrobials, through antimicrobial stewardship.

Even beyond our almost 300 live participants, our hashtag #NebStewardSummit2018 was active on twitter as members of our team live-tweeted and shared the conference all over the globe, leading to a potential reach of over 340,000 impressions. Continue to follow us on our websites here and here, and follow us on twitter @UNMC_ID for more updates on what we are doing in Antimicrobial Stewardship here in Nebraska.

Content provided courtesy Phil Chung, PharmD