Division of Infectious Diseases

Pharm to Exam Table – Trimethroprim/Sulfamethoxazole for Nocardiosis

Pharm to Exam Table: Clinical Pharmacology/Antibiotic Updates – Trimethroprim/Sulfamethoxazole for Nocardiosis

Nocardia is an aerobic, gram-positive bacterium commonly found in soil, decomposing vegetation, fresh water, and salt water. Nocardia is typically considered an opportunistic pathogen, but there have been several cases of nocardiosis occurring in immunocompetent hosts. Patients that are most at risk of developing nocardiosis are those with malignancies, human immunodeficiency virus (HIV), solid-organ and hematopoietic stem cell transplants, and long-term use of cell depleting medications such as corticosteroids. Nocardia infections most commonly present as a pulmonary infection, but may also include central nervous system involvement and skin abscesses. Nocardiosis usually requires a long course of treatment and traditionally, trimethoprim/sulfamethoxazole (TMP/SMX) has been the drug of choice.

Although there are numerous case reports available about the treatment of Nocardia infections, the lack of randomized controlled trials hinder the ability to make concise recommendations on drug dosing and treatment duration. Regardless of the site of infection, high dose TMP/SMX (800mg/160mg) given twice a day seems to be the most effective for eradicating Nocardia infections. The duration of treatment varies based on the location of the infection. Pulmonary infections should be treated for at least 3 months upon hospital discharge. Extending that duration to 6 months may also be appropriate if the patient is not responding as quickly or abscesses are still present on the CT exam at follow-up. Brain infections should be treated for at least 12 months upon hospital discharge. Cutaneous infections should be treated for at least 2 months. As with any of these infections, patients should be started on treatment as soon as Nocardia infections are identified. One area of variability is the amount of time patients are treated while inpatient because it will take each patient a different amount of time to become stable enough to discharge. The impact of the variation of overall treatment duration still remains unknown in the treatment of Nocardia. These recommendations are based on individual case studies and while they can be applied to other similar cases, it is important to take into account that additional agents may need to be added or substituted if susceptibility testing demonstrates resistance to TMP/SMX.

References

Wilson JW. Nocardiosis: Updates and Clinical Overview. Mayo Clinic Proceedings. 2012 April; 87(4); 403-407.
Valdezate S, Garrido N, Carrasco G, Medina-Pascual M, Villalon P, Navarro A, et al. Epidemiology and susceptibility to antimicrobial agents of the main Nocardia species in Spain. Journal of Antimicrobial Chemotherapy. 15 Dec 2016; 72: 754-761.
Galacho- Harriero A, Delgado-Lopez P, Ortega-Lafont M, Martin-Alonso J, Catilla-Diez J, et al. Nocardia farcinica Brain Abscess: Report of 3 Cases. World Neurosurgery. 18 July 2017.
Sharrif M, Gunasekaran J. Pulmonary Nocardiosis: Review of Cases and an Update. Canadian Respiratory Journal. 9 November 2015.
Zhu, N, Zhu, Y, Wang Y, Dong S. Pulmonary and cutaneous infection caused by Nocardia farcinica in a patient with nephrotic syndrome. Medicine. 16 May 2017; 96:24(e7211).

Content Courtesy Patricia Malinowski Burch, University of Nebraska Medical Center Pharmacy Student

Thank A Resident Day 2018 has ARRIVED

We recently posted about Resident Awareness Week in Canada and we are THRILLED to support this new initiative today.

Nebraska Medicine, UNMC and The Gold Humanism Honor Society are excited to celebrate all Residents today on Thank a Resident Day. Thank a Resident Day offers faculty and students the chance to show their gratitude to the unsung teachers of their medical school clerkship, the house-staff.

While Residency is an important stage in medical training, it is also a period of peak burn out. Physician burnout affects more than half of U.S. doctors. Burnout is characterized by three symptoms; exhaustion, cynicism or dehumanization, and sense of ineffectiveness and lack of accomplishment. Thank a Resident Day is meant to Celebrate Residents and Explore their Resiliency. This is a medical-student led activity that will provide residents with resiliency-promoting physical and social activities as well as show support for their efforts.

A simple, but heart-felt, thank you may carry a larger impact than any of us realize. Please take a moment today to personally thank a resident.

Here in the ID world, we would like to extend a particular thanks to our residents here in ALL specialties at UNMC. Thank you for EVERYTHING you do to help prevent and treat infections in the community and here in the hospital. We need your help every day in preventing the spread of disease, in antimicrobial stewardship and in providing the best possible care for our patients.

Honoring Black Women and Men Physician Leaders in Infectious Diseases

African Americans account for only 6% of newly minted doctors graduating from medical school in the USA. Within our specialty of Infectious Diseases, only 3% of ID physician members of the Infectious Diseases Society of America (IDSA) self-report as Black/African American. Many of these physicians make it their career goals to provide care for and advance clinical research pertaining to People of Color, often underrepresented in clinical trials and underserved in clinical practice.

In honor of Black History Month, let us recognize and honor Black Women and Men Physician Leaders who have and continue to advance our specialty.

Dr. William Augustus Hinton (1883-1959) was a microbiologist, and would be considered an Infectious Diseases Physician before the field of Infectious Diseases existed as a separate specialty. The son of two former freed slaves, Dr. Hinton graduated with honors from Harvard Medical College in 1912; by 1915 he had become the lab director for the Massachusetts State Department of Health. He went on to become the first African American to be appointed Professor at Harvard Medical School. His contributions to the field of Infectious Diseases were primarily regarding diagnosis and treatment of syphilis, which he worked on in his lab after being denied a medical internship due to his race. He developed a diagnostic test for syphilis called the Hinton test, a precipitation assay that was the most accurate of its time (later replaced by the RPR). He founded a school for women laboratory technicians, leading to countless job opportunities for hundreds of women. In 1936, Dr. Hinton was the first African American to publish a medical textbook: Syphilis and Its Treatment. Dr. Hinton’s legacy has been honored by the creation of the American Society of Microbiology William A Hinton Research Training Award dedicated toward research training of underrepresented minorities in microbiology.

Incidentally, his daughter, Dr. Jane Hinton (1919-2003) [photo not available] was one of the beneficiaries of Dr. Hinton’s Medical Laboratory Techniques course. Before becoming one of the first African American woman veterinarians, she worked in Harvard laboratories to co-develop the Mueller-Hinton agar, which is still used today for antibiotic susceptibility testing. Infectious diseases doctors know that our jobs would be infinitely more difficult without antibiotic susceptibility testing.

There are over thirty-six million people worldwide living with HIV, twenty-five million of whom reside in African countries. In the United States, 1.1 million people are living with HIV, and although African Americans make up only 12% of the entire US population, they account for 44% of the persons living with HIV in the USA. The doctors highlighted next have dedicated their lives to studying and caring for persons living with HIV.

Drs. N’Galy Bosenge and Kapita Bila Minlangu were passionate doctors from Zaire (now known as the Democratic Republic of Congo), who led the charge towards understanding the HIV/AIDS epidemic in Africa. In 1984, Drs. N’Galy and Kapita were the Zairean co-leaders of Projet SIDA (Project AIDS), along with American ID physician scientist Dr. Jonathan Mann and other contributions from Belgian epidemiologists, the Centers for Disease Control and Prevention, and World Health Organization. Much of what we know about HIV/AIDS today can be traced back to early epidemiological studies and clinical research conducted at one hospital in Kinshasa.

Dr. N’Galy Bosenge led research and advocated for change in practices increasing risk for HIV transmission, particularly blood transfusions. Dr. N’Galy died tragically in a car accident in 1989, and for his early work in understanding HIV and establishing Projet SIDA, Dr. N’Galy is honored annually along with Dr. Mann at the Conference on Retroviruses and Opportunistic Infections (CROI) with the N’Galy-Mann lectureship.

Dr. Kapita Bila Minlangu has been credited as perhaps “one of the first African [doctors] to recognize the disease”, identifying individuals who he thought clinically were infected, so that the American/Belgian researchers could perform tests to confirm the diagnosis based on absence of T-helper cells. These key observations led to the 1984 publication of data in The Lancet proving that HIV/AIDS was NOT a disease of gay men only, and that heterosexuals of all genders were susceptible to infection. Projet SIDA was discontinued abruptly in 1991 due to civil war in the country, but its impact on our understanding of HIV is still relevant today.

Dr. Kimberly Smith MD, MPH once referred to herself as “a trouble maker”. Those three words tell a story about Dr. Smith spending her life advocating for women and children living with HIV (traditionally underrepresented in clinical studies), being a voice for those who cannot speak for themselves. Dr. Smith’s invaluable contribution to the world of Infectious Diseases through research addressing gender and racial disparities among people living with HIV is evident by countless published papers on the topic. She has demonstrated her dedication to the community by her years of engagement in Chicago as a clinician. Dr. Smith was awarded the Black AIDS Institute “Heroes in the Struggle” Award in 2008, the Thurgood Marshall College Fund Award of Excellence in Medicine in 2011, and in that same year, the HIV Medical Association (HIVMA) Clinical Educator Award. Dr. Smith is now the head of Global Research and Medical Strategy at ViiV Healthcare, the only pharmaceutical company 100% dedicated to providing treatment options for persons living with HIV. As head of this group, Dr. Smith has committed to including more women in clinical trials in order to improve the treatment of women living with HIV.

Adaora Adimora, MD, MPH, FIDSA, FACP: When asked for suggestions about names of African American ID physicians who have impacted our field, Dr. Adaora Adimora’s name was invariably on everyone’s list. She is a Professor of Medicine & Epidemiology at University of North Carolina. Dr. Adimora has been caring for persons living with HIV since the disease was first starting to be recognized, and her passion for caring for this patient population has not wavered. Her research career has identified socioeconomic and racial disparities in HIV infection and management, as well as other sexually transmitted diseases. She has been a leader in both research and clinical care of women living with HIV, who are often underrepresented in clinical research and prevention initiatives. Her commitment to HIV and clinical/research impact is internationally known. She was the program director of the Fogarty AIDS International Training and Research program at University of North Carolina from its inception in 1998, providing opportunities in HIV/AIDS for researchers from China, Cameroon and Malawi. A member of the US Department of Health and Human Services Antiretroviral Treatment Guidelines Panel, she was an instrumental author in multiple iterations of the Sexually Transmitted Infections Guidelines. In 2014, she was appointed to President Obama’s Advisory Council on HIV/AIDS. In the same year, she was Chair of the HIV Medical Association (HIVMA). In 2009 Dr. Adimora was named to the Root’s its inaugural list of The Root 100, an annual list of “the most influential African Americans ages 25-45…honoring the innovators, the leaders, the public figures and game changers whose work from the past year is breaking down barriers and paving the way for the next generation”.

Editorial note: This is obviously not an exhaustive list, but an introduction: As inspiring as these stories are, there are many others out there that are just as exceptional, and still others whose stories have yet to be told. Follow us on twitter @unmc_id to learn about them!

Acknowledgements: Many thanks to Drs. Wendy Armstrong and Igho Ofotokun, who shared some insights into African Americans who have influenced our field of Infectious Diseases. Other sources are included in hyperlinks throughout the post.

Image Sources:

Dr. Hinton: http://kentakepage.com/william-a-hinton-the-first-african-american-to-author-a-medical-textbook/

Drs. N’Galy and Kapita: http://www.medizinisches-coaching.net/artikel/medical_coaching/projet-sida-kinshasa.html

Dr. Smith: http://www.telegraph.co.uk/education/stem-awards/healthcare/working-on-a-cure-for-hiv/

Dr. Adimora: https://www.med.unc.edu/infdis/about/faculty/adaora-adimora-md

Whitney Knuth, NP on “Why I Love ID”

Why I Love ID:

“I love the detective work we get to do on a daily basis and the unpredictability each day brings. The field is a constant challenge, with no two days being the same. I specifically love working with our oncology patients and their families and the interpersonal relationships we are privileged to establish. There is no better reward or satisfaction when we are able to find the missing piece of the puzzle and in return, help the patient get better and be able to again focus on their oncologic treatments.”

-Whitney Knuth, NP

Learn more about the UNMC ID Division here.

Reflections on a year of blogging

On February 14, 2017, led by our Division’s own Social Media Maven Dr. Kelly Cawcutt, we launched our UNMC Infectious Diseases Blog with a welcome post. 365 days, 134 posts, and almost 14,000 views later, we are still here! We have introduced our faculty, shared thoughts on why ID is special to us, recruited for and filled open positions (including 2 amazing fellowship matches), celebrated faculty/staff achievements and involvement in medical education, commented on conference proceedings and dived into important themes like Antimicrobial Stewardship and HIV Awareness.

Here are further thoughts from Dr. Cawcutt and Dr. Rupp on the blog and it’s impact.

When we first started the blog, it was because so many of our colleagues, current and future trainees, and patients are on social media now. Our medical journals, national organizations and world-renowned experts are posting, commenting and bringing academic medicine into a realm that is both approachable and searchable, by anyone and everyone. We wanted to create an online presence to share all of the amazing work being done in our Division, provide expertise, and networking opportunities in the conversations surrounding Infectious Diseases, Antimicrobial Stewardship, Infection Control and training the next generations of medical practitioners. Gone are the days of the proverbial “ivory towers” and inaccessible experts. Thank you all for contributing, following, subscribing and sharing. Without all of you, this blog would not still remain today. – Dr. Kelly Cawcutt, MD, MS

Happy Birthday ID Blog! – Dr. Mark Rupp MD (Professor of Medicine and UNMC ID Division Chief)

One year ago, with leadership supplied by Dr. Kelly Cawcutt, the UNMC ID Blog was launched. It has been a terrific success with a large number of regular followers. In the fall of 2017, we further expanded our social media presence by posting to Twitter.

Why is UNMC ID stepping into social media? Several reasons:

UNMC ID is full of talented people who are doing terrific things and we want folks to be aware of who we are and what we do. Social media is just one way to get the message out.
We hope that by expanding our reach and touching more people, we will increase awareness of UNMC ID, resulting in a greater number of persons who “catch the ID fever” and go into ID as a profession.
We hope the blog increases awareness of studies and projects that we are conducting, resulting in increased participation by patients who need cutting-edge treatments and collaboration with colleagues who can carry the work forward.
On a broader level, the UNMC blog increases knowledge of science in general, and microbiology and ID in particular.
In this era of “fake news”, “alternative facts”, and “talking-head experts”, we hope our readers learn to trust the UNMC ID Blog as a place to get reliable information on ID issues that are important in our own locale from our own local experts.

Thank you for your support over the last 12 months, and continued support as we forge ahead. We have a lot planned for the coming months, so stay tuned for new themes, journal article commentaries, and follow us on twitter @unmc_id.

Calamities of Kissing – Happy Valentine’s Day from UNMC ID

It’s almost Valentine’s day, and in honor of the one day of the year commercially dedicated to L’Amour, we thought would be fun to talk about some of the Infectious Diseases associated with “kissing”.

Let’s start with “The Kissing Disease” – Infectious Mononucleosis:

Infectious Mononucleosis or “Mono” is an illness most commonly caused by a herpesvirus called Epstein Barr Virus (EBV). Mono is characterized by a constellation of non-specific symptoms including sore throat, fatigue, muscle pains, fever, headache and lymphadenopathy (swollen lymph nodes). It is transmitted through exchange of body fluids like saliva, semen, blood, etc.

Mono is diagnosed clinically, and sometimes with additional serologic testing which can identify EBV as the specific cause of Mono. A recent case of Mono is likely if a person has antibodies to the viral capsid antigen (VCA) in the absence of EBV nuclear antigen (EBNA) antibodies. The monospot (heterophile antibody) test relies on a patient’s serum ability to agglutinate sheep blood red blood cells, but is not very sensitive and may miss cases of Mono.

There is no recommended treatment for Mono other than symptomatic therapy. Patients diagnosed with Mono are usually advised to avoid body fluid contact with others, avoid sharing personal items such as toothbrushes. Additionally, because of enlargement of the spleen, patients diagnosed with Mono are typically advised to avoid contact sports for 6-8 weeks after diagnosis, as they would be at higher risk for splenic rupture as a result of rough contact.

Did you know that Kissing Ulcers can be caused by several sexually transmitted diseases?

Kissing ulcers refer to symmetrical ulcerated lesions occurring in folds of skin. It is thought that they are formed as a result of the ulcer on one side of the skin fold auto-infecting the other side after prolonged contact. This can be seen on the lips, labia or penis. This is not specific to one particular infection, and can occur with infections due to syphilis (caused by Treponema pallidum), genital herpes (caused by herpes simplex virus), chancroid (caused by Haemophilus ducreyi), lymphogranuloma venereum (caused by Chlamydia trachomatis L1-3 serotypes).

This bug’s bite may be mistaken for a kiss, but the effects are not so sweet: Kissing bugs transmit trypanosomes causing Chagas Disease

Chagas Disease is caused by Trypanosoma cruzi, a protozoan parasite transmitted to humans by triatomine bugs, also known as reduvid bugs, vampire bugs or kissing bugs. The bugs are called kissing bugs because they typically bite near the mouth or eyes. The bites are painless and although the bugs take blood meals during bites, T. cruzi is actually transmitted when the insect defecates near the site of the bite.

Chagas Disease is endemic in South America, and is generally asymptomatic. If symptoms do occur in the acute stage of infection, they can consist of fever, lymphadenopathy, myocarditis (inflammation of heart muscles), and liver/spleen enlargement. Years after infection, the chronic stage of Chagas disease can include enlargement of the esophagus and colon, weight loss, and the most serious complication of infection is cardiomyopathy.

In the acute stage of Chagas Disease, blood smears can identify various forms of the parasite. In the chronic stage (or in cases of solid organ transplant or transfusion-related infections), serologic testing (antibodies) or molecular testing (PCR) is necessary to make the diagnosis. Treatment for Chagas Disease generally involves a consultation with the Centers for Disease Control and Prevention, as the antiparasitics (nifurtimox and benznidazole) are not readily available.

Of course, this list is not exhaustive. I’m sure there are other Infectious Disease syndromes that are associated with the word “kiss”. If you know others that were not mentioned, feel free to add a comment!

Happy Valentine’s Day!

Going Global – Supporting UNMC & Los Chavalitos in Nicaragua

Dr. Florescu will be joining an upcoming medical service trip to Los Chavalitos clinic in Managua, Nicaragua, sponsored by UNMC’s Student Alliance for Global Health.

Los Chavalitos Clinic is the outreach of APUSAN, a Spanish acronym meaning “Association of Pediatricians United for the Health of the Children.” APUSAN was founded by a small group of ambitious young Nicaraguan medical residents in the early 1990s. The doctors, who saw a multitude of children in advanced stages of diarrhea in the emergency departments of the hospital where they worked, knew that diarrhea can be prevented and should not be a major cause of childhood death, as it was in Nicaragua (and in many underdeveloped countries). They knew that education of the parents was the key to prevention and they formed APUSAN, a legal corporation in Nicaragua. However, they had no funding to put their dreams of preventive measures into action. Through unpredictable, but fortuitous circumstances, UNO social work professor on sabbatical in Nicaragua, learned of the aspirations of the APUSAN physicians and engaged her Rotary Club back in Omaha to support the mission of the Nicaraguan MDs. One of the Rotary members brought the cause to his Omaha church, Countryside Community Church. Subsequently, between the active support of the district Rotary Clubs and Countryside Community Church, a small structure in an impoverished Managua community was purchased and Los Chavalitos (“little kids”) Clinic opened in 1994. From the beginning, and to this day, the front of the building has both the Rotary Club emblem on it and the words “Countryside Community Church” emblazoned on it. It is truly an “Omaha” product in the heart of this Nicaraguan capitol city, Managua. There is no government funding and the clinic provides primarily free care, with a small proportion of patients paying on a sliding scale. Private donations sustain the clinic on an ongoing basis.

UNMC began sending individual student volunteers to work at Los Chavalitos in 1995 and the first SAGH-sponsored medical service trip took place in Nicaragua in 1996, with 13 participants. UNMC has offered the service trips to Nicaragua annually since 2000. The SAGH medical service trips, which also take place in Jamaica and a Native American Reservation, have grown in student participation since the first trip. Twenty-two years there will be 41 UNMC students in Nicaragua participating in one-week SAGH medical service trips. Of these 41 students, nine of them will be based in Managua, volunteering under the auspices of the Los Chavalitos medical director. Every day the group will go into the neighborhoods served by Los Chavalitos and establish “puestos” (posts) in one of these communities – perhaps the home of a community leader, a school, or a church, and provide immunization services to the community members, and will also offer vitamin A, anti-parasite pills, and fluoride treatments. The presence of the UNMC group is well-publicized in advance, so that the community members can plan to take advantage of the free services offered, which have been approved by the Nicaraguan Ministry of Health (and it is the government who provides the vaccines that the group uses). Four of the student members are physical therapy students, who will spend part of their time serving in other sites with a geriatric population and severely handicapped children.

The UNMC students (from medicine, nursing, pharmacy and allied health) volunteering through Los Chavalitos typically serve up to 1000 patients during their service week. All of these activities take place in community locations (not on the clinic premises), which eliminates the need for client transportation (requiring both time and money) to receive valuable services. The student participants see/experience first-hand the living conditions of a poor population and have ample opportunity to directly interact with the local personnel. It is a valuable lesson in cross-cultural communication and demonstrates the value of serving the under-served.

To donate to help fund the upcoming SAGH Nicaragua medical service trip (to help defray trip expenses): cash or check (payable to SAGH/UNMC and put SAGH Nicaragua on the bottom left corner of the check. Please send to the attention of Sara Pirtle at campus zip 5700, or mail to the address below.

To donate to directly assist Los Chavalitos with their community outreach and clinical services, cash or check payable to SAGH/UNMC and note “Los Chavalitos” on the bottom left corner of the check. Please send to the attention of Sara Pirtle at campus zip 5700, or mail to the address below.

985700 Nebraska Medical Center

Omaha, NE 68198-5700

Content courtesy of Sara E. Pirtle, MBA

IHME Program Manager

SAGH Advisor

402 559 2924

www.unmc.edu/ihme

#ResidentAwarenessWeek – Thank You to ALL residents around the world

This week marks resident awareness week in Canada.

Why are we talking about a week celebrated by our colleagues to the North?

First, because as I first came across this trending on Twitter (#residentawarenessweek), I was excited and wanted to find a similar week to celebrate our US residents. I do not recall such a week in the past, but I was sure I was wrong and just missed it in my sleep-deprived years of residency. Sadly, I have yet to find such a week on a US calendar. Perhaps I am not looking in the right places. Perhaps I am using the wrong search terms. Or perhaps, we need to follow the lead of our Canadian friends and start a week celebrating all of the hard work our residents do every year.

So, today, in honor of the Canadian Resident Awareness Week, I want to extend a note of deep gratitude from the UNMC ID Division, and as a faculty physician, to our resident colleagues who truly help keep the wheels of medicine turning.

Residents are critical for providing excellent care to our patients, but how often do we truly say ‘thank you’? How often do we express gratitude for the hard work of any of our colleagues? Gratitude has been associated with decreased stress in healthcare practitioners and associated with overall wellbeing. A simple, but heart-felt, thank you may carry a larger impact than any of us realize. So, with that…

To the resident who is exhausted and overwhelmed, thank you for putting the needs of you patients and team first.

To the resident who covered service for a sick colleague, thank you for keeping both our patients and colleagues healthier by your service today.

To the resident who feels like they are not good enough, thank you for showing up everyday and continuing to forge ahead. The road is not easy, it is ok to ask for help. Success is not in knowing everything, it is about developing the competence to know when you need help and to get it.

To the resident who is teaching all of us on rounds, thank you for your initiative and know you are bringing value to the entire team.

To the resident who had to break bad news, thank you for for your support and care for that patient and family.

To the resident toiling on research on nights and weekends, thank you for working to improve medical practices.

To the resident dreaming of leadership roles, keep dreaming! You are the future leaders – thank you for your future innovations.

To the resident who wants to quit, know you are not alone. Thank you for carrying the emotional toll of medicine, but now it is time to ask for help carrying that burden. Please talk to someone, seek mentorship and help. Thank you for your bravery in doing so.

To all of the residents working around the clock in hospitals, emergency rooms and clinics, thank you for being part of this healthcare team. Thank you for your dedication, your blood, sweat and tears. We need you, we appreciate you even if we are not always expressing this as often as we should, and we are grateful for you.

Thank you!

And thank you Canada for your initiative this week.

Plazomicin: Will it be the future of MDRO treatment?

Today at our UNMC Infectious Disease Research Conference, Dr. Kelly Cawcutt’s presentation included details on Plazomicin, a new antibiotic recently granted FDA Breakthrough Therapy Designation, aimed at treating multi-drug resistant organisms (MDROs).

Antibiotic resistance continues to be a clinical problem. The CDC Antibiotic Threat Report has estimated 2 million infections with antibiotic resistant organisms and 23,000 deaths, with antibiotic resistant organisms estimated to cost up to 20 billion healthcare dollars.

Hospital Acquired Pneumonia (HAP) is one of the most common diagnoses in the intensive care unit (ICU), and many are ventilator associated pneumonia (VAP). Given the significant antibiotic exposure experienced in ICUs, it is no surprise that the number of MDROs causing HAP/VAP has increased.

Despite known concern for increased incidence/prevalence of MDROs, there are relatively few new or re-purposed antibiotics in development. Further complicating the situation, often when new drugs are developed, they are usually restricted, to attempt to conserve them for totally drug resistant organisms in severely ill patients. Nevertheless, new drugs still need to be developed.

Plazomicin is a next generation aminoglycoside/neoglycoside targeting MDROs with similar spectrum of activity to gentamicin and amikacin. It is bactericidal, with concentration-dependent killing and is administered intravenously once daily. Aminoglycosides have been known to cause some significant adverse drug effects including nephrotoxicity and ototoxicity. Plazomicin is unique in that compared with the other aminoglycosides, these adverse effects are reduced, and there are low risks of drug-drug interactions.

Dr. Cawcutt shared brief data about two phase 3 clinical trials fast tracked by the FDA looking at effectiveness of plazomicin to currently used antimicrobials.

The EPIC trial: (Evaluating plazomicin in cUTI). This trial evaluated the use of plazomicin vs. meropenem for the treatment of complicated enterobacteriaciae urinary tract infections and acute pyelonephritis. This study showed that plazomicin was superior to meropenem for microbial eradication on a test of cure (81.7%-70%), and that there were fewer relapses (1.8% vs 7.9%).

The CARE trial: (Combating Antibiotic Resistant Enterobacteriaceae). This was an open label trial of plazomicin vs colistin (combined with either meropenem or tigecycline) looking at mortality and safety with use of plazomicin. They showed a reduction of mortality or significant disease (as a composite endpoint) (23.5% with plazomicin vs 50% with colistin). Additionally, the all-cause mortality was reduced with plazomicin (11.8% vs 40%).

Finally, Dr. Cawcutt discussed future research opportunities surrounding the utilization of plazomicin for critically ill patients to assess further potential clinical uses among this high risk, high morbidity and mortality patient population.

Dr. El-Ramahi on “Why I Love ID”

Why I Love ID:

“I love ID because it is an exciting field and every day brings interesting cases and unique challenges. It is a field where I have a chance to form strong doctor-patient relationship since we spend a lot of time talking to the patient and as a group, we do ask a lot of questions! It is also gratifying to see patients’ health improve after you cure their infection(s) which happens in the majority of the cases we treat. “

-Dr. El-Ramahi

See more about the UNMC ID Division here.