Division of Infectious Diseases

Infectious Diseases Clinical faculty participate in UNMC College of Medicine curriculum re-design: Training the Physicians of Tomorrow

Undergraduate medical education has long been a delicate balance between providing knowledge of basic sciences and providing experience on clinical rotations. Traditional education curricula have approached this as an even split over 4 years of medical education. The first two years of basic science education were typically classroom lectures of topics over several month semesters. However, there have been new trends in medical education to explore alternate pathways, given the realization that as adult learners, medical students require more interactive learning experiences. The UNMC College of Medicine is one place where this innovative curriculum design is being implemented.  What once were semester-long traditional Microbiology and Immunology courses have now been transformed into an integrated focused block called Defenses and Invaders (course directors: Sara Bares MD, Paul Fey PhD, Geoff Thiele PhD, and Andrea Zimmer MD).  The ingenious course name conjures up images of epic battles between brave immune system soldiers and their formidable adversaries constantly trying to infiltrate our bodies. Defenses and Invaders inspires medical students to learn more about these sneaky organisms, why they do what they do, and how our own bodies protect us from harm, sometimes even without our knowledge!

The new course design involved some traditional lectures, but had the addition of multiple small group sessions. In these sessions, 12 or fewer first year medical students had the opportunity to have intimate time with one or two faculty members, most of whom were clinical Infectious Disease faculty, in addition to Microbiology/Pathology faculty. They reviewed cases together as a group, with students learning and teaching each other through specific clinical scenarios focusing on the microbiology that clinicians use for decision making, with added pearls from faculty facilitators. This approach created an earlier opportunity for interaction between medical students and clinical faculty, and provided a way to expose students to disease processes caused by microbial pathogens to make them more relatable, interesting and memorable.

The ID faculty enjoyed their interactions with the students and the cases sparked some interesting questions and discussions within the groups. While it will be years before the effect of the curriculum can be tested by board scores, the redesign has already borne fruit of interest in Infectious Diseases, with many students feeling emboldened to directly engage the experts, arrange meetings and volunteer to shadow in the ID clinics. Though not the intent of the course, this is proof that a grass-roots effort by Infectious Diseases groups can help to increase interest in and awareness of our specialty. Infectious Diseases faculty will also be providing lectures within other block topics; and core exposure to Infectious Diseases topics will be revisited throughout the next year and a half, with plans for an Infectious Diseases synthesis block before the students’ clinical years, to review concepts for boards and wards.

 Content courtesy Dr. Andrea Zimmer, MD

Dr. Mark Rupp (Professor of Medicine and Division Chief, Infectious Diseases) teaching his small group about respiratory infections

Dr. James Wisecarver (Professor of Pathology/Microbiology and Medical Director, Clinical Laboratory) and his small group

Dr. Diana Florescu (Associate Professor of Medicine and Transplant ID physician) engaged in discussion with her group

At Nebraska Medicine, we are proud to Be Antibiotics Aware!

At Nebraska Medicine, we have been supporting Antimicrobial Stewardship activities for over a decade, and we are proud to Be Antibiotics Aware. The CDC has recognized our efforts by including the Nebraska Medicine Stewardship Program as an example for other institutions to model. We have recently partnered with the state of Nebraska to promote these activities at the state level through the Nebraska Antimicrobial Stewardship Assessment and Promotion Program (ASAP).

Check out our Nebraska Medicine Antimicrobial Stewardship website for more information, and meet our team below.

     Nebraska Medicine Stewardship Team
Front Row L-R: Jasmine Marcelin MD (Associate Medical Director), Philip Chung, PharmD, Scott Bergman PharmD (Pharmacy Coordinator)
Back Row L-R: Salman Ashraf MBBS, Mark Rupp MD, Trevor Van Schooneveld MD (Medical Director)

Celebrating Nurse Practitioner’s Week – Spotlight on Solid Organ Transplant ID NP’s!

As part of our Nurse Practitioner’s week feature, our third spotlight features Heather Chambers, Lisa Hill, and Jennifer Hrbek, who serve our Solid Organ Transplant ID patients.

 

Heather Chambers

A graduate of Pensacola Christian College (BSN) and the University of Nebraska Medical Center for her Masters and Doctor of Nursing Practice, Heather joined the nursing field because of her desire to help others. While Heather was unit nurse, she knew that she wanted to do more with her knowledge and expertise. The drive for knowledge and continual growth attracted her to pursue Nurse Practitioner school.

As a Nurse Practitioner with the Solid Organ Transplant ID team, Heather loves helping our patients. She finds it very rewarding to help patients improve and guide families along the care process. Heather enjoys the comradery that comes from collaborating with other services and the knowledge that she gains with every patient she treats to help her become a better clinician.

 

Lisa Hill

A graduate from the University of Nebraska Medical Center (BSN) and Creighton University (MSN-FNP), Lisa was drawn to healthcare from the guidance from a friend. As a nurse, Lisa found the care she provided to her patients to be extremely rewarding. However, she desired more and pursued Nurse Practitioner school.

As a Nurse Practitioner with the Solid Organ Transplant ID team, Lisa finds gratification in the care she provides as part of the team for our complex patients. Lisa develops a strong rapport with the patients and families, making the best interest of our patients her priority.

 

Jennifer Hrbek (photo unavailable)

A graduate from Auburn University, Clarkson College (BSN) and Creighton University (MSN-FNP), Jennifer was inspired to be a Nurse Practitioner by the birth of her brother. Her mother’s provider, an OB/GYN Nurse Practitioner, delivered her brother that left a profound impact on Jennifer’s journey. As a nurse, Jennifer knew she wanted to increase her skills and expertise and pursued Nurse Practitioner school.

As a Nurse Practitioner with the Solid Organ Transplant ID team, Jennifer finds rewarding the comradery from working with her colleagues. She enjoys the complex patient population that she serves and the continual learning each and every day.

Content courtesy of Jonathan Nguyen.

Be Antibiotics Aware…in the Outpatient Clinics

Nebraska Medicine and Antimicrobial Stewardship in the Outpatient Setting

Antimicrobial stewardship is not only about inpatient prescribing. Recent studies measuring antibiotic use in ambulatory settings have estimated that antibiotics are prescribed inappropriately 30-77% of visits(1).  Despite being one of the leaders in implementing antimicrobial stewardship in hospitals, Nebraska ranks 44th (out of 50 states and District of Columbia) in outpatient antibiotic prescriptions dispensed. The practice of inappropriate antibiotic prescribing is one of the factors that has led to world-wide spread of antibiotic resistant bacteria. Due to the ongoing issue of antibiotic resistance, in 2014 the president called for a 50% reduction in appropriate outpatient antibiotic use in his National Action Plan for Combating Antibiotic-Resistant Bacteria. In 2016, the Centers for Disease Control and Prevention (CDC) outlined the Core Elements of Outpatient Antibiotic Stewardship(2).  

The CDC suggested that in order for an outpatient antimicrobial stewardship program to be successful, it needs leadership commitment within healthcare institutions, definitive action by implementation of policies to improve prescribing practices, accurate tracking of prescribing and individual reporting to prescribers, education of healthcare professionals and patients/families, and finally access to experts in antimicrobial stewardship. Put simply, the goal of these elements, when implemented, are to improve patient care by treating infections with antibiotics when needed, avoiding patient adverse effects (like drug toxicities or C. difficile infections) from unnecessary antibiotic treatment, and avoiding the development of antimicrobial resistance in the community.

Here at Nebraska Medicine we have several ongoing projects geared towards improving our antibiotic use in the outpatient setting. We have been working with hospital and ambulatory clinic leadership to improve vaccination protocols, particularly with an inpatient nurse-driven influenza protocol that identifies patients who need the flu vaccine and administers prior to discharging from the hospital. Alerts have also been developed in our electronic health record which prompt clinicians when vaccines are indicated. Additionally, we partnered with the Nebraska Health Network to develop evidence-based guidance documents for the treatment of sinusitis and C. difficile infections in the outpatient setting. Additional guidance documents focused on the inpatient setting are also applicable to outpatient encounters, such as Acute Exacerbations of Chronic Obstructive Pulmonary Disease (AECOPD), Urinary Tract Infections (UTI), Skin/Soft Tissue Infections (SSTIs), and Community Acquired Pneumonia (CAP).

Finally, we have partnered with the  Nebraska Antimicrobial Stewardship Assessment and Promotion Program (ASAP) to create a large-scale antimicrobial stewardship education program for ambulatory clinics.  Through this program, we hope to implement several educational strategies for providers and patients, evaluate and measure the effectiveness of these strategies, and improve on them to achieve our goal of 50% reduction of inappropriate outpatient antibiotic use by 2020.

References:

  1.  Fleming-Dutra KE et al, JAMA. 2016;315(17):1864., Antimicrob Agents Chemother. 2015;59(7):3848. Epub 2015 Apr 13.
  2.  Sanchez GV, Fleming-Dutra KE, Roberts RM, Hicks LA. Core Elements of Outpatient Antibiotic Stewardship. MMWR Recomm Rep 2016;65(No. RR-6):1–12

Be Antibiotics Aware Logos Courtesy Centers for Disease Control and Prevention

 

Dr. Dr. Jasmine Riviere Marcelin is the Associate Medical Director, Nebraska Medicine Antimicrobial Stewardship Program

Celebrating Nurse Practitioner’s Week – Spotlight on Specialty Care Clinic NP’s!

As part of our Nurse Practitioner’s week feature, our second spotlight features Ann Fitzgerald, Nikki Regan, and Christine Tran, who serve our Specialty Care Clinic patients.

 

Nikki Regan (on left)

A graduate from the University of Nebraska Medical Center College of Nursing – Lincoln for both her Bachelor and Masters of Science in Nursing, Nikki’s journey originally started towards biochemistry until she realized a lab environment did not provide her the opportunity serve others. She quickly found nursing, which provided the perfect combination of her love for science and caring for others. For many years, during nursing school and after, Nikki volunteered at Camp Kindle, which provides camps free of cost for kids and teens with HIV. The time spent at Camp Kindle would inspire Nikki to go to Nurse Practitioner school to increase her autonomy and skill set.

As a Nurse Practitioner at the Specialty Care Clinic, Nikki enjoys the collaborative environment with the faculty that constantly provides teaching moments. Nikki embraces the challenges that come with her role but finds her ability to serve our patients to be rewarding and gratifying.

 

Ann Fitzgerald (middle)

A graduate from the University of Nebraska Medical Center (BSN) and the University of California, Los Angeles (MSN-FNP), Ann was drawn to healthcare from her desire to help people and passion for science. Ann’s mother was also a nurse, which solidified her decision to join the field. Ann contemplated between Medical School and Nurse Practitioner School and chose Nurse Practitioner School because of her love of nursing.

As a Nurse Practitioner at our Specialty Care Clinic, Ann enjoys the collaborative environment she participates in every day serving our patients. She finds it rewarding to use her skills and talents with the Specialty Care team to improve the health of the patients in our community.

 

Christine Tran (on right)

A graduate from Marquette University (BSN), Creighton University (MSN) and UNMC(DNP), Christine’s journey originally started toward business but was redirected to nursing in part from her love of science, working with others, and her two aunts who were nurses that she admired. Immediately after graduation, Christine volunteered as an RN with the Jesuit Volunteer Corps (JVC), where she served the homeless in Cleveland, OH. During her time with JVC, Christine valued the independence and patient continuity the role provided that it was apparent she wanted to be a Nurse Practitioner.

As a Nurse Practitioner at the Specialty Care Clinic, Christine finds her role rewarding through the holistic care, physical, emotional, and social, provided for the patients of the Specialty Care Clinic. Christine enjoys the camaraderie and collaboration that the Specialty Care Clinic provides, but also the independence that her role enables her to serve patients. Christine acknowledges that she is very fortunate that her patients let her into their lives in such as personal way.

 

Thank you Nikki, Ann and Christine for your excellent care of patients!

 

Content courtesy of Jonathan Nguyen. 

Be Antibiotics Aware…in Small and Critical Access Hospitals

In 2014, the CDC published The Core Elements of Hospital Antibiotic Stewardship Programs to assist acute care facilities implement antimicrobial stewardship program (ASP).  While these efforts were relatively successful in hospitals with more than 50 beds, they were less successful in hospitals with 25 beds or less.  In response to this disparity based on hospital size, the CDC published The Implementation of Antibiotic Stewardship Core Elements at Small and Critical Access Hospitals to assist these smaller acute care facilities implement stewardship activities.

In the spring of 2017, using the antimicrobial stewardship content expertise from UNMC/Nebraska Medicine, Nebraska ASAP also partnered with 1 small and 4 critical access hospitals to guide and assist the implementation of antimicrobial stewardship programs in these facilities. Learn more about these efforts here.

 

Be Antibiotics Aware and Stewardship logos courtesy Centers for Disease Control and Prevention

Content provided by Philip Chung PharmD, Pharmacy Coordinator for Nebraska ASAP

Celebrating Nurse Practitioner’s Week – Spotlight on Oncology Infectious Diseases NP’s!

Nurse Practitioner’s Week runs from November 12 to November 18. During this week, the ID wants to recognize and extend our appreciation to our Nurse Practitioner’s that provide extraordinary care to our patients at Nebraska Medicine. Our first spotlight features Whitney Knuth and Jolene Tijerina, who serve our Oncology ID patients.

 

Whitney Knuth (on right)

A graduate of the University of Iowa (BSN) and Clarkson College (MSN-FNP), Whitney was drawn to the healthcare field from her desire to help others. Nursing provided Whitney the opportunity to make a difference in her patients’ lives in a challenging and rewarding field. As Whitney’s nursing career progressed, she had a drive for greater clinical knowledge and professional autonomy. With her foundation as a nurse, Whitney knew pursuing her dream to become a nurse practitioner would allow her to continue to advocate for her patients and provide advanced holistic care.

As a Nurse Practitioner with the Oncology ID team, Whitney enjoys the ability to work with the patients and their families. With a background as a nurse in Oncology & Hematology, being able to work with this patient population with the Infectious Diseases team has been extremely rewarding. Many of the patients served by Oncology ID team are immunocompromised, that when the team is able to prevent, diagnose, and treat an infectious complication, is extremely gratifying.

 

Jolene Tijerina (on left)

A graduate of Creighton University (BSN) and the University of Nebraska Medical Center (MSN-FNP), Jolene was drawn to the healthcare field from family experiences with Oncology. From these experiences, Jolene started in healthcare apart of the research team and quickly built relationships with the patients. Because of these meaningful relationships, Jolene pursued her nursing degree. As a nurse, Jolene loved the role that she served with caring of patients. However, she was drawn to increase her responsibility in the care process related to treatment plans.

As a Nurse Practitioner with the Oncology ID team, Jolene loves that she learns something new every day. The patient population cared by the Oncology ID team is complex and requires Jolene to dive deeper, at times playing detective, with their patient’s background. Jolene finds her role as part of the team rewarding from rapport she is able to build with their patients through the care she provides every day.

 

Thank you Whitney and Jolene for all you do everyday to provide excellent care to our patients!

 

Content courtesy of Jonathan Nguyen.

Be Antibiotics Aware…in Long-Term Care Facilities

Nebraska ASAP efforts promote antimicrobial stewardship activities in long-term care facilities across the state

Up to 70% of residents in long-term care facilities receive at least one course of systemic antibiotic annually, with 40-75% of prescribed antibiotics being considered unnecessary or inappropriate.  As part of the condition for participation, the Centers for Medicare and Medicaid Services (CMS) will require all long-term care facilities to have an antibiotic stewardship program (ASP) by November 28, 2017.  However, most nursing home lack both the experience and the expertise required to develop a comprehensive ASP.

The Nebraska Antimicrobial Stewardship Assessment and Promotion Program (ASAP), which represents a partnership between University of Nebraska Medical Center/ Nebraska Medicine and Nebraska Department of Health and Human Services, is focused on helping LTCF across Nebraska in development of their own ASP. The Nebraska ASAP has already partnered with 5 LTCFs to provide assessments, implementation strategies and shared resources to start and sustain their own ASP. Learn more about these efforts here.

The Nebraska ASAP team
Front row L-R: Trevor Van Schooneveld MD (co-medical director), Regina Nailon (Clinical Nurse Research Coordinator), Sue Beach (administrative senior assistant), Kate Tyner (Nurse Coordinator), Scott Bergman PharmD (co-Pharmacy coordinator)
Back row L-R: Terri Micheels (Infection Control manager), Mark Rupp MD (Associate medical director), Jonathan Nguyen (Administrator), Shelly Schwedhelm (Executive Director of Emergency Preparedness), Salman Ashraf MBBS (ASAP medical director), Philip Chung PharmD (Pharmacy Coordinator)

Content provided by Dr. Salman Ashraf, Medical Director, Nebraska ASAP

Be Antibiotics Aware… in Hospitals

Since 2004, (Antimicrobial Stewardship Program (ASP) at Nebraska Medicine) has been helping patients to receive the best antimicrobials for their infection, and assisting with decisions by prescribers on when to avoid giving antibiotics. The philosophy of the program is not to restrict access to life saving medications, but to focus on patient safety by guiding clinicians in the optimal use of these potentially dangerous drugs. Antibiotics are associated with more adverse events than any pharmaceutical class besides cancer chemotherapy and account for 19% of all emergency department visits for adverse drug reactions.  As they became safer and more convenient to use over the last several decades, prescriptions for antibiotics went up. The spectrum also improved against Gram-negative organisms that live in our gastrointestinal tract which led to a rise in epidemic Clostridium difficile infection. Resistance to these miracle drugs also increased over the same time. Therefore, the situation we find ourselves in with antibiotics today is a product of their own success. In a recent study, it was found that 20% of patients receiving antibiotics during hospitalization developed an adverse event related to their therapy.1 Furthermore, it was discovered that 20% of these patients were receiving antibiotics that weren’t clinically necessary for their condition.

The ASP at Nebraska Medicine has become well-known for developing guidance documents that help clinicians choose antibiotics and diagnostic testing according to evidence and local epidemiology. This year we have developed guidance for treating diabetic foot infections and acute exacerbations of chronic bronchitis while revising our standards for managing bloodstream infections and Clostridium difficile. Although patients with diabetes do have frequent exposure to the healthcare system that could put them at risk for multi-drug resistant infections, the reality is soft tissue infections in this population are only rarely caused by pathogens such as methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa at our institution. We are taught in medical and pharmacy school that diabetes causes immunosuppression and these resistant organisms are more prevalent in infections of the foot than other skin sites. While this is true, the incidence is under 10% overall. It is important to put this in perspective since the fear of resistant infection has led to virtually all patients with diabetes receiving vancomycin and piperacillin-tazobactam upon admission to the hospital. This is despite the cause of resistance being overuse of antibiotics. Couple this with the discovery of synergistic toxicity between these agents that damages kidneys at an alarming rate, and you have a significant patient safety concern.2 Bringing these facts to the attention of clinicians is why having an antimicrobial stewardship program is so important.  That is one of the reasons the state of Nebraska has followed the lead of the Centers for Disease Control and Prevention and named this Antibiotic Awareness week.

References

  1. Tamma PD, Avdic E, Li DX, Dzintars K, Cosgrove SE. Association of Adverse Events with Antibiotics in Hospitalized Patients. JAMA Internal Med. 2017; 177(9):1308-1315 https://www.ncbi.nlm.nih.gov/pubmed/28604925
  2. Luther MK, Timbrook TT, Caffrey AR, Dosa D, Lodise TP, LaPlante KL. Vancomycin plus piperacillin-tazobactam and acute kidney injury in adults: A systematic review and meta-analysis. Crit Care Med. 2017 (Oct 28): Ahead of Print https://www.ncbi.nlm.nih.gov/pubmed/29088001.

Content provided by Scott Bergman, PharmD, Pharmacy Coordinator, Nebraska Medicine Antimicrobial Stewardship Program

Be Antibiotics Aware…to Preserve our Future

Antimicrobial Stewardship: Preserving the Future

Antimicrobials were an amazing discovery and have been appropriately credited, along with vaccination and sanitation, with the significant improvements in human life expectancy over the last century.  With their amazing impact has come the opportunity for new therapies including organ transplant, complex surgery, and care for extremely preterm infants.  The success of these medical interventions is founded upon the ability to treat the inevitable infections which develop with highly effective and safe antimicrobials.  Unfortunately, we now live in an era where the utility of these amazing agents is threatened by the emergence and spread of antimicrobial resistance.

Antimicrobial resistance is a growing worldwide problem.  The CDC highlighted this in their Antibiotic Resistance Threat Report, which estimated at least 2 million people become ill and 23,000 die from antibiotic-resistant infections each year.  The key driver of antimicrobial resistance is antimicrobial use which eliminates susceptible pathogens leaving only those which are resistant to grow and expand.  Antimicrobial use in both humans and animals can promote resistance and resistant pathogen infections are associated with worsened clinical and economic outcomes.  One group estimated that if antimicrobial resistance is left unchecked, by the 2050 it would kill more persons yearly than cancer.

Compounding the issue of resistance is the fact that the antimicrobials used in hospitals, ambulatory clinics, and long-term care facilities (LTCF) are often inappropriate or unnecessary.   Inappropriate antimicrobial use results in worsened patient outcomes, toxicity including C. difficile infection, and increased cost.  To mitigate these issues the CDC has recommend facilities of all types institute antimicrobial stewardship programs.  Antimicrobial stewardship programs employ strategies or processes designed to help clinicians decide if an antimicrobial is necessary and if so what agent, dose, and duration is optimal.  The CDC states, “Antimicrobial stewardship interventions have been proven to improve individual patient outcomes, reduce the overall burden of antibiotic resistance, and save healthcare dollars.”  Implementation of antimicrobial stewardship programs offer the advantages of making patient care safer, more effective, more efficient, and often less expensive.

The CDC and the State of Nebraska have appointed this week as 2017 US Antibiotic Awareness Week, and so over the next five days, we will be highlighting the ongoing antimicrobial stewardship activities at the University of Nebraska Medical Center (UNMC) and Nebraska Medicine (NM).  We will describe the successes of the NM Program, which has been promoting improvements in antimicrobial use for over a decade.  We will also explain the role the Nebraska Antimicrobial Stewardship Assessment and Promotion Program (ASAP), a partnership between NM, UNMC and the State of Nebraska, has had in promoting stewardship in smaller hospitals, LTCF, and ambulatory settings.  Finally, we will be highlighting some of the strategies and activities that are effective in improving antimicrobial use and with each post, introducing you to some key members of our stewardship teams.

Content Provided by Dr. Trevor Van Schooneveld, Medical Director, Nebraska Medicine Antimicrobial Stewardship Program