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Division of Infectious Diseases

Seeking a Full-time Physician to Join UNMC’s HIV Program

We are looking for a board-eligible/board-certified ID physician to join our HIV team.

As the largest provider of care to patients living with HIV in the Omaha area, the HIV clinic provides quality health care in a truly integrated system wherein medical care, case management and advocacy are provided via a multidisciplinary approach. Alongside the clinical care, the UNMC HIV program actively participates in both clinical and translation research and has a team of research nurses and support staff and a culture that is fully supportive of research. Finally, the HIV team is involved in education both in the community and in UNMC’s colleges of medicine, nursing, and pharmacy.

We are looking for an Infectious Diseases physician with a passion for HIV care to join our group and look forward to hearing from anyone who is interested in the position.

If you are interested, please submit your application here.


 

Do the Right Thing and Get a Flu Vaccine

Content courtesy of Dr. Mark Rupp.

As the days shorten and there is a bit of fall nip in the morning air, it is a reminder that the respiratory virus season will be here soon.

Although the flu vaccine is not perfect (about 50% protection), it remains our best means to prevent influenza.  We are not able to predict with accuracy whether this will be a mild or severe flu season.  However, it was a worse than average flu season in Australia (remember their winter season is our summer) and this may mean we are in store for a severe flu season.  In any case, it is wise to prepare for the worst.

This year’s quadrivalent vaccine will again contain two “A” strains and two “B” strains and will hopefully match up well with the circulating strains in the community.  The flu vaccine is highly recommended by the CDC for all persons aged greater than six months of age.   Flu vaccination is particularly important for healthcare providers because we are in close contact with vulnerable patients who can experience serious complications or death if they contract the flu.  As healthcare providers, we have a moral and ethical responsibility to provide safe care to our patients.  At Nebraska Medicine, we take this responsibility seriously.  Last year, 92% of our providers received the flu vaccine without a mandate.  We are doing the right thing for the right reason- to protect ourselves, our patients and our families.

However, our high rate of influenza vaccination acceptance does not happen by accident.  Months in advance, our colleagues in the pharmacy make sure we order an adequate supply of vaccine.  Each unit and clinic has a “Flu Vaccine Champion” who undergoes special training and then promotes and administers flu vaccine to colleagues. We routinely provide, free of charge, quadrivalent vaccine for most persons.  A high dose vaccine is provided for our co-workers over the age of 65 and a recombinant “egg-free” vaccine is available for those with serious allergy to eggs. The Employee Health Department holds over a dozen open clinics that are conveniently located and scheduled to allow our workers, students, and volunteers to receive the vaccine.

Vaccine status is conveniently tracked and reported via an online database that is constructed and maintained by our experts in Information Technology.  Finally, the whole program is supported by administration at the highest levels.  It truly takes a village to pull this off every year-but it pays off with >90% voluntary vaccine acceptance.

In addition, there are other features to our campaign to prevent the spread of respiratory viruses.  We post signs throughout the hospital to alert visitors to not visit if they are sick.  Similarly, we try to avoid “presenteeism” and we urge our healthcare providers to stay home if they are ill.  We aggressively promote hand hygiene, environmental cleanliness, and respiratory etiquette (e.g. “cover your cough”).

So, do the right thing and get your flu vaccine.

See more about influenza and vaccinations at UNMC here.

Vitamin C and Sepsis – Miracle, Madness or Still Murky?

Experimental and emerging data suggest intravenous ascorbic acid may be a potential therapy in patients presenting with septic shock, but more evidence is needed to confirm or refute the clinical utility of ascorbic acid (vitamin C). Proposed mechanisms of this essential water-soluble vitamin include anti-inflammatory effects, reduction in oxidative damage, and preservation of endothelial function and microcirculatory flow.1 Additionally, ascorbic acid is a cofactor in the enzymes required for synthesizing endogenous norepinephrine and vasopressin.2 Intravenous administration may be required to achieve normal serum levels in these patients due to saturable intestinal absorption.3 Findings indicate serum levels of ascorbic acid are lower in critically ill patients due to the increased metabolic turnover in this acute inflammatory response and are associated with severity of illness.4,5 Low plasma levels of ascorbic acid have been shown to be inversely correlated with multiple organ failure incidence and directly correlated with survival.6

A randomized controlled trial of intravenous ascorbic acid in patients with severe sepsis in a medical ICU in the United States showed no study-related adverse events (i.e., tachycardia, hypotension, hypernatremia, nausea/vomiting), a faster reduction in Sequential Organ Failure Assessment (SOFA) scores, and improved inflammatory markers.7 A total of 24 patients were assigned to placebo, low dose ascorbic acid (50 mg/kg/day), or high dose ascorbic acid (200 mg/kg/day) for 96 hours.7

Further, Zabet et al. conducted a randomized double blind trial in Iran and evaluated the effect of ascorbic acid 25 mg/kg IV q6h on 28 critically ill surgical patients with septic shock requiring vasopressor support.8 Mean norepinephrine dose (7.44 ± 3.65 vs. 13.79 ± 6.48 mcg/min, p=0.004) and duration of use (49.64 ± 25.67 vs. 71.57 ± 1.60 h, p=0.007) were significantly lower in patients treated with ascorbic acid than placebo. There were no differences in length of ICU stay; however, patients in the treatment group had a significantly lower 28-day mortality (14.28% vs. 64.28%, p=0.009) and no adverse effects were found during the study.8

The most recently published study was a retrospective review comparing the clinical course of 47 septic patients with a procalcitonin > 2 ng/ml treated with thiamine 200 mg IV q12hr, ascorbic acid 1.5 g IV q6hr, and hydrocortisone 50 mg IV q6hr.9 Hospital mortality was significantly reduced in the treatment group (8.5% vs. 40.4%, 95% CI 0.04-0.48). A reduction in SOFA scores, requirement for RRT, and duration of vasopressor use were also shown. The authors believe ascorbic acid and hydrocortisone act synergistically by restoring glucocorticoid function, improving transport of ascorbic acid into the cell, and preserving endothelial integrity.  A concern with high doses of ascorbic acid is the metabolic conversion to oxalate. Although oxalate is excreted through the kidneys, patients with renal impairment may have increased serum levels resulting in crystallization in the kidney. However, within the small sample size, Marik et al. reported improvement in renal function.9  There were many scientific limitations in Marik et al study which are highlighted within a letter to the editor of CHEST written by Drs. Kalil, Johnson and Cawcutt. Click here to read the letter.

The optimal dose and time of administration are still to be determined. The safety concerns of oxalate accumulation and pro-oxidant effects should also be considered with high-dose ascorbic acid. Although recent and very limited evidence suggests potential benefits with intravenous ascorbic acid, further studies are needed to confirm these preliminary findings. A large double-blind placebo-controlled randomized clinical trial is necessary to confirm or refute the efficacy and safety of ascorbic acid in patients with septic shock.

 

References

  1. Oudemans-van Straaten HM, Spoelstra-de Man AM, de Waard MC. Vitamin C revisited. Crit Care. 2014;18(4):460.
  2. Carr AC, Shaw GM, Fowler AA, et al. Ascorbate-dependent vasopressor synthesis: a rationale for vitamin C administration in severe sepsis and septic shock? Crit Care. 2015;19:418.
  3. Padayatty SJ, Sun H, Wang Y, et al. Vitamin C pharmacokinetics: implications for oral and intravenous use. Ann Intern Med. 2004;140(7):533-7.
  4. Long CL, Maull KI, Krishnan RS, et al. Ascorbic acid dynamics in the seriously ill and injured. J Surg Res. 2003 Feb;109(2):144-8.
  5. Schorah CJ, Downing C, Piripitsi A, et al. Total vitamin C, ascorbic acid, and dehydroascorbic acid concentrations in plasma of critically ill patients. Am J Clin Nutr. 1996;63(5):760-5.
  6. Borrelli E, Roux-Lombard P, Grau GE, et al. Plasma concentrations of cytokines, their soluble receptors, and antioxidant vitamins can predict the development of multiple organ failure in patients at risk.Crit Care Med. 1996;24(3):392–397.
  7. Fowler AA, Syed AA, Knowlson S, et al. Phase I safety trial of intravenous ascorbic acid in patients with severe sepsis. J Transl Med. 2014;12:32.
  8. Zabet MH, Mohammadi M, Ramezani M, Khalili H. Effect of high-dose Ascorbic acid on vasopressor’s requirement in septic shock. J Res Pharm Pract. 2016;5(2):94-100.
  9. Marik PE, Khangoora V, Rivera R, et al. Hydrocortisone, Vitamin C and Thiamine for the Treatment of Severe Sepsis and Septic Shock: A Retrospective Before-After Study. Chest. 2016.S0012-3692(16)62564-3.

Content courtesy of Stephanie Willis, Scott Bergman and Dr. Andre Kalil. Commentary and opinions reflect those of the authors and may not reflect the opinions of the Division or UNMC as a whole.


 

Welcome to Stacy Severin – Transplant Infectious Diseases Clinical Study Associate

Tell us about the position you are starting?

I am starting as a research nurse coordinator in infectious disease, solid organ transplant division.

Tell us about your background?

I have been an RN for the last 9 years, with the last 4 in research.  I have always worked in the Oncology field prior to this position. My first nursing position was here at Nebraska Medicine on the Oncology/Hematology Special Care Unit. (OHSCU). Before coming back to UNMC,   I was working as an Oncology Research Nurse coordinator with CHI Health Bergan Mercy Creighton Medical Center.

Why UNMC?

I chose to come to UNMC because I was looking for a new challenge and an opportunity to learn and expand my nursing research knowledge. I feel that UNMC will grant me the opportunity to further not only my research education, but also my academic education.

What about ID makes you excited?

I chose Infectious disease because I find the different types of infections and treatments very interesting.  I am looking to expand my experience outside of oncology and felt this field would be fascinating.  I look forward to working in clinical trials with transplant patients and I am excited at the opportunity to offer these patients potential new treatments.

Tell us something about yourself UNRELATED to medicine?

Outside of work, I am married and have two beautiful daughters ages 19 and 17. We love animals and have 3 dogs. I love to travel and try and to visit a new city or country every year!

HIV Clinic Nurse Case Manager Receives a Community Award

Precious Davis, BSN, MSN received the “Field of Medicine Award” on Saturday, August 26th from the Omaha Section of the National Council of Negro Women (NCNW).  This organization recognizes individuals in the community for outstanding achievement. Each year individuals are recognized for excellence in medicine, education, leadership, community involvement, embodiment of the Mary McLeod Bethune Legacy and youth in excellence.

Precious is a Nurse Case Manager in the Nebraska Medicine HIV Clinic, and the clinic staff are very proud of her.  The award was presented at the annual Mary McLeod Bethune Award Luncheon on Saturday, August 26th . The community was invited to attend this important event.

The keynote speaker was Shawntal M. Smith Esq. Human Resources and Talent Development Leader for Omaha Home for Boys. Smith is also a social justice attorney. The theme was “Extraordinary Women: Breaking Barriers, Rising above Challenges, Transforming Lives.” The Omaha Section of the NCNW advocates for women of African descent as they support their families and communities. It fulfills its mission through research, advocacy and national and community based services and programs on health, education, and economic empowerment.

Congratulations, Precious!

 

Content courtesy of Dr. Swindells. 

Widespread use of chlorhexidine in hospitalized patients does not promote resistance in Staphylococcus aureus

Content courtesy of Dr. Rupp.

Investigators from the University of Nebraska Medical Center (UNMC) Division of Infectious Diseases recently published reassuring data indicating that use of chlorhexidine (CHG) to bathe hospitalized patients does not lead to CHG-resistance in S. aureus.  (Marolf CT, et al Infection Control and Hospital Epidemiology 38:873-75, 2017).

CHG is a very effective disinfectant that has been successfully utilized to prevent the spread of multi-drug resistant organisms (eg. MRSA) and prevent healthcare associated infections such as central-line associated bloodstream infections (CLA-BSI).  Unfortunately, there is concern that widespread use of CHG will promote resistance- particularly in staphylococci in which it has been observed that multi-drug efflux pumps encoded by qac A/B genes lead to low-level CHG resistance.

At UNMC, over a 7.5-year period, CHG was used to bathe patients in two distinct periods that were separated by over a year when CHG was not in use.  This served as a terrific “natural experiment” to see if use of CHG led to decreased susceptibility.  The research team tested strains of S. aureus clearly responsible for invasive nosocomial infections (bloodstream infections) for susceptibility to CHG.  Reassuringly, no emergence of resistance (decreased susceptibility) was observed.  In fact, the level of resistance was higher in the baseline period (when CHG was not in use) than during the study periods.

The results of this study provide reassurance that CHG can be used broadly in hospitalized patients without selecting for CHG-resistance in S. aureus.  However, these results do not exclude the emergence of resistance in the future and continued vigilance is warranted.

Read the entire study at:  https://www.cambridge.org/core/journals/infection-control-and-hospital-epidemiology/article/susceptibility-of-nosocomial-staphylococcus-aureus-to-chlorhexidine-after-implementation-of-a-hospitalwide-antiseptic-bathing-regimen/776D48E0315B4C44D2E161FD3C9B4E59

 

P.S. It should be noted that this research effort was largely conducted by an UNMC medical student!

 


 

Infectious Diseases Interest Group Kicks Off the Year with an Upcoming Panel!

The Infectious Diseases Interest Group here at UNMC will be hosting a panel of ID physicians covering a range of sub-specialties within ID. Our goal is to provide an introduction to incoming students about the many opportunities in ID and allow physicians to share their passion for the field. Additionally, students will be able to ask the faculty any questions they might have. Lunch will be provided for the first 50 attendees.

The event is scheduled for Thursday, September 7th at noon in MSC 2010 – Mark you calendars to attend!

Content courtesy of Jonathan Seaman and the IDIG. 

For further information regarding this group or how to join it, please email: idig@univnebrmedcntr.onmicrosoft.com


 

UNMC Clinical Microbiology Fellowship Program Welcomes Dr. Arryn Craney!

Content courtesy of Dr. Paul Fey and Dr. Arryn Craney.

UNMC’s Department of Pathology and Microbiology in collaboration with Nebraska Medicine sponsors a Clinical Microbiology Fellowship Program that is accredited by the Committee on Postgraduate Educational Programs (CPEP) of the American Academy of Microbiology.  This two year training program provides the trainee hands-on experience in the basic disciplines of clinical microbiology.  Upon successful completion of the Clinical Microbiology Fellowship Program, the Fellow will be eligible to sit for the examination as the next step to certification as a diplomate by the American Board of Medical Microbiology (D [ABMM]).  Our new fellow is Dr. Arryn Craney.  Dr. Craney received her PhD from McMaster University in Canada and most recently finished a post-doctoral fellowship at the Scripps Research Institute in San Diego where she studied the type I signal peptidase as a potential antibiotic target.

See more about the Clinical Microbiology Fellowship here.


 

Welcoming our new ID fellows – Focus on Dr. Karnatak

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

Tell us about the position you are starting?
I am starting infectious diseases fellowship at UNMC. I plan to do two years of specialization in infectious diseases followed by one year in critical care medicine.
Tell us about your background? 
I  finished medical school from the Himalayan Institute of Medical Sciences in India and further training in cardiac critical care at the All India Institute of Medical Sciences in New Delhi. I did my Internal Medicine residency at the Brookdale University Hospital in Brooklyn, New York. Post residency I have been practicing academic internal medicine from last three and half years. 
Why UNMC?
Omaha is second home for my wife. She always wanted to come back to Omaha. I was well aware of great training environment at UNMC as my wife did part of her residency and fellowship training here at UNMC. During my fellowship interview I realized infectious disease fellowship program at UNMC is designed to create a great learning environment for fellows and help fellows to grow in their career irrespective of whatever they want to achieve.  
What about ID makes you excited?
Infectious diseases is very exciting due to its complexity. During my practice I often noticed when I needed an specialist experienced in complexity I would call ID!! Infectious disease in today’s era is incredibly important due to crisis of multi-drug resistance, growing number of immunosuppressed oncology and transplant population, international travel related infections, infection control and need for expertise in health care epidemiology. According to a recent CDC report health care infections costs around 26-33 billion annually. In 2013 “Infectious Diseases Specialty Intervention is Associated with Decreased Mortality and Lower Healthcare Costs”,  study by Steven K. Schmitt, MD and Daniel McQuillen, MD provided data when ID specialists were involved early  less patients died in the hospital and after discharge and when ID docs were involved patients had 5.1% shorter ICU stays and had fewer readmissions within 30 days discharge from the hospital. ID physicians reduced costs by estimated 6%. Infectious disease is consistently changing and unpredictable as seen by recent emergence of infections like Ebola to  MERS to bioterrorism. For me, choosing infectious disease after finishing internal medicine residency was simply right thing to do.
Tell us something about yourself UNRELATED to medicine?
Apart from medicine I enjoy spending time with my family. My wife and I both have our families back in India. We chat with our folks almost every day. We both love cooking and travel. We both grew up in northern India close to Himalayas and love mountains and lakes!!! In the future, I want own a boat and take it to lake every weekend to go fishing!! 
See more about the UNMC Infectious Diseases Fellowship here.


 

Advancing Healthcare and Antimicrobial Stewardship in Nebraska

Content courtesy of Phil Chung and the Nebraska ASAP. 

The Nebraska Antimicrobial Stewardship Assessment and Promotion Program (ASAP) is funded by the Nebraska Department of Health and Human Services, Healthcare-Associated Infection Team through a CDC grant.  It is closely affiliated with the nationally recognized Antimicrobial Stewardship Program (ASP) at Nebraska Medicine and Division of Infectious Diseases at University of Nebraska Medical Center. The ASAP program employs a full-time ID trained pharmacist, ID trained medical directors as well as infection control and research nurses, all with extensive experience in establishing and running successful stewardship programs.

Nebraska ASAP has recently launched a completely revamped website.  The purpose of the website is to stimulate and support antimicrobial stewardship activities in a variety of healthcare settings.  The website offers a number of ASP tools, templates and guidance documents developed by Nebraska ASAP team in addition to providing links to other available resources. These resources will help hospital and long-term care facility administrators, healthcare providers, infection preventionists, pharmacists and other healthcare personnel working on promoting appropriate use of antibiotics in establishing or improving their own institutional antimicrobial stewardship program.

In addition, a blog will regularly post news and study highlights related to antimicrobial stewardship and antimicrobial therapy.  Recorded ASAP antimicrobial stewardship educational webinars geared toward hospitals and long-term care facilities will also be posted on the website in the future.

Nebraska ASAP team is also maintaining an email distribution list for website users who would like to get an email alert for important new postings on the website. Healthcare personnel can join the distribution list by sending an email to Nebraska ASAP Community Network Pharmacy Coordinator Phil Chung, PharmD, MS, BCPS at pchung@nebraskamed.com.

To learn more about ASAP and the ASAP website, visit https//asap.nebraskamed.com.

 


 

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