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Division of Infectious Diseases

What’s Hot in Infection Control?

Here are some fantastic take-home points from our Infection Preventionists who attended APIC 2017 – the national meeting of the Association for Professionals in Infection Control and Epidemiology. 

Water management Legionella  – Building water safety & Management

Legionella is endemic to overall water systems, not just the cooling towers, therefore infection control programs need to be concerned about the sporadic nosocomial risk, not just outbreak risk. Even portable risks, such as patients bringing in personal equipment that may have biofilm due to poor cleaning and disinfection at home.

Urine antigen test is inadequate for water related testing as only one serotype is detected, therefore Legionella cultures are required instead.

When is Legionella considered a nosocomial infection?  At  >10 days, but 2-10 days may still be nosocomial, so think about performing an environmental investigation. Finally, don’t necessarily chase zero;  zero legionella contamination is not the goal and may be impossible in some cases, zero patient cases is the goal. There are MANY waterborne pathogens with potential risk of infection. A water safety & management plan is the key component, not focus on mitigation and eradication of a single pathogen.

 

Central Line Insertion Site Assessment (CLISA Score)

There is a lot of focus on insertion, but maintenance is critical. Standardize criteria & expectations for early risk detection. At what point of site assessment, can you intervene and prevent a CLABSI? Beyond asking if you need the line, assess the site for signs of erythema and if progressing beyond 3mm radius of erythema, documentation of the scoring would prompt providers to starting looking toward removing the line BEFORE a CLABSI occurred.  Multidisciplinary approach – daily site assessment & documentation, communication with providers when results warrant further assessment/intervention. Read more here.

 

Disinfectants used in the hospital and what should we use? Are we thoughtful enough in our choices?

There are many critical pieces of information to consider when choosing a disinfectant, but one piece that often has been overlooked is the consideration of the end-user – are we also considering the patients, nursing and environmental service staff?

 

3 Fatal Flaws – Hand Hygiene

The three Fatal Flaws of Bias are: 1) Sampling bias; 2) Observer bias; 3) Hawthorne Effect.  Many Hand Hygiene programs across the country suffer from these Fatal Flaws. Due to lack of resources and competing priorities many Hand Hygiene programs are based on individual observations.

A successful Hand Hygiene program needs appropriate resource allocation, as well as an elevated design and reporting process. Particular attention needs to be given to the statistical design of the program to ensure meaningful data is shared across the organization.  The design must highlight the link between clean hands and a reduction of all hospital-acquired infections. The most successful programs are embraced by each layer of leadership; linking hand hygiene scores to leadership goals/rewards have been successful to garner appropriate support and resources

 

Learn more about Infection Prevention and Control at UNMC here.

Content courtesy of Terry Micheels, Kim Hayes and Joleen Strosahl.


 

New Faculty Spotlight – Dr. El-Ramahi

Background:

I am Jordanian but grew up in Riyadh, Saudi Arabia where my dad used to work. I moved back to attend medical school at the Jordan University of Science and Technology. After graduation, I worked in Jordan for two years before moving to the United States. We recently moved to Omaha and before that we lived in Tucson, Arizona for more than 6 years.

Why UNMC:

I decided during my training that I wanted to work in an academic institution because I wanted to teach and be a part of educating our medical students and residents/fellows. I also realized that working in a tertiary referral center offers the clinician the opportunity to take care of a variety of disease processes and a good number of intriguing cases. The other appealing quality is that there is a lot of support for research.

UNMC is well-renowned for offering high quality patient care and medical education along with exceptional research opportunities. The infectious diseases division here is unique in that it offers different service teams tailored to different patient populations which I believe enables the ID physicians to focus their interests and provide better care for the patients.

What about ID makes you excited?

When evaluating patients as infectious diseases physicians we are doing a detective’s work trying to gather as many clues as we can. What is also appealing to me is that it is a very intellectual specialty rather than procedure-driven. In addition to using our infectious diseases analytical skills, we also utilize a lot of our internal medicine knowledge trying to decide if what is making the patient sick is an infection or not. What is rewarding at the end of this hard work and after identifying a specific infection, is that we get to see patients improve and feel better with the treatment(s) we provide.

Something interesting about me not related to medicine:

I like outdoor activities such as hiking and riding my bike. I recently started to learn how to play the piano.

See more about the UNMC ID Division here.


 

Dr. Paul Fey on “Why I Love Clinical Microbiology”

 

Dr. Paul Fey on “Why I Love Clinical Microbiology:

“I love clinical microbiology because each pathogen that invades a human host has a different strategy. Our job is to determine how these processes occur mechanistically but also practically utilize this information to find new diagnostic strategies for our patients and clinical colleagues. ”

 

See more about UNMC Clinical Microbiology here.

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.


 

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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. 

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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!

 


 

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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


 

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