Division of Infectious Diseases

New Faculty Spotlight: Dr. Mackenzie Keintz

Dr. Mackenzie Keintz is no stranger to UNMC ID as a third-year ID fellow, but she is joining UNMC ID faculty as a clinical instructor. She is also the associate medical director of Nebraska ICAP’s Project First Line, which enhances the ID training of frontline healthcare workers. Read on to learn more about Dr. Keintz. Congratulations, Mackenzie!

Tell us a little about your background in medicine.

I was born in a small town in northern Wisconsin. I went to the University of Wisconsin-Madison for my undergraduate degree. The major I had chosen my freshman year at UW-Madison was discontinued leading me to select Medical Microbiology and Immunology, which ended up being very fortunate as it led me to my decision to become an infectious disease physician.  I went to St. George’s University in Grenada, West Indies for medical school. I lived in Grenada for two years before moving to Atlanta, GA for my clinical rotations. I came to UNMC in 2018 for my internal medicine residency and completed my training in infectious disease here as well! 

Tell us about your new position.

I am joining the Division of Infectious Disease faculty as a clinical instructor and third-year fellow. I am also the associate medical director of Project First Line through our Nebraska ICAP program and associate medical director of the Nebraska ASAP program. I will see patients on the General Infectious Disease service both at main campus and at Bellevue. I will also take care of patients living with HIV in clinic. 

I am pursuing a third year of fellowship to further my training in antimicrobial stewardship or using antibiotics wisely. I am particularly interested in antibiotic prescribing in the outpatient setting. Over the next year, I will be working with UNMC providers in the outpatient setting to improve antibiotic prescribing. In my role in Nebraska ASAP, I will utilize those skills to improve outpatient antibiotic prescribing across the entire state of Nebraska! I also am very interested in medical education. Through my role with Project First Line, I have been working on educating frontline healthcare workers, including CNAs, RNs, and environmental service workers, in infection control practices. These trainings help keep all our of colleagues safe while they provide care for our patients. 

Why did you want to work at UNMC?

I was drawn to UNMC during residency interviews due to the friendly collegial culture. I knew that I wanted to return to the Midwest after living abroad and in the southern US for a couple of years. UNMC has a nationally recognized division of infectious diseases. Even as an internal medicine resident, I was welcomed into the ID division, leading to excellent mentorship experiences throughout training. After finishing training, I knew I wanted to stay at an academic medical center. UNMC has everything I was looking for in terms of clinical, stewardship, and medical educational opportunities. 

What about ID makes you excited?

Clinically, the thing I like most about ID is the puzzle. Sometimes, that is in the form of a diagnostic mystery, while other times, it comes in the form of management strategy. I like being able to piece together what is the most efficient and effective antibiotic combination I can create for a given infection. I also enjoy that I get to learn really interesting things about my patients. I get to hear about their travel, pets, and passions, which not only helps me to understand their infection risk but also them on a deeper level. 

I am also very excited about antimicrobial stewardship. I love being able to help my colleagues in other areas of medicine take care of patients better. Antimicrobial resistance is a problem that continues to grow so it is very important to utilize our antibiotics thoughtfully to preserve their function in the future. 

Tell us something interesting about yourself unrelated to medicine.

In addition to my interest in microbes, I have an interest in growing rare plants. The prize of my collection right now is a Monstera Albo (pictured right)!

PharmToExamTable: Urine Luck- Navigating ESBL UTI Treatment (Part 2)

Part 2 of this #PharmToExamTable post explores treatment options for complicated ESBL UTIs, offers patient case examples, and was authored by Anna Rehberg, 2024 UNMC College of Pharmacy PharmD Candidate

Haven’t read part one yet? Check it out here!

(Content reviewed by: Jenna Preusker, PharmD, BCPS, BCIDP, Scott Bergman, PharmD, BCIDP, and Nicholson Perkins, PharmD)

Fast Facts about ESBL UTI treatment:

  • People who have more healthcare exposure are more likely to get ESBL infections, but it can also be community-acquired. 
  • ESBL-producing organisms cannot be treated with oral beta-lactam antibiotics. 
  • Guidelines recommend uncomplicated cystitis caused by an ESBL-producing organism be treated with oral SMX-TMP or nitrofurantoin if they are susceptible.
  • Guidelines recommend ESBL cUTIs and pyelonephritis be treated with oral SMX-TMP, fluoroquinolones, or IV carbapenems.

What are preferred antibiotics for the treatment of complicated cystitis and pyelonephritis caused by ESBL-producing organisms?

Treatment for complicated cystitis (cUTI) and pyelonephritis differ in terms of preferred antibiotics and duration compared to uncomplicated cystitis. Nitrofurantoin and fosfomycin cannot be used because they do not achieve adequate concentrations in the renal parenchyma.8,9

Preferred options to treat complicated cystitis and pyelonephritis include SMX-TMP, fluoroquinolones, and carbapenems.1 One study compared cure rates with ciprofloxacin 500 mg twice daily for 7 days to SMX-TMP 800-160 mg twice daily for 14 days.10 There were 255 premenopausal women analyzed in the study, with half in each antibiotic arm. Ciprofloxacin had cure rates of 99%, while SMX-TMP cured 89%. Of note, 24% of patients had side effects from ciprofloxacin, and 33% had side effects from SMX-TMP.10 Specific side effects and drug information can be seen in Table 2.

Another study compared IV levofloxacin 750 mg daily for 5 days versus IV levofloxacin 500 mg until clinical symptoms subside then transition to oral (PO) levofloxacin 500 mg daily for 7-14 days for the treatment of complicated UTIs and pyelonephritis.11 The five-day course of IV levofloxacin 750 mg daily had an 89.87% clinical effectiveness rate, and the 7 – day course of IV then PO had an 89.31% effectiveness rate, with both microbiological rates also being similar. These courses were deemed non-inferior, meaning the short course therapy of IV levofloxacin 750 mg daily can be utilized for treatment, meanwhile mitigating resistance.11 Of note, levofloxacin 750 mg and 500 mg has been proven to have 99% bioavailability in its oral tablet formulations compared to the IV option.12 With this study showing IV levofloxacin 500 mg for 5 days treats cUTI and pyelonephritis successfully, it can be extrapolated based on the bioavailability studies that oral levofloxacin can be used in place of IV.  As most patients are initiated on IV antibiotics when admitted into the hospital, it would seem reasonable after the diagnosis of complicated UTI or pyelonephritis to switch patients to oral levofloxacin for the remainder of treatment, given the patient can take and absorb oral medications. However, these two studies did not include ESBL-producing organisms but are included in the ESBL-producing organisms treatment guidelines.1

Lastly, if the patient is critically ill, has a history of ESBL, or has resistance to fluoroquinolones and SMX-TMP, carbapenems can be used for treatment.1 However, time on carbapenems should be limited to save bacterial activity for future use by the patient.1

Patient Case Examples:  

A 74-year-old female (weight: 90 kg) who lives in a nursing home, reports to her nurse that she is having new burning urination, nausea, incontinence, and lethargy. Her past medical history (PMH) includes COPD, CKD stage 3, osteoporosis, and a hysterectomy. Her urinalysis (UA) shows the urine is positive for nitrites and leukocyte esterase. The urine culture demonstrates ESBL Klebsiella oxytoca which has never been in her urine before. The patient reports unilateral lower back pain and has developed intermittent temperatures peaking at 38°C while receiving acetaminophen 1000 mg Q8H. The diagnosis for pyelonephritis is made by the medical team when the resident is asked for. No reported drug allergies or past use of antibiotics. What is the best antibiotic choice and duration for her?

  1. Levofloxacin 750 mg PO daily for 5 days (preferred pyelonephritis treatment) 
  2. Nitrofurantoin 100 mg BID for 3 days (Beers Criteria)
  3. Ertapenem 1g q24 hours for 5 days (Too broad spectrum & increased cost/burden of administration)
  4. Ciprofloxacin 250 mg BID for 3 days (uncomplicated UTI treatment)

A 33-year-old female at the clinic reports she just got back from her vacation in the Maldives this weekend and reports burning urination, nausea, vomiting, and subjective fever. Her PMH only includes type 1 diabetes, with an A1c below 7% for many years. Her UA is positive for nitrites and leukocyte esterase. Her urine culture resulted as ESBL E. coli. No reports of back pain at the time. She said she’s never had a UTI before and hasn’t taken antibiotics for many years, but mentioned she is allergic to Sulfa drugs (reaction: difficulty breathing). What is the best antibiotic choice and duration for her?

  1. Nitrofurantoin 100 mg BID for 5 days (Preferred uncomplicated UTI treatment)
  2. Ertapenem 1g q24 hours for 5 days (Too broad spectrum & increased cost/burden of administration)
  3. Levofloxacin 750 mg QD for 3 days (Not first line per ESBL guidelines & risky side effect profile)
  4. Sulfamethoxazole-trimethoprim 800 -160 mg BID for 3 days (Allergic)

References: 

  1. Pranita D Tamma and others, Infectious Diseases Society of America 2023 Guidance on the Treatment of Antimicrobial Resistant Gram-Negative Infections, Clinical Infectious Diseases, 2023;, ciad428, https://doi.org/10.1093/cid/ciad428
  2. Tamma PD, Smith TT, Adebayo A, et al. Prevalence of bla CTX-M Genes in Gram-Negative Bloodstream Isolates across 66 Hospitals in the United States. J Clin Microbiol 2021; 59(6). 
  3. CDC. ESBL-producing Enterobacteriaceae. Centers for Disease Control and Prevention. Published 2019. https://www.cdc.gov/hai/organisms/ESBL.html
  4. ‌Gupta K, Hooton TM, Roberts PL, Stamm WE. Short-course nitrofurantoin for the treatment of acute uncomplicated cystitis in women. Arch Intern Med. 2007;167(20):2207-2212. doi:10.1001/archinte.167.20.2207   
  5. Hooton TM, Scholes D, Gupta K, Stapleton AE, Roberts PL, Stamm WE. Amoxicillin-clavulanate vs ciprofloxacin for the treatment of uncomplicated cystitis in women: a randomized trial. JAMA. 2005;293(8):949-955. doi:10.1001/jama.293.8.949 
  6. Ito R, Mustapha MM, Tomich AD, et al. Widespread Fosfomycin Resistance in Gram-Negative Bacteria Attributable to the Chromosomal fosA Gene. mBio. 2017;8(4):e00749-17. Published 2017 Aug 29. doi:10.1128/mBio.00749-17 
  7. Huttner A, Kowalczyk A, Turjeman A, et al. Effect of 5-Day Nitrofurantoin vs Single-Dose Fosfomycin on Clinical Resolution of Uncomplicated Lower Urinary Tract Infection in Women: A Randomized Clinical Trial. JAMA. 2018;319(17):1781–1789. doi:10.1001/jama.2018.3627 
  8. Agwuh KN, MacGowan A. Pharmacokinetics and pharmacodynamics of the tetracyclines including glycylcyclines. J Antimicrob Chemother. 2006;58(2):256-265. doi:10.1093/jac/dkl224 
  9. Ten Doesschate T, Kuiper S, van Nieuwkoop C, et al. Fosfomycin Vs Ciprofloxacin as Oral Step-Down Treatment for Escherichia coli Febrile Urinary Tract Infections in Women: A Randomized, Placebo-Controlled, Double-Blind, Multicenter Trial. Clin Infect Dis. 2022;75(2):221-229. doi:10.1093/cid/ciab934 
  10. Talan DA, Stamm WE, Hooton TM, et al. Comparison of ciprofloxacin (7 days) and trimethoprim-sulfamethoxazole (14 days) for acute uncomplicated pyelonephritis pyelonephritis in women: a randomized trial. JAMA. 2000;283(12):1583-1590. doi:10.1001/jama.283.12.1583 
  11. Ren H, Li X, Ni ZH, et al. Treatment of complicated urinary tract infection and acute pyelonephritis by short-course intravenous levofloxacin (750 mg/day) or conventional intravenous/oral levofloxacin (500 mg/day): prospective, open-label, randomized, controlled, multicenter, non-inferiority clinical trial. Int Urol Nephrol. 2017;49(3):499-507. doi:10.1007/s11255-017-1507-0 
  12. Levofloxacin. Drugs@FDA. Revised June 2006. Accessed: September 5, 2023. https://www.accessdata.fda.gov/drugsatfda_docs/label/2006/020634s040,020635s043,021721s007lbl.pdf

New Faculty Spotlight: Dr. Jennifer Davis

Dr. Jennifer Davis joins UNMC ID as an assistant professor following her ID fellowship at Massachusetts General Hospital/Brigham and Women’s Hospital. She is an expert in HIV care and will practice in the HIV clinic, but will also see a broad range of other patients on the ID consult service. Read on to learn more about our superb new ID physician. Congratulations, Jennifer!

Tell us a little about your background in medicine.

I was born in Maine and raised in Andover, Massachusetts. I did my undergraduate work at Middlebury college in Vermont where I was a double language and culture major in Japanese and Mandarin Chinese. I lived in Japan for a few years after college where I taught English in public elementary and junior high school in rural Okinawa. I then attended Emory University School of Medicine in Atlanta where I fell in love with ID and HIV in particular. I completed residency in Internal Medicine at the University of California San Francisco and then Infectious Diseases fellowship at the Massachusetts General Hospital/Brigham and Women’s Hospital (BWH) combined fellowship program. In my second year of fellowship, I was the HIV Clinician Educator Fellow at BWH under Dr. Paul Sax and was also a scholar in the Harvard Macy Program for Educators in Health Professions. Moving to Omaha will be the first time I have lived in the Midwest, and I’m looking forward to the new adventure.

Tell us about your new position.

I’m joining the Infectious Diseases Division as an Assistant Professor of Medicine in mid August. My clinical practice will primarily be devoted to seeing patients in the HIV clinic. I will also see patients on the General Infectious Diseases consult service which cares for patients with a wide range of infections and symptoms suggestive of infection.

Why did you want to work at UNMC?

When I started looking for post-fellowship jobs, I knew that I wanted to stay in academic medicine with a focus on HIV and medical education. A co-scholar in the Harvard Macy Program (the amazing Dr. Jasmine Marcelin) introduced me to UNMC and I was very impressed both by the HIV team and the general atmosphere and culture of the ID division as a whole. It was clear to me when I interviewed that this is a place where I would be valued and given ample support and opportunity to grow.

What about ID makes you excited?

Chocolate cupcakes with chocolate and vanilla buttercream frosting made by Dr. Davis for a co-fellow’s birthday a few months ago.

Everything! I love thinking about itty bitty bugs and the drugs that do battle with them. I love being able to spend time with patients to learn their stories because you never know when the smallest detail about an afternoon spent with a grandson’s pet bearded dragon will explain the source of a Salmonella bacteremia. It is a privilege to get to know our patients so intimately, and often times in ID (though not always) our patients improve to the point where they seem like different people at their follow-ups a few months later.

Tell us something interesting about yourself unrelated to medicine.

I love to read and bake. My book tally at the end of the year is often embarrassingly high. I’m very much looking forward to experimenting in my new kitchen and feeding my new colleagues with the results of those experiments. 

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#PharmToExamTable: Urine Luck- Navigating ESBL UTI Treatment (Part 1)

Part 1 of this #PharmToExamTable post explores treatment options for uncomplicated ESBL UTIs and was authored by Anna Rehberg, 2024 UNMC College of Pharmacy PharmD Candidate

(Content reviewed by: Jenna Preusker, PharmD, BCPS, BCIDP, Scott Bergman, PharmD, BCIDP, and Nicholson Perkins, PharmD)

Fast Facts about ESBL UTI treatment:

  • People who have more healthcare exposure are more likely to get ESBL infections, but it can also be community-acquired. 
  • ESBL-producing organisms cannot be treated with oral beta-lactam antibiotics. 
  • Guidelines recommend uncomplicated cystitis caused by an ESBL-producing organism be treated with oral SMX-TMP or nitrofurantoin if they are susceptible.
  • Guidelines recommend ESBL cUTIs and pyelonephritis be treated with oral SMX-TMP, fluoroquinolones, or IV carbapenems.

Introduction to ESBLs

ESBLs, or Extended Spectrum Beta Lactamases, are enzymes produced by Gram-negative bacteria that inactivate most penicillins, cephalosporins, and aztreonam while remaining susceptible to carbapenems in the absence of other resistance mechanisms.1 ESBLs do not inactivate non-beta lactam antibiotics such as levofloxacin, sulfamethoxazole-trimethoprim, fosfomycin, or gentamicin.1 However, organisms harboring ESBLs often contain additional mechanisms of resistance that could render these antibiotics ineffective.  ESBLs can be found in any gram-negative organism but are most prevalent in Escherichia coli, Klebsiella pneumoniae, Klebsiella oxytoca, and Proteus mirabilis.2 In the United States, the CTX-M enzyme is the most common type of ESBL present, accounting for approximately 80% of all ESBL infections nationally.1

ESBL infections occur most frequently in those with high healthcare exposure, particularly those requiring prolonged hospital stays, residents of skilled nursing homes, or residents of long-term acute care facilities, but they can also cause community-acquired infections in otherwise healthy people who have taken antibiotics before.3 Bacteria with ESBL enzymes can spread from person to person in healthcare settings or through contaminated food or water, just like other bacteria and microbes.3  

IDSA guidelines do not provide recommended durations of therapy for ESBL infections, but expert clinicians advise the duration of therapy should not differ for infections caused by organisms with resistant phenotypes compared to infections caused by more susceptible phenotypes.1 Also, oral antibiotics can be an equally efficacious step-down therapy option when the patient meets the following criteria:1

  1. Hemodynamic stability
  2. Source control
  3. Susceptible to an appropriate, non-beta lactam, oral agent
  4. No concerns for insufficient intestinal absorption

What are preferred antibiotics for the treatment of uncomplicated cystitis caused by ESBL-producing organisms?

Nitrofurantoin and sulfamethoxazole–trimethoprim (SMX-TMP) are the preferred agents for the treatment of uncomplicated cystitis caused by ESBL-producing organisms.1 In an open-label non-inferiority study, five days of nitrofurantoin therapy was compared to three days of double-strength SMX-TMP for the treatment of uncomplicated cystitis.4 A total of 338 women, aged 18 – 45 years old, enrolled in this trial with the primary outcome of clinical cure at 30 days after therapy completion with secondary outcomes including cure rates at 5 to 9 days. Clinical cure was achieved in 79% of patients in the SMX-TMP group and 84% of patients in the nitrofurantoin group. Clinical and microbiological cure rates at first follow-up visit were equivalent between groups. Though this study did not exclusively evaluate ESBL cystitis, the authors concluded that a five-day course of nitrofurantoin is equivalent clinically and microbiologically to a three-day course of SMX-TMP and should be considered an effective fluoroquinolone-sparing alternative for the treatment of uncomplicated cystitis in women.4

 Fluoroquinolones and carbapenems are also effective agents for treatment of uncomplicated cystitis caused by ESBL-producing organisms, but their use is discouraged in this disease state.1 Limiting the use of these agents reduces the risk of antibiotic adverse events and benefits patients in the future by preserving antimicrobial activity.1  In a randomized, single-blinded study done in 2005, a three-day course of amoxicillin-clavulanate and ciprofloxacin were compared for the treatment of uncomplicated cystitis.5 There was a total of 370 women enrolled, aged 18 – 45 years old, who were then randomized 1:1 into two groups. The results demonstrated the three-day regimen of amoxicillin-clavulanate was not as effective as ciprofloxacin for the treatment of acute uncomplicated cystitis, even in women infected with susceptible strains. Inferiority of amoxicillin-clavulanate was partially due to not fully eradicating E. coli from the vaginal area. This outcome can be explained by the increasing resistance to amoxicillin along with the length of time amoxicillin and clavulanate are in the serum (1.3 hours and 1 hour, respectively) compared to ciprofloxacin (4 hours). This study did not monitor side effects of fluoroquinolones, but general side effects for all medications mentioned can be seen in Table 1.5

Fosfomycin is also an option for the treatment of uncomplicated ESBL cystitis.1 However, infections caused by K. pneumoniae, Serratia marcescens, Enterobacter spp. and P. aeruginosa are resistant to fosfomycin due the presence of FosA genes.6 However, this gene is often absent in ESBL E. coli, so fosfomycin can be used as treatment in those cases.6 But in a study done comparing a five – day course of nitrofurantoin to a single dose of fosfomycin for uncomplicated cystitis clinical cure, fosfomycin only had a 58% cure rate compared to 70% in the nitrofurantoin group.7

To be continued next week…

References: 

  1. Pranita D Tamma and others, Infectious Diseases Society of America 2023 Guidance on the Treatment of Antimicrobial Resistant Gram-Negative Infections, Clinical Infectious Diseases, 2023;, ciad428, https://doi.org/10.1093/cid/ciad428
  2. Tamma PD, Smith TT, Adebayo A, et al. Prevalence of bla CTX-M Genes in Gram-Negative Bloodstream Isolates across 66 Hospitals in the United States. J Clin Microbiol 2021; 59(6). 
  3. CDC. ESBL-producing Enterobacteriaceae. Centers for Disease Control and Prevention. Published 2019. https://www.cdc.gov/hai/organisms/ESBL.html
  4. ‌Gupta K, Hooton TM, Roberts PL, Stamm WE. Short-course nitrofurantoin for the treatment of acute uncomplicated cystitis in women. Arch Intern Med. 2007;167(20):2207-2212. doi:10.1001/archinte.167.20.2207   
  5. Hooton TM, Scholes D, Gupta K, Stapleton AE, Roberts PL, Stamm WE. Amoxicillin-clavulanate vs ciprofloxacin for the treatment of uncomplicated cystitis in women: a randomized trial. JAMA. 2005;293(8):949-955. doi:10.1001/jama.293.8.949 
  6. Ito R, Mustapha MM, Tomich AD, et al. Widespread Fosfomycin Resistance in Gram-Negative Bacteria Attributable to the Chromosomal fosA Gene. mBio. 2017;8(4):e00749-17. Published 2017 Aug 29. doi:10.1128/mBio.00749-17 
  7. Huttner A, Kowalczyk A, Turjeman A, et al. Effect of 5-Day Nitrofurantoin vs Single-Dose Fosfomycin on Clinical Resolution of Uncomplicated Lower Urinary Tract Infection in Women: A Randomized Clinical Trial. JAMA. 2018;319(17):1781–1789. doi:10.1001/jama.2018.3627 

New Faculty Spotlight: Dr. Sias Scherger

Dr. Sias Scherger completed his ID fellowship at the University of Colorado, where he stayed on as faculty for a few years. He now joins us at UNMC ID, where he will focus on the treatment of immunocompromised patients. A Nebraska native and graduate of UNMC’s College of Medicine, we welcome him back! Read on to learn more about our great new addition to the UNMC ID faculty. Congratulations Sias!

Tell us a little about your background in medicine.

I was born in Lincoln, NE, and have also lived in North Platte and Omaha. I did my undergraduate education at the University of Nebraska-Lincoln, medical school at the University of Nebraska Medical Center, and Internal Medicine Residency at Wake Forest Baptist Health in Winston-Salem, NC. I completed an Infectious Diseases Fellowship at the University of Colorado, where I stayed as faculty for 3 years before returning to UNMC. 

Tell us about your new position.

I started at UNMC on July 1st, 2023. My main area of focus is infections in immunocompromised hosts, including solid organ transplant and hematopoietic stem cell transplant recipients, but also patients with malignancies, immunosuppressive medications, or congenital/acquired immune deficiencies. I am also working toward developing a research career to investigate some of the challenges that patients with impaired immune systems face. 

Why did you want to work at UNMC?

I like the balance between clinical patient care, research and scholarly pursuits, and education that an academic medical center like UNMC provides. As a referral hospital, we also see some of the sickest and most challenging patients and are able to work with experts from all disciplines. The Infectious Diseases division is robust, productive, and provides excellent support for junior faculty.  Lastly, I think the friendliness and sense of community in Nebraska is unique.

What about ID makes you excited?

I love several things about Infectious Diseases. To me, the interplay between the host immune system and infectious pathogens is the most fascinating concept in medicine. ID also has a unique role in treating not only the individual but also public health at large, which we have seen throughout the COVID-19 pandemic. I also love the variety; I see patients with infections in all organ systems, including both medical and surgical patients.

Tell us something interesting about yourself unrelated to medicine.

Outside of work, I mostly spend time with my wife and children. I try to read (something non-medical), do something outside when the weather permits, and enjoy practicing Brazilian Jiu Jitsu.

New Faculty Spotlight: Dr. Juan Teran

Dr. Juan Teran joins UNMC ID as an assistant professor and the medical director of the Nebraska Infection Control Assessment and Promotion Program (ICAP). He recently completed an ID fellowship at Boston University. Read on to learn more about this great new addition to the UNMC ID team. Congratulations Juan!

Tell us a little about your background in medicine.

I was born and raised in Quito, Ecuador and completed my medical education at Universidad Internacional del Ecuador. After obtaining my degree, I did a year of community medicine as a general practitioner in outskirts of Quito. That was my first exposure to ID by caring for diseases ranging from your bread-and-butter pathology like community-acquired pneumonia to more unique infections such as leishmaniasis and tuberculosis. With an enlivened interest for clinical medicine and ID, I moved to Florida where I completed my Internal Medicine Residency at the University of Miami/JFK Hospital in West Palm Beach. After three years in South Florida, I made my way northeast to Boston where I completed my fellowship in Infectious Diseases with a strong emphasis in Antimicrobial Stewardship.

One defining step in my career was completing an additional year of training in Infection Control and Hospital Epidemiology at the Boston VA Healthcare System. That year provided a great introduction to the inner workings of a hospital and all the work that goes behind the scenes to control and prevent health care-associated infections.

Tell us about your new position.

I’m joining UNMC as an Assistant Professor of Medicine in the Division of Infectious Diseases. Most of my work is dedicated to working with Nebraska ICAP as their new medical director. ICAP provides infection control and antimicrobial stewardship expertise to many healthcare settings, such as hospitals, dental offices, and dialysis centers, but also no non-healthcare settings, such as schools and daycares. I will also care for patients both in the inpatient and clinic settings.

Why did you want to work at UNMC?

I enjoy working in an academic setting where I get to learn from colleagues who are renowned experts in their fields. In addition, I really enjoy teaching medical students, residents, and fellows. Moreover, it is an honor to work at ICAP with an outstanding team that has provided such a positive impact on the state of Nebraska. 

What about ID makes you excited?

I might be biased, but I love ID! I really enjoy the fact that I don’t have to focus on a single organ or system but rather, I can take a holistic view of my patients. Within ID, not only do I have to understand my patient, but also track down the microbe involved. I really enjoy that detective work.

Tell us something interesting about yourself unrelated to medicine.

I come from a family of musicians and artists. In 2022 they awarded my family with the Guinness world record for Most Family Members in a Musical (sadly, I was not able to join them in Ecuador for that show). I always have music on in the background, and I enjoy playing the guitar in my free time.  

Research Digest: Antimicrobial Advances at UNMC

Research Digest is a periodic installment that recognizes the world-class clinical research performed right here at UNMC ID. This week, we feature two articles exploring the pharmaceutical treatment of two different infectious diseases with wide-reaching implications. As always, be sure to check out the linked full articles for more details.

The first article, co-authored by Dr. Fadul (left) and Dr. Bares (right; among others at UNMC and other institutions), details work conducted to assess the readiness of clinics providing care for people with HIV to implement a new generation of antiretroviral therapies (ARTs): long-acting injectables (LAIs). This new class of drugs repurposes current ART treatments in a form that can be taken once every 1-2 months instead of daily, improving patient compliance and viral suppression. Sparked by FDA approval of the first of these therapies in January 2021, the authors set out to determine the readiness of clinics to shift to this new ART platform. Among a wealth of detailed conclusions, the article found that the overwhelming majority of clinics surveyed (+90%) welcomed the implementation of LAIs and declared that the treatment was applicable, fitting, and suitable to their clinics. However, there was considerable variability in the current readiness of clinics to administer this new form of treatment, with clinics citing patient non-adherence to monthly visits and cost as primary concerns. The authors conclude that new approaches to increase patient compliance with regular visits are needed to optimize the roll-out of current and future LAI ARTs. Read the full story here.

The second article, authored by Dr. Sunagawa (right) and many others from the UNMC ID community, reports a new effort at UNMC to adequately address and document patient-reported penicillin allergy and graded challenges used for test doses in patients. Penicillin allergy is reported by 7-10% of patients, although more than 90% of these patients have been subsequently found to not be allergic to the antibiotic class. Lingering incorrect reports of allergy is a major factor driving providers to prescribe antibiotic agents with broader spectrums, higher adverse effect risk profiles, and increased antibiotic resistance. Furthermore, patient charts from those undergoing graded challenges to improve tolerability to these drugs may still falsely report allergy following testing. Assessing the clinical landscape of graded challenges and the magnitude of this problem was one of the primary goals of this study. The authors found that both oral and IV graded challenges with beta-lactam antibiotics were implemented successfully in a hospital setting without inpatient allergy consult and with a low rate of adverse events (1-4%), none severe. Additionally, 92% of EHR charts were updated following desensitization. Read the full article here.

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New Faculty Spotlight: Dr. Shawna Sunagawa

Dr. Shawna Sunagawa is not new to UNMC ID, having completed her pharmacy residency here at Nebraska Medicine/UNMC. She is, however, transitioning to a new role within the division, and we are very excited to have her stay on! Read on to learn more about this fantastic new addition to the UNMC ID faculty. Congratulations, Shawna!

What is your background in medicine? How did you get to this point in your career?

I’m originally from Hawaii but completed my undergraduate and pharmacy degrees at Creighton University. I was fortunate enough to complete my PGY1 and PGY2 ID pharmacy residencies here at UNMC/Nebraska Medicine. And as much as I miss the year-round warm weather, I am so excited to continue to work with and learn from the phenomenal ID Division and College of Pharmacy faculty/staff!

Tell us a little about your new position.

I initially matched and started my PGY1 pharmacy residency here in 2021; however, I have just transitioned into my new Clinical Instructor role in July 2023. My main practice site will be supporting patients at the ID Specialty Care Center while participating in research and teaching activities within the College of Pharmacy.

Why did you want to stay at UNMC?

100% – the people! I get to work with some of the top infectious diseases clinicians/researchers in the nation, who are not only exceptional clinicians/researchers but are also fantastic people! They are clearly super supportive of new faculty’s career development/pursuits – education, research, clinical services, etc! Plus, with my practice site being the ID Specialty Care Center, I have the opportunity to continue to support and care for a diverse patient population.

What about ID makes you excited?

There are constantly evolving new concerns and issues within the realm of infectious diseases (pandemics, new anti-infective therapies, multi-drug resistant organisms, etc.), and I am excited to be able to play a role in helping solve many of these therapeutic puzzles/challenging cases. There’s always something new to learn!

Tell us something interesting about yourself unrelated to medicine.

I love attending sporting events, playing tennis, trying new restaurants, and hanging out with my husband and two pups! My husband and I have a lifelong goal of trying to watch an MLB game in every stadium. Now that we are coming out of the pandemic, we are excited to make it to a few more stadiums this upcoming year!

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Our Fellowship Leaders can’t wait to review your applications!

The following content was provided by Dr. Abbas (R) and Dr. Van Schooneveld (L), UNMC ID fellowship program directors. Read on to learn about our great program and please share with those who may be interested!

Fellowship application season is open, and as the leaders of our ID fellowship, we wanted to highlight some of the exciting aspects of our program. Our program and our division are growing. We began in 2011 with 2 fellows, grew to 4 in 2017, 5 in 2020, and our full complement now includes 6 fellows. Our faculty also continues to grow, as we now have 32 physician faculty and 4 full-time ID pharmacists with diverse expertise. Dr. Trevor Van Schooneveld is the Program Director and Director of the Antimicrobial Stewardship program and Dr. Anum Abbas is the Associate Program Director. This year we are looking forward to meeting you on our remote interviews via Zoom!

Dr. Casey Zelus teaching medical students about blood cultures

Fellows at UNMC enjoy a robust clinical experience that includes not only the typically complex patients seen at a tertiary referral center, but also includes extensive experience caring for immunosuppressed patients.  In addition to our General ID service, where our fellows gain experience in teaching medical students and Internal Medicine residents, we have two separate immunocompromised services that care for oncology and solid organ transplant patients.  We also have an orthopedic infectious diseases rotation where fellows gain experience managing these complex patients and work with faculty who have extensive experience in this area.  We have expanded our ambulatory offerings with the creation of a non-tuberculous mycobacteria (NTM) clinic and a travel clinic.  Fellows have the opportunity to spend time in the microbiology laboratory, as well as learn infection control and antimicrobial stewardship. The faculty at UNMC are nationally recognized experts in their field, and are also very approachable and devoted to the education and success of trainees. They have created extensive educational opportunities, covering topics from opportunistic infections in solid organ and hematopoietic stem recipients to emerging global pathogens and biopreparedness. Fellows gain knowledge in HIV/AIDS management working in our multidisciplinary HIV clinic which cares for over 1200 people with HIV. In addition to having access to world class ID expert antimicrobial stewardship, OPAT, and HIV pharmacists, our division also includes an ID pharmacy residency program and opportunities for research collaboration and rounding with pharmacy students, residents and faculty.

As new career opportunities develop for ID physicians, we have worked to provide our fellows with the skills to engage in these fields.  UNMC ID fellows receive extensive experience in the area of infection control and antimicrobial stewardship as well as dedicated biocontainment training.  UNMC also offers the opportunity to stay for an optional third year to further develop a research portfolio or pursue additional clinical expertise in subspecialty areas.

Graduate Dr. Raj Karnatak presenting his research

An important part of fellowship is developing skills in interpreting and performing research, and we provide our fellows with six months of mentored research experience centered on their career goals.  A research committee assists fellows in mentor identification and project development.  Fellows also participate in a week-long UNMC sponsored research training program, and typically present their work at national conferences like IDWeek and SHEA.

Our goal as program directors is to provide fellows with an educational experience that provides them with skills and knowledge to make them successful in whatever career path they choose.  The opportunities available to ID physicians continue to expand and we hope you will consider UNMC ID.  If you are interested in more information, please feel free to visit our website where you can check out a video to learn more about us. You can also contact us at the following:

Dr. Trevor Van Schooneveld
Program Director, Infectious Diseases Fellowship
Medical Director, Antimicrobial Stewardship Program
University of Nebraska Medical Center
985400 Nebraska Medical Center
Omaha, NE 68198-9400
Email: tvanscho@unmc.edu

Dr. Anum Abbas
Associate Program Director, Infectious Diseases Fellowship
Assistant Professor, Division of Infectious Diseases
985400 Nebraska Medical Center
Omaha, NE 68198-9400
Email: anum.abbas@unmc.edu

Top Tips for Acing Fellowship Interviews

It is August, and fellowship application season is upon us once again. Watch the UNMC ID blog in the coming weeks for fellowship application content. We begin with a practical guide to fellowship interviews. If you know someone gearing up for this important step, please share this post. A refresher on these skills can always be useful!

Multiple ID faculty contributed to this list and thus the credit goes to the entire UNMC Division.

As faculty, we have the amazing opportunity to both mentor and interview residents applying for fellowship in Infectious Diseases, and we have seen it all. From the great, well-prepared interviewee to the one who had the institutional information completely incorrect. We wish we could mentor every resident in person, but since that is not possible, we decided to do the next best thing and offer our tips and tricks to acing the ID (or any other) interview! Tips and tricks are in no particular order. 

  • Be yourself and relax.
  • Articulate why you are interested in this fellowship program, what your ID interests are and where you think you would like your career to go (even if you acknowledge that might change or be a little vague at this time).
  • Have an idea of how the program works and ask specific questions to help deepen that knowledge regarding the education you will receive. What are the strengths, weakness and unique aspects of the program you want to know more about?
  • Remember that you are interviewing the fellowship program as much as they are interviewing you. Do your research and come prepared with questions about everything from how the fellowship will prepare you for your career as an ID physician to where you will park.
    • Need suggestions on how to curate your list of questions?
      • Look up the program and Division on their website.
      • It is helpful to know a little about the faculty you are interviewing with, so if you get a schedule ahead of time find out what their clinical/research interests are and ask them about it – you can check out their publications on PubMed or Google Scholar to focus questions on specific topics.  If you don’t get a schedule ahead of time, ask them what their interests are or what their role is during your interview.
      •  Formulate questions important to you about the program, the institution and the local area regarding resources, lifestyle and more.
  • Be prepared to talk about your successes and the challenges you have encountered. For example, if you have an unexpected break in training, use that as example to illustrate what you learned from that experience. We do not expect perfection, but value honesty and clarity.
  • If you have something on your application that might be viewed negatively (academic difficulties, etc.) take the initiative and explain how you have overcome it and why you are a good candidate now before we have to ask you about it.
  • Consider a “highlight” reel handout for faculty on an updates to your CV since you submitted your application in ERAS. This can be incredibly beneficial if you have had a new publication, presentation or other activities demonstrating your interest in ID and future potential as a fellow.
  • Be friendly and treat everyone, including program coordinators and other office personnel kindly and with respect. Your interview starts from the moment some first meets you (a current fellow, administrative assistant or staff) and ends when you say goodbye to the last person. ALL opinions count. If you are rude to anyone, trust us, we will find out.
  • Be truthful and be yourself. Don’t answer questions with what you think the interviewer wants to hear (e.g. don’t say you want to do academic medicine if you are interested in private practice). This is the only way for both you and the program to determine whether or not you are truly a good fit.
  • Tell us something interesting about yourself, even if it doesn’t relate to ID.  It is important to be well-rounded, and hearing about hobbies, experiences and interests helps keep the interview conversation fun and flowing.
  • Thank the faculty for their time; the emails and cards with a personal comment regarding a specific detail of the interview are both appreciated and noticed.

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