Infectious Diseases Fellowship

General Description

The Infectious Diseases Fellowship is a two-year postgraduate training program in the Division of Infectious Diseases of Creighton University Department of Medical Microbiology and Department of Medicine along with the Infectious Diseases Division from the University of Nebraska Medical Center. The faculty have appointments at both institutions with Dr. Laurel Preheim being the Chief of the combined Division of Infectious Diseases. The list of faculty with their ranks and special interests are listed below.

Faculty

Marvin J. Bittner, M.D. Associate Professor of Medicine and Medical Microbiology and Immunology. Physician Director, Douglas County Health Department Traveler's Clinic. Special interests: travel medicine and nosocomial infections.

Edward A. Dominguez, M.D. Associate Professor of Medicine and Medical Microbiology. Special interests: Rapid viral diagnosis; immunocompromised host infections; clinical infectious diseases and transplant infectious diseases.

Paul D. Fey, Ph.D. Assistant Professor of Medicine, Pathology and Microbiology. Special interests: staphylococcal pathogenesis, molecular epidemiology, and clinical microbiology.

Alison Freifeld, M.D., Associate Professor of Medicine and Microbiology.  Special interests: management of infections in the immunocompromised cancer patient.

Howard E. Gendelman, M.D. Professor of Pathology, Microbiology and Medicine. Special interests: Role of macrophages in HIV resistance and pathogenesis; neuronotoxicity in HIV-associated encephalopathy and AIDS.

Martha J. Gentry-Nielsen, Ph.D. Assistant Professor of Medicine and Medical Microbiology and Immunology. Special interests: pathogenesis of pneumococcal pneumonia in rat models of liver disease and ethanol abuse.

Gary L. Gorby, M.D. Associate Professor of Medicine and Medical Microbiology and Immunology. Program Director, Adult Infectious diseases Fellowship. Special interests: pathogenesis of gonococcal infections and clinical infectious diseases.

Edward A. Horowitz, M.D. Associate Professor of Medicine and Medical Microbiology. Chairman, St. Joseph Hospital Infection Control Committee. Special interests: clinical infectious diseases.

Elizabeth L. Lien, M.D., Assistant Professor of Medicine and Medical Microbiology. Special interests: HIV infection, AIDS, and gynecological infections.

Jenae D. Limoges, M.D. Assistant Professor of Pathology, Microbiology and Medicine. Special interest: animal models of HIV pathogenesis and AIDS.

Laurel C. Preheim, M.D. Professor of Medicine and Medical Microbiology and Immunology. Chief, Infectious Diseases Section at Creighton University School of Medicine and Omaha VA Medical Center. Special interests: rat models of pneumococcal infections and clinical infectious diseases.

Mark E. Rupp, M.D. Associate Professor of Medicine and Medical Microbiology and Immunology. Special interests: Pathogenesis of staphylococcal and catheter-related infections; molecular epidemiology, and nosocomial infections.

Thomas J. Safranek, M.D. Assistant Clinical Professor (part-time) of Medicine and Medical Microbiology. State Epidemiologist, State of Nebraska. Special interests: epidemiology; nosocomial infections.

Philip W. Smith, M.D. Professor of Medicine. Chief of Infectious Diseases, University of Nebraska Medical Center. Special interests: hospital epidemiology and infection control in long-term care facilities.

Susan Swindells, M.D. Associate Professor of Medicine and Medical Microbiology and Immunology. Director, University of Nebraska Medical Center HIV Clinic. Special interests: HIV infection and AIDS.

INPATIENT FACILITIES

Saint Joseph Hospital (SJH). Saint Joseph Hospital is the primary teaching hospital for Creighton University School of Medicine. The current facility was constructed in 1977 and represents a modern, up to date, fully equipped and accredited tertiary care medical center. There are 419 licensed beds with a breakdown of 397 acute care beds and 22 intermediate care beds. There are 75 intensive care unit beds and a telemetry unit for intermediate care. It is a designated shock trauma center for the Omaha metropolitan area and owns and operates a rescue helicopter which is based at the hospital.

All members of the hospital staff have faculty appointments at Creighton University. All subspecialties of internal medicine are represented and include nephrology, cardiology, pulmonary medicine, allergy immunology, endocrine, metabolic, neurology, preventive medicine, rheumatology, hematology, oncology, gastroenterology, dermatology, and infectious diseases. Our regional renal dialysis center as well as cancer center provide access to patients with immunocompromised states. All major surgical procedures are performed including general surgery, renal transplant surgery, organ retrieval, orthopedics, urology, cardiovascular, thoracic, neuro, plastic and reconstructive, ENT, gynecology, and ophthalmology. Other primary care services include family practice, obstetrics, and pediatrics. A full complement of support services are available including pathology, microbiology, radiology, nuclear medicine, radiation therapy, rehabilitation medicine, social services, dietary, nursing, psychiatric, pharmacy, nutritional counseling and behavior modification, bone metabolism center, diabetes center, neonatal intensive care, infertility center, hereditary cancer center, speech and audiology center, and epidemiology.

The diagnostic microbiology laboratory is directed by Stephen Cavalieri, Ph.D., a full time faculty member in the Department of Medical Microbiology. Dr. Cavalieri plays a large role in training our fellows in the basics of diagnostic microbiology and virology. He also helps oversee diagnostic microbiology laboratory rounds which are made daily by the Infectious Diseases Team.

The laboratory is fully equipped, computerized, and serves as the regional reference laboratory for a variety of diagnostic tests including serologic titers, antigen detection, special antimicrobial levels, serum bactericidal titers, toxin assays, and other "non-routine" requests. The BACTEC system is used for rapid detection of bacteria and mycobacteria. In addition, research laboratories in our Creighton University Department of Medical Microbiology offer unique expertise and assistance in numerous areas. Multi-resistant clinical isolates can be sent to Dr. Christine Sanders and Dr. W. Eugene Sanders, Jr. for evaluation of the resistance mechanisms as well as for susceptibility tests with new antimicrobials. Dr. Richard Goering performs phage typing and plasmid analysis of isolates as needed for epidemiological studies. Dr. Floyd Knoop provides expertise and assays for toxin producing strains of organisms.

University of Nebraska Medical Center/University Hospital (UNMC). University Hospital commenced operations in 1917, and has now achieved national status as a bone marrow and liver transplant center. Each year, the hospital accommodates more than 10,000 inpatients, 22,000 emergency patients, and 225,000 outpatients. The hospital has 319 beds, plus 30 skilled nursing beds at the University Geriatric Center. There are 26 adult ICU beds, 10 pediatric ICU beds, and 34 neonatal ICU beds. Given the emphasis on transplants, 35 beds on a separate floor have been designated as a Bone Marrow Transplant Unit. The Unit accommodates about 200 transplants annually, predominantly autologous in nature. Over 1,000 transplants were performed over the last 10 years. Liver transplants have been performed at UNMC since 1985. Currently UNMC ranks as the third or fourth most active transplant center in the country. Approximately 2/3 of these have been in adults. Increasing numbers of pancreas/liver transplants and small bowel/liver transplants are being performed annually.

Internal Medicine subspecialties include rheumatology, cardiology, gastroenterology, hematology/oncology, infectious diseases, pulmonary medicine, geriatrics, endocrinology and neurology. All surgical subspecialties are likewise represented. Formal training programs also include family practice, pediatrics (including infectious diseases), primary care, obstetrics/gynecology, pathology, nuclear medicine, radiology, ophthalmology and psychiatry. Other than the College of Medicine, UNMC is comprised of several educational units: College of Dentistry, College of Nursing, College of Pharmacy, School of Allied Health Professions, and the Office of Graduate Studies and Research. The commitment of the University to oncologic disease is exemplified by the Eppley Institute for Research in Cancer and Allied Diseases, one of 15 National Cancer Institute research centers.

Educational resources on campus include McGoogan Library, which serves as a six-state regional library. Through their online search services, fellows have access to GRATEFUL MED and MEDLINE. CD-ROM technology also allows access to many more databases. The library carries approximately 2,000 journals, including all major infectious diseases and microbiology journals.

The diagnostic microbiology lab is supervised by Steve Hinrichs, M.D. BACTEC and MICROSCAN systems are used for bacterial cultures. Rapid identification of mycobacteria, gonococcus, and chlamydia with DNA gene probes is also available. Given the emphasis on transplants at UNMC, the clinical lab has a large mycology and mycobacterial load. Approximately 8000 fungal cultures per year are performed. Almost 300 mycobacterial cultures per month are also done, with a positivity rate of 4-5%. Finally, the lab is a regional reference lab for a tri-state area. It is currently one of only a handful of labs nationwide evaluating automated viral serology.

Omaha Veterans Affairs Medical Center (VAMC). This facility was constructed in 1948 with a modern Ambulatory Care Facility added in 1987 and serves as a regional referral for veteran patients in western Iowa and the entire state of Nebraska. The Omaha VAMC is a Dean's hospital affiliated with Creighton University School of Medicine and UNMC. All physicians on staff have faculty appointments at either or both of these medical schools. The program is fully integrated at the service levels which consist of medicine, surgery, neurology, and psychiatry. The Omaha VAMC has 250 beds with a yearly average of 63.6 patient days per bed broken down as 57.3 surgical, 67.5 medical, 14.9 neurological, 76.1 psychiatric. There are 142 designated surgical beds, 15 designated neurology beds, 68 psychiatry beds and 173 designated medical beds. The surgical intensive care unit has 10 designated beds and the medical intensive care unit has 11 designated beds. The center has a renal hemodialysis and chronic ambulatory peritoneal dialysis unit.

A full complement of medical subspecialties are represented including nephrology, cardiology, pulmonary medicine, allergy-immunology, endocrinology, rheumatology, hematology-oncology, gastroenterology, hepatology, dermatology, neurology, and infectious diseases. In addition to infectious diseases, other subspecialties with fellowship programs at this hospital include gastroenterology, hematology-oncology, cardiology, allergy-immunology, and pulmonary. Surgical specialties include general, thoracic, vascular, orthopedic, plastic and reconstructive, ENT, ophthalmology, neurosurgery, urology, and oral surgery. Excellent support services include pathology, radiology, (including ultrasound, computerized tomography, and MRI), nuclear medicine, rehabilitation medicine, social services, dietary, nutritional counseling, and audiology.

The diagnostic microbiology laboratory is under the direction of Donald Giger, Ph.D., Assistant Professor of Medical Microbiology, Creighton University School of Medicine. Dr. Giger provides instruction in diagnostic microbiology for our fellows, residents and medical students and oversees the daily infectious diseases team's microbiology laboratory rounds. The laboratory utilizes the BACTEC and VITEC automated systems for rapid detection, identification and susceptibility testing of clinical isolates.

INPATIENT EXPERIENCE

Each Infectious Diseases Fellow is responsible for 5-10 patients at any given time. At SJH the Infectious Diseases Service accepts primary care patients on occasion and will have an average of 0-1 such patients on its service at any one time. The Infectious Diseases Fellow is responsible for the supervision of these patients under the auspices of the attending staff. There are no Infectious Diseases categorical beds at Omaha VAMC or UNMC. At these facilities the trainee serves as a consultant on all cases.

Trainees participate in acute management of all patients with infectious diseases seen by the service. This includes consideration of appropriate diagnostic, therapeutic, and preventive or infection control measures as needed. As consultants, fellows communicate directly with the consulting primary physicians and with other consultants involved with the patient. In some cases, the primary physicians relinquish to the trainee the entire responsibility for ordering or performing diagnostic tests or procedures as well as for prescribing and monitoring antimicrobial therapy. Patients with chronic illnesses who require continued hospitalization are followed by the Infectious Diseases Service throughout their course to insure appropriate therapy and for educational purposes.

In the course of their fellowship, trainees are exposed to virtually every type of infection with the possible exception of some rare tropical diseases. Trainee participation in staffing the Douglas County Travelers Clinic assures their familiarity with common as well as unusual diseases encountered among travelers in foreign lands. The patient mix at the major teaching hospitals complement each other. At SJH, the trainee's experience includes infections in children and young adults whereas patients tend to be older and more debilitated at the Omaha VAMC. UNMC provides excellent training in traditional adult and pediatric infections. In addition, during rotations there fellows see numerous immunocompromised patients with infectious complications of bone marrow and organ transplantation as well as AIDS. Fellows have the responsibility of planning appropriate diagnostic and therapeutic intervention and staff on each case.

The trainee is appointed an Assistant Instructor of Medical Microbiology and of Medicine. Trainees are responsible for coordinating the consultative service and supervising the performance of both the residents and the students. As junior faculty, they participate in teaching, research, and patient care. At the Omaha VAMC trainees are responsible with attending faculty, for approval and supervision of the use of controlled antibiotics. Fellows are not required to take night call in the hospital and serve as first backup for residents for night and weekend consultations.

AMBULATORY CARE FACILITIES EXPERIENCE

At SJH, outpatients are seen in the adjacent Health Professions Center of Creighton University. This clinic was newly remodeled in 1987. It is adequately staffed by competent nurses, has sufficient examining rooms to allow an efficient clinic, and provides outpatient laboratory support with rapid reporting of results.

The outpatient clinic wing at the Omaha VAMC was constructed in 1987. It is a modern, fully equipped facility with excellent staffing, availability of examining rooms, and outpatient laboratory support. Outpatient intravenous therapy can be provided in this clinic and at the clinics in SJH and UNMC.

The HIV Clinic at UNMC is the largest HIV clinic in a region which includes western Iowa, northern Kansas, the Dakotas as well as Nebraska. Of the 500 patients currently enrolled, approximately 11% of patients are women, 11% are black, and 3% Hispanic, reflecting the demographics of the region. A recent affiliation with the University of Minnesota will allow UNMC access to some ACTG protocols, providing the fellows exposure to advanced HIV clinical research.

The Douglas County Health Department Travelers Clinic is under the professional direction of the Infectious Diseases Section, Creighton University School of Medicine. The clinic is located at Douglas County Hospital, which is across the street from the Omaha VAMC. Four to six months per year, each trainee helps an attending faculty member staff the clinic one afternoon each week. Travelers are counseled on malaria, yellow fever, cholera, viral hepatitis, typhoid fever, travelers diarrhea, polio, AIDS, meningococcal meningitis, rabies, tetanus, influenza, and numerous other preventable diseases. Immunization schedules are devised and malaria prophylaxis is prescribed. This clinic serves 250-300 travelers each year. Returning travelers who contract tropical diseases consult our Infectious Diseases Section for diagnosis and therapy.

The Infectious Diseases Service has over 2,000 outpatient visits annually between the various clinics at SJH, Omaha VAMC, and UNMC. Trainees are responsible for the diagnosis and therapy of Infectious Diseases outpatients under the supervision of the attending faculty member. Continuity of care experience is maintained by Fellow participation in patient management and discussions at weekly patient care conferences.

Trainees are supervised by full-time Infectious Diseases Faculty. Faculty are present and help staff all clinics. Faculty members help trainees supervise medical students and residents in the outpatient clinic. Fellows may see patients evaluated by the medical students or residents and help formulate their management plans. Each case is reviewed with the faculty member who then interviews and examines the patient. The case is discussed within the group and a decision is made regarding appropriate patient management.

EDUCATIONAL PROGRAM

All trainees who have entered our program to date have been competent in routine internal medicine procedures based upon their Internal Medicine Residency training program. These routine technical procedures would include spinal tap, liver biopsy, bone marrow aspiration and biopsy, skin biopsy, thoracentesis, paracentesis, arthrocentesis, and needle aspiration of cutaneous or subcutaneous abscesses. Those who may lack training in such technical procedures would be identified. They would be supervised in the performance of such procedures and their experience would be documented in their monthly evaluation form.

An individual faculty member is responsible for daily rounds at each hospital every month. University faculty rotate their responsibility between SJH, UNMC, and the Omaha VAMC. Faculty rounds usually begin in the microbiology laboratory. The faculty member directs the trainee, resident and student education in the laboratory with the help of the clinical microbiologist(s). The attending faculty then reviews pertinent X-rays or other diagnostic test results with the team. All patients currently followed and new consults are presented to the attending faculty by members of the team including the Infectious Diseases Fellow, resident, or student. New patients are interviewed and examined during bedside rounds by the attending faculty followed by an indepth discussion of salient features of the case. Faculty members assign topics to the trainee and other members of the infectious diseases team for presentation on subsequent rounds. Attending rounds last an average of 4-5 hours per day on weekdays and 2 hours per day on weekends.

First year Fellows spend 4-6 weeks in the diagnostic microbiology, virology, and immunology laboratories. During this time they are trained in the basic laboratory diagnosis of bacterial, mycobacterial, fungal, viral, chlamydia, and parasitic diseases. Fellows are given progressive clinical responsibilities and play a graduated role in patient management as their experience and knowledge progresses. Trainees are encouraged to participate in on-going educational experiences including journal clubs, research conferences, Department of Medical Microbiology seminars, and Department of Medicine Grand Rounds and Subspecialty Conferences. They are encouraged to audit graduate level courses in the Department of Medical Microbiology. These courses span the entire spectrum of microbiology, immunology, pathogenesis, microbial genetics, and antimicrobial agents. All fellows are expected to attend the annual Interscience Conference on Antimicrobial Agents and Chemotherapy and/or the annual meeting of the Infectious Diseases Society. The section of Infectious Diseases pays the fellows' expenses for this trip. The section will also pay for any additional meeting where the fellow presents a scientific paper. Fellows are expected to attend University and VAMC Infectious Diseases conferences, visiting lectureships, and symposia throughout the year. They are encouraged to take advantage of similar conferences held at the Omaha-Midwest Clinical Society and other private hospitals in the community.

Each year, fellows are responsible for preparing and presenting one fifty-minute conference for the Department of Medicine and/or the Department of Medical Microbiology. Senior Fellows may participate as lecturers in the Medical Microbiology Course for Sophomore Medical Students. In addition, each fellow is responsible for preparing one Infectious Diseases Case Conference monthly. This conference involves coordinating the presentation and discussion of 3-4 interesting cases presented to the infectious diseases physicians and clinical microbiologists of the Omaha metropolitan area. Fellows are responsible for preparing and giving informal presentations during teaching sessions for residents and students.

The annual Creighton-University of Nebraska Infectious Diseases Symposium is a unique learning experience for the entire section. National experts are invited to speak on their areas of special expertise. Fellows are given the opportunity to meet and learn from the most distinguished leaders in Infectious Diseases.

RELATED DISCIPLINES

Creighton University Department of Medicine offers Subspecialty Training Programs in Pulmonary, Cardiology, Allergy/Immunology, and Infectious Diseases. The University of Nebraska Medical Center Department of Medicine has subspecialty training programs in Gastroenterology, Pulmonary, Cardiology, Hematology-Oncology, and Neurology. All subspecialty training programs at Creighton or the University of Nebraska utilize the Omaha Veterans Affairs Medical Center, so there is significant interaction between Infectious Diseases trainees and other subspecialty training programs.

At Saint Joseph Hospital and the University of Nebraska Medical Center, trainees work closely with the Section of Infectious Diseases of the Department of Pediatrics. Joint rounds may be conducted with the Sections of Adult and Pediatric Infectious Diseases beginning with microbiology laboratory rounds and extending to bedside rounds and clinical conferences. Dr. Stephen Chartrand, Chief of Pediatric Infectious Diseases, is committed to providing our trainees with excellent exposure to pediatric infectious diseases at the laboratory and clinical level.

Faculty members from the adult and pediatric Sections of Infectious Diseases as well as private Infectious Diseases practitioners participate in the Weekly Infectious Diseases Case Conference. They provide additional instruction for Creighton University Infectious Diseases Fellows by sharing their expertise at these joint conferences. One conference each month is devoted to pediatric infectious diseases. Our trainees are invited to all infectious diseases conferences and symposia sponsored by other hospitals and institutions in Omaha.

RELATIONSHIP TO THE INTERNAL MEDICINE PROGRAM

Internal Medicine residents and students rotate on the Infectious Diseases Service at either SJH, UNMC, or the Omaha VAMC on a monthly basis. As Assistant Clinical Instructors in the Department of Medicine, Infectious Diseases Fellows are responsible for both teaching and supervising the medical students and residents during this rotation. Fellows direct students and residents to pertinent articles in the current literature and help assign topics to be presented for discussion on daily rounds. Fellows supervise the performance of diagnostic procedures as needed and help teach residents and students some of the essentials of diagnostic microbiology.

Patients are referred to the Internal Medicine or Subspecialty Services at SJH or UNMC by private physicians or are assigned to these services from the emergency room or ambulatory care area. At the Omaha VAMC patients are assigned in a similar fashion although there are no categorical subspecialty beds. All infectious diseases patients are cared for by primary care internal medicine residents at the Omaha VAMC and at UNMC.

RESEARCH

Trainees have available to them outstanding medical libraries at Creighton University, the State Medical Library at the University of Nebraska Medical Center, and a smaller but very adequate library at the Omaha Veterans Affairs Medical Center. Computer-assisted searches are available for literature review projects.

All Fellows participate in some form of research activity. This may be a retrospective review study, prospective clinical study, or basic laboratory project. Fellows participate in all phases of investigation including development and review of protocols, data collection, data analysis, and data reporting. A full-time clinical research coordinator helps gather data and monitor patients during clinical trails of investigational agents. During clinical studies, trainees learn the requirements of Institutional Review Boards and other agencies such as the Food and Drug Administration. Fellows learn how to obtain potentially lifesaving but investigational antimicrobials from pharmaceutical firms or government agencies for use under "compassionate release" circumstances. Fellows learn to compose abstracts, give scientific presentations, and write manuscripts submitted for publication in peer-reviewed journals.

If desired, fellows can participate in a variety of laboratory research projects. Some current areas of basic investigation include the following:

a) Studies on the molecular basis of HIV neuronotoxicity and the role of macrophages in HIV resistance and pathogenesis. (Dr. Gendelman)

b) Effects of chronic ethanol intake on the pathogenesis of pneumococcal pneumonia in a rat model. (Dr. Gentry)

c) Computerized image analysis of gonococcal mucosal invasion using fallopian tube organ tissue culture system. (Dr. Gorby)

d) Pathogenesis of pneumococcal infections in a rat model of cirrhosis. (Dr. Preheim)

e) Significance of hemagglutinin and other virulence factors in the pathogenesis of staphylococcal infections. (Dr. Rupp)

f) Molecular epidemiology of staphylococcal infections. (Dr. Fey)

g) Mechanisms of antimicrobial resistance (Dr. W.E. Sanders, Jr.)

OTHER ASPECTS OF TRAINING

The unique alignment of the Infectious Diseases Section with the Departments of Medicine and Medical Microbiology and Immunology is a distinct advantage for our trainees. As internists, section members participate in all the usual Department of Medicine clinical and educational activities. The close working relationship between the basic science and clinical faculty in the Department of Medical Microbiology and Immunology facilitates basic science instruction of our fellows. Our fellows admire, respect, and learn a great deal from the basic scientists in our department. They observe firsthand the benefits of collaborative clinical and research efforts conducted by M.D.'s and Ph.D.'s. Many fellows take the opportunity to work with our basic or clinical microbiology faculty in some of their research projects. Our fellows interact with post-doctoral, doctoral, and masters program graduate students in our department. Fellows are encouraged to audit departmental graduate level courses. Additional instruction in basic science is achieved by mandatory participation by trainees in the weekly Department of Medical Microbiology and Immunology seminar program. The seminar consists of basic presentations related to microbiology and infections diseases. Presentations are made by visiting scientists, graduate students, faculty members, and fellows. The Medical Microbiology Journal Club and the Department of Medicine Research Conference also serve as vehicles to instruct trainees in the basic sciences.

Psycho-social and economic considerations as well as ethical issues are considered with each patient seen in consultation. Group discussions on rounds, at seminars, and in conferences highlight these areas. Ethical and legal issues of medicine and infectious diseases are discussed at a Department of Medicine Medicolegal Conference held monthly. Matthew Severin, Ph.D., J.D., is a colleague in the Creighton University Department of Medical Microbiology and Immunology. He is a valuable resource because of his extensive knowledge of medicine and the law. Marvin J. Bittner, M.D., one of our Infectious Diseases faculty, has developed a special interest in the area of medical ethics and informed consent. He provides thoughtful direction when fellows are confronted with ethical issues involving patient care or clinical research. Dr. Dworzack is Chairman of the Creighton University Institutional Review Board and is well versed on ethics in research. In addition, outside experts in these areas are invited to Creighton University to speak on these topics.

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Updated Feb 2005