Infectious Disease Infectious Disease This is a four week block rotation under the supervision of Rana Zaman, MD and Infectious Disease faculty. Residents gain experience in the evaluation and care of infectious diseases.
Additionally, infectious disease training takes place longitudinally throughout all 3 years. Block rotations in Ambulatory Medicine, Adult Medicine, Critical Care, Continuity Clinic and weekly conferences may also include an Infectious Disease component. Experiences include travel clinic, wound care clinic, and infection control and isolation practices.
I. GOALS
Demonstrate competence in the ambulatory and hospital care of patients with infectious diseases, including competency in the performance of an appropriately directed history and physical examination, selection and interpretation of laboratory studies, and determination of treatment.
Objective 1: Demonstrate clinical skills of comprehensive medical interview, history and physical examination, including functional assessment and mental status as needed.
Objective 2: Demonstrate clinical skills in the diagnosis and medical management of acute and chronic illness. Generate a differential diagnosis and problem list in accepted format.
Objective 3: Perform and record procedures
a. Demonstrate competence in the performance of standard invasive procedures in internal medicine employed by infectious disease consultants
b. Perform, examine, and interpret Gram stains.
B. MEDICAL KNOWLEDGE
Objective 1: Demonstrate understanding and application of key facets of the following infectious diseases and their treatments as follows:
a. Implement correct usage of antibiotic therapy
1. Antibacterial antibiotics
2. Antifungal agents
3. Antiviral agents
4. Antiparasitic agents
5. Toxicity of above agents
6. Antimicrobial prophylaxis
b. Recognize upper respiratory and pulmonary infections
1. Aspiration pneumonia
2. Diagnostic procedures
3. Viral pneumonia
4. Atypical pneumonia
5. Anaerobic pneumonia
6. Utility of gram stain
7. Gram negative pneumonia
8. Nosocomial pneumonia
9. Pneumonia in the elderly
10. Epiglottitis
11. Pharyngitis
c. Recognize cardiovascular infections, including endocarditis and prophylaxis of infective endocarditis
d. Recognize urinary tract infections
e. Recognize central nervous system infections
1. Acute meningitis
2. Encephalitis
3. Brain abscess
4. Subdural empyema
5. Chronic meningitis
f. Recognize skin and soft tissue infections
g. Recognize gastrointestinal infections
h. Recognize bone and joint infections
i. Recognize gynecologic infections and sexually transmitted diseases
j. Recognize Hepatitis and hepatitis syndromes
k. Recognize viral infections
1. Herpes simplex virus infections
2. Epstein-Barr virus infections
3. Varicella zoster virus infections
4. Cytomegalovirus infections
5. Miscellaneous viruses
l. Recognize chlamydial infections, including nongonococcal urethritis
m. Recognize mycoplasma infections
n. Recognize infections related to rickettsia
o. Recognize fungal infections
1. Candidiasis
2. Histoplasmosis
3. Blastomycosis
4. Cryptococcosis
p. Recognize infections caused by protozoans and helminths
1. PCP, malaria, and toxoplasmosis
q. Understand and apply principles of infection control and prevention of nosocomial infections
r.. Recognize catheter-related infections
s. Recognize mycobacterial infections
t. Recognize intra-abdominal and peritoneal infections
1. Peritonitis
2. Abdominal abscess
u. Recognize infections after solid organ transplantation and in the immunocompromised host
v. Recognize HIV infection and associated infections
w. Recognize sepsis and septic shock
x. Recognize immunizations, including travel related immunizations
y. Understand and utilize health advice and resources for travelers
z. Recognize miscellaneous organisms
1. Anaerobes
2. Moraxella
3. Hemophilus
4. Legionella
5. Borrelia burgdorferi (lyme disease)
6. Neisseria meningitides
7. Pseudomonas aeruginosa
8. Xanthomonas maltophilia
9. Staphylococcus aureus
10. Staphylococcus epidermidis
11. Streptococcus
12. Enterococcus
13. Salmonella
14. Zoonoses
15. Cat scratch disease
aa. Fever and fever of unknown origin
C. PRACTICE-BASED LEARNING AND IMPROVEMENT
Objective 1: Analyze and evaluate practice experiences, and implement strategies to improve the quality of patient care.
Objective 2: Use information technology and other available methodologies to access and manage information, support patient care decisions and enhance both patient and resident education.
D. INTERPERSONAL AND COMMUNICATION SKILLS
Objective 1: Create an atmosphere of positive regard for the patient and family to promote the best medical outcome through accessibility, and affability.
Objective 2: Incorporate psychosocial and ethical concerns of the patient and family in the development of the care management plan.
Objective 3: Dictate timely, comprehensive patient care notes, including admission and discharge summaries, and write thorough, succinct daily progress notes in accepted format.
E. PROFESSIONALISM
Objective 1: Demonstrate compassionate use of medical skills for patients. This includes high-quality care and technology and, in the event of terminal illness, an awareness of the limits of medical intervention and the obligation to provide humane care.
Objective 2: Recognize the legal requirements of advanced directives and describe the process of assessing a patient's advance directives, including the patient's perspective.
Objective 3: Model appropriate professional attitudes and behaviors of time management and punctuality, reliability, peer support, objective peer evaluation, community teaching, and ethical behavior.
F. SYSTEMS-BASED PRACTICE
Objective 1: Recognize financial issues of heath care, with emphasis on understanding acute and chronic care, and medication coverage and the role of the Centers for Medicare and Medicaid Services (CMS), and other third party payers.
Objective 2: Actively participate in the multidisciplinary approach to caring for patients, including appropriate recognition of other health professional and paraprofessionals' roles and demonstrate competence in team interactions, i.e. pharmacist, case manager, nurses, occupational and physical therapist, social worker.
III. METHODS
The resident is expected to contact Dr. Zaman prior to the onset of the rotation to discuss the planned schedule for the block. On day one, after attending sub-specialty rounds, the resident pages Dr. Rana Zaman at 0830. If Dr. Zaman is not available, the resident is expected to page the infectious diseases attending on-call. During each week, the resident spends 1 day at the DVAIHS, 3 days at Carle, one half day at CUPDH, and one half day at continuity clinic. There is no scheduled call. If the resident is scheduled for more than one week of leave from the rotation, s/he will be required to work weekends to complete curricular requirements.
As part of the rotation, the resident completes a non-weighted pre and post knowledge assessment test, i.e. day one pretest and final day post test.
The resident has access to the current edition of A Practical Approach to Infectious Diseases (Reese, RE, Betts, RF, eds. Little, Brown) through the Carle Medical Library. Required reading assignments prior to the rotation start include fever work-up; bacteremia, line sepsis; urinary tract infection; and community-acquired and hospital-acquired pneumonia. At a minimum, the resident should be familiar with Reese pertinent to each patient being followed, and review the text to achieve broad familiarity with the field. The resident is also expected to read the infectious diseases section of the latest MKSAP syllabus.
The resident is expected to use the Infectious Diseases Reading List in conjunction with issues which arise during the rotation. Special attention should be focused to core readings, copies of which are available from the Infectious Disease Clinic.
Ambulatory
Residents work under the direct supervision of an assigned attending. Patient care responsibilities extend from Monday through Friday, 0730 to 1700. The residents perform the initial history and physical examination, and present findings and available laboratory data to the attending. After reviewing patient data and pertinent teaching points, the resident and attending complete the patient encounter together. Selected components of the examination may be repeated and demonstrated to the resident. Residents are responsible for documenting the patient encounter with a written or dictated note.
During the block, the resident visits the Microbiology Laboratory for 2-4 hours to review practical aspects of gram staining and culture media, and become familiar with other tests specific to the infectious disease subspecialty.
Inpatient
The resident participates in the care of 5 to 10 inpatients. The resident performs history and physical examination, outlines treatment plan, and manages the case under the supervision of the attending. After hours and on weekends, the resident will be alerted to patients who have conditions of special educational interest and, when possible, will return to the hospital to see such patients. Work hours must strictly conform to ACGME standards.
When a patient's infectious diseases problems become stable or inactive, the resident will follow the patient on an intermittent basis or will cease to follow the patient; this mutual decision with the attending faculty member will reflect the resident's entire patient load and mix to optimize the educational experience.
The resident obtains references concerning the patient management to further his/her education and assist in patient care; the content is reflected in the progress notes; copies are placed on the chart and shared with faculty members and other residents.
Conferences
A bimonthly Infectious Disease Case Conference is held for residents and medical students. This teaching experience is a collaboration with microbiology and pathology laboratory personal to review pertinent slides, microbiological appearance and discuss treatment. The resident provides a 30-minute presentation on an infectious disease topic for medical students and residents
Infectious Disease conference is held the first and fourth Friday of the month. The resident assists in the selection and presentations of patients' conferences. The resident assumes primary responsibility for coordinating conferences. The resident contacts faculty prior to both weekly and monthly conferences to coordinate the conference. The focus is on case presentation to optimize instructional impact, which may depart from the standard history and physical format. The resident obtains pertinent x-rays and other clinical materials; in addition, s/he performs pertinent literature searches to share, and discuss.
IV. EVALUATION
According to Accreditation Council of Graduate Medical Education (ACGME), training and evaluation must include the following competencies: Patient Care, Medical Knowledge, Practice – Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, and System-Based Practice.
Patient Care will be evaluated by assessment of the attending physician and chart audit. Procedures performed will be documented.
Medical Knowledge will be evaluated by assessment of the attending physician and chart audit.
Practice-Based Learning and Improvement will be evaluated by assessment of the attending physician and chart audit.
Interpersonal and Communication Skills will be evaluated by assessment of attending physician and additional information from nursing staff, patients and families; and chart audit. .
Professionalism will be evaluated by assessment of attending physician and additional information from nursing staff, patients and families.
System-Based Practice will be evaluated by assessment of the attending physician and chart audit.
The evaluation method is primarily accomplished electronically. Residents' performance is evaluated by the attending physician. Evaluations are reviewed with the residents for formal feedback. Face to face interaction between the attending physician and the resident is the preferred method. At the midway point of the rotation, the resident is encouraged to approach the attending to assess and discuss performance. In addition, ongoing feedback is provided related to residents' patient care responsibilities and activities.
Residents will document the Infectious Disease rotation in portfolios, e.g. patient care responsibilities. This tool will provide individual learning, reflection and assessment. Additionally, residents will evaluate the rotation experience.
Residents provide input on the Infectious Disease core lecture series, which is used in scheduling future topics and speakers. Conference lectures include: Antibiotic Use, Basics of Antimicrobial Therapy, Bone and Joint Infections, Central Nervous System Infections, Hand Hygiene and Isolation Practices, Human Immunodeficiency Virus, Immunizations, Infections in Solid Organ and Bone Marrow Transplant Recipients, Infective Endocarditis, Introduction to Mycology, Introduction to Parasitology, Introduction to Virology, Mycobacterial Diseases, Sexually Transmitted Diseases and Pelvic Inflammatory Disease, and Tick-borne Illnesses.
V. REFERENCES
See Teaching File in Dr. Rana Zaman's office
Principles and Practice of Infectious Diseases – Library, ID physicians
Manual of Clinical Microbiology- Cora Musial, MD
2003 Red Book - Library, Cora Musial, MD
Infectious Diseases in Primary Care – Cora Musial, MD
AIDS Knowledge Base- Library
Infectious Disease Reading List
HIV
Johns Hopkins Hospital Medical Care of Patients with HIV Infection
2001-2002 Medical Management of HIV Infection
Presenting Syndromes of HIV Orenstein, MC Proc. 2002 77:1097-1102
Interactions among Drugs for HIV and OI's Piseitelli NEJM 344: 984-996
Medical Letter Drugs for HIV Infection 11/26/01 , 103-108
Guidelines for Using Antiretroviral Agents in HIV MMWR 5/17/02
Guidelines for Preventing OI's in HIV- 2002 MMWR 6/14/02
STD
Medical Letter Drugs for STD's 9/24/99
MMWR STD Guidelines 2002 5/10/02
TB
MMWR Targeted Tub. Testing & Rx of LTB1 6/9/00
IDSA Practice Guidelines for Rx of TB CID 2000 31:633-9
Dx Stds & Classification of TB AmJ Resp Crit Care Med 161:1376-1395 2000
Rx of TB AmJ Resp Crit Care Med 167: 603-662 2003
Dx & Rx of Disease caused by nontub. Mychondria AmJ Resp Crit Care Med 156:51-525 1997
Core Curriculum on TB CDC 4 th ed 2002
Antimicrobics
MC Proc Symposium on Antimicrobial Agents 98', 99', 00
Med. Letter Antimicrobial Prophylaxis in Surgery 8/27/99
Med. Letter the Choice of Antibacterial Drugs 8/20/01
Med. Letter Drugs for Non-HIV Viral Infections 2/4/02
Med. Letter Drugs for Parasitic Infections 1/2/98
Intro to Antifungal Drugs CID 2000 30: 653-7
Infection Control
The IC Committee Wiblin IC&Hosp. Epid 1996 17: 44 -46
Requirements for Infrastructural and Essential Activities of IC….Scheckler IC & Hosp Epid 1998 19: 114-124
Basics of Surveillance-An Overview Rottinger IC & Hosp Epid 1997 18: 513-527
Guidelines for Isolation Precautions…. Garner IC & Hosp Epid 1996 17: 53 -80
Isolation Edmond IC & Hosp Epid 1997 18: 58 -64
Hosp Epid in Smaller Hospitals Boyo IC & Hosp Epid 1995 16: 600-606
MMWR Guidelines for Management of Occupation Exposures HBV, HCV, HIV
and Recs for post exposure prophylaxis 6/29/01
Endocarditis, Mycarditis, Vascular Grafts
IE in Adults Mylonakis NEJM 345:1318-1330 6/1/01
Prevention of Bacterial Endocarditis AHA Recs Dajan1 JAMA 277: 1794-1801 6/11/97
Antibiotic Rx for IE Wilson JAMA 12/6/95 274: 1706-1713
Myocarditis Feldman NEJM 343: 1388-1398 11/9/00
Arterial Prosthetic Infections Goeau-Brissonniere book Infections Associated with Indwelling Medical Devices 3 rd Edition Chapter 7 p127-144
Travel
Health Advice and Immunizations for travelers Ryan NEJM 342: 1716-1725 6/8/00
Medical Advice for International Travelers Vink MC Proc 76: 831-840 2001
Protection of Travelers Wolfe CID 25: 177-86 CID
Illness After International Travel Ryan NEJM 347: 505-516 8/15/02
Medical Letter Advice for Travelers 4/15/02
Fever/Fever and Skin Eruption
FUO in Adults Hirschmann 1997 24:291-302 CID
Practice Guidelines for Evaluating New Fever in Critically Ill Adult Pts O'Grady CID 1998 26:1042-1059
Practice Guidelines Evaluation of Fever and Infection in Long Term Care facilities Bentley CID 2000 31: 640-53
An approach to Acute Fever and Rash in the Adult Levin Current Clinical Topics in Infectious Diseases p19-75
Clinical Approach to Rash & Fever Cunha Inf Dis Practice 20: 1-5 1/96
Fever in Immunocompromised Patients Pizys NEJM 341: 893-900 9/16/99
2002 Guidelines for the use of Antimicrobial Agents in Neutropenic Patients with Cancer Hughes CID 34: 730-51 3/02
Transplant ID
Infection in Organ-Transplant Recipients Fishman NEJM 338:1741-1751 6/11/98
Sepsis
The Pathophysiology and Treatment of Sepsis Hotchire NEJM 348: 138-150 1/9/03
Catheter Related Infections
Guidelines for the Mgmt of Intravascular Catheter Related Infections Normal CID 2001 32:1249-72
MMWR Guidelines for the Prevention of Intravascular Catheter Related Infections 8/9/02
Output IV Rx
Outpatient Parenteral Antimicrobial Drug Therapy NEJM 337: 829-838 9/18/97
Practice Guidelines for OPAT CID 2004
Fungal Infections
Practice Guidelines for Diseases Causes of Aspergillus CID 30:696-709 2000
Practice Guidelines for the Management of Patients with Blastomycosis CID 30: 679-683 2000
Practice Guidelines for the Treatment of Candidias CID 30: 662-678 2000, CID 2004
Practice Guidelines for the Treatment of Coccidiomycosis CID 30: 658-661 2000
Practice Guidelines for the Treatment or Cryptococcal Disease CID 30:710-718 2000
Practice Guidelines for the Management of Patients with Histoplasmosis CID 30: 688-695 2000
Practice Guidelines for the Management of Patients with Sporotrichosis CID 30: 684-687 2000
CNS Infections
Practice Guidelines for Bacterial Meningitis CID 2004
Acute Encephalitis CID 23: 219-226 1996
Brain Abscess CID 25: 763-781 1997
Bacterial Meningitis in the US in 1995 NEJM 337: 970-976 10/2/97
Treatment of Bacterial Meningitis NEJM 336: 708-716 3/6/97
Meningococcal Disease NEJM 344: 1378-1388 5/3/01
West Nile Virus: A primer for the Clinician Annals of Int Med 137: 173-179 8/6/02
Infections of CNS Shunts in Infections Associated with Indwelling Medical Devices 3 rd ed. Chapter 11 p231-246
CSF Shunt Infections: a personal view Ped Inf Dis 4: 113-118 1985
Treatment of Infections of CSF Shunts RID 9: 595-603 1987
Shunt Infections ID Clinics of NA 4:683-691 12/90
Herpes Zoster NEJM 347: 340-346 8/1/02
Lyme Disease
Practice Guidelines for the Treatment of Lyme Disease CID 31: 51-514 2000 Supplement
Lyme Disease NEJM 345: 115-125 editorial 133-134 7/12/01
Rabies
Human Rabies Prevention - US 1999 48: 1-21 No. RR-1 1/8/99
Reemergence of Rabies in the US (Medscape p1-11) Infect Med 16:129-138
Eye
The Red Eye NEJM 348: 345-351 8/3/00
Infections Endophthalmitis Inf Dis Clinics of NA 6: 859-873 12/92
Skin and Soft Tissue Infections
Handout - STAYS IN FILE
Respiratory Infections
Practice Guidelines for the Management of CAP in Adults CID 31: 347-382 2000
Diagnosis and Management of Group A Streptococcal Pharyngitis: A Practice Guideline CID 25: 574-583 1997
Acute Community-Acquired Sinusitis CID 23: 1209-1225 1996
Rhinosinusitis Medical Clinics of NA 83: 27-41 1/99
GI Infections
Peritonitis: Update on Pathophysiology, Clinical Manifestations and Management CID 24: 1035-1047 1997
Intro-Abdominal Abscesses p 397-409
Practice Guidelines for the Management of Infections Diarrhea CID 32: 331-350 2001
Antibiotic Associated Diarrhea NEJM 346: 334-339, 333 7/31/2002
Hepatitis C Virus Infection NEJM 345: 41-52 7/5/01
UTI
Guidelines for Antimicrobial Treatment of Uncomplicated Acute Bacterial Cystitis and Acute Pylonephritis in Women CID 29: 745-758 1999
Management of Urinary Tract Infections in Adults NEJM 329: 1328-1334 1993
Infections Arthritis
Infections Arthritis CID 20: 225-231 1995
Infection Arthritis Current Treatment Options in Infectious Diseases 2: 238-246 2000
Osteomyelitis
Osteomyelitis NEJM 336:999-1007 4/3/1997
Osteomyelitis in Elderly Patients CID 35: 287-193 2002
Osteomyelitis of the Foot in Diabetic Patients CID 25: 1318-1326 1997
Foot Ulcers/Wound Healing
Foot Ulcers NEJM 343: 787-793 9/14/00
Assessment and Management of Foot Disease in Patients with Diabetes NEJM 331: 854-860 9/29/94
Diabetic Foot Ulcers and Infections Current Treatment Options in Infections Diseases 2:214-225 2000
Cutaneous Wound Healing NEJM 341: 738-746 9/2/99
Diagnosis and Treatment of Diabetic Foot Infections CID 2004
Prosthetic Joint Infections
Prosthetic Joint Infections in Infections Associated with Indwelling Medical Devices, 3 rd ed. ASM Press 2000 p173-209
Ambulatory Management of Infected Orthopedic Implants in Infections Associated with Indwelling Medical Devices , 3 rd ed. ASM Press 2000 p. 211-230
Prevention and Management of Infections after Total Joint Replacement CID 25: 1310-1317 1997
Clinical Microbiology
General Principles of Specimen Collection and Transport CID 22: 766-777 1996
Current Blood Culture Methods and Systems: Clinical Concepts, Technology and Interpretation of Results CID 23-40-46 1996
Microbiology and Laboratory Diagnosis of Upper Respiratory Tract Infections CID 23: 442-448 1996
Role of the Microbiology Laboratory in the Diagnosis of Lower Respiratory Tract Infections CID 23: 1292-1301 1996
Effective Use of the Clinical Microbiology, Laboratory for Diagnosis of Diarrheal Diseases CID 23: 1292-1301 1996
Antimicrobial Susceptibility Testing: General Principles and Contemporary Practices CID 26: 973-980 1998
Antifungal Susceptibility Testing: Technical Advances and Potential Clinical Applications CID 24: 776-784 1997
The Clinical Microbiology Laboratory and Infection Control: Emerging Pathogens, Antimicrobial Resistance and New Technology CID 25: 858-870 1997
Miscellaneous
QD aminoglycoside dosing
List of IDSA Practice Guidelines- in Up To Date
Recommended Adult Immunization Schedule-US 2002-2003
MMWR Vol 51 No. 40 pages 905, 907
Rev 8/1/05, 7/1/06, 7/1/07