Infectious Diseases

Educational Plan: A competency based development of knowledge and skills in Infectious Diseases through clinical experience, bedside teaching, didactic conferences and readings to achieve competence, proficiency and the foundation for mastery. 

Educational Methods:

Clinical Information and Didactics

• Residents will independently evaluate patients on one of the following inpatient consult services: Medicine/Neuro, Surgery/HemeOnc or Transplant. Residents will also aid in forming diagnostic and treatment recommendations in conjunction with the infectious disease fellow and attending.
• Daily didactic consultation rounds will take place facilitated by an infectious disease faculty member and fellow.
• Residents are expected to attend all infectious disease conferences listed below and will attend general medicine conferences at all other times.
• NMH Infectious Diseases Inpatient Consultation Service Fellow Pager:
  • Medicine/Neurology 312-695-4522
  • Surgery/HemeOnc 312-695-6380
  • Transplant 312-695-1872

Evaluation: Click here

Goals and Objectives:  Review the 6 core competencies that apply to your clinical rotations.Click here.

PGY 1

• Evaluation of the febrile patient
• Knowledge of presentation and management of common infectious syndromes: Meningitis, Pneumonia, Gastroenteritis/Colitis, Cellulitis, Wound Infection, Urinary Tract infections, Bactermia/Sepsis and Nosocomial Infections.
• Discuss the major classes of antibiotics, their appropriate use, and important side effects.
• Read and interpret gram stains, AFB smears, fungal stains, and understand the general principles of obtaining and interpreting microbiologic cultures and sensitivity reports.
• Perform literature searches, read textbooks and journal articles pertinent to the infectious disease cases that are being seen on service.

PGY 2,3

1. Evaluate microbiology lab results to help distinguish between colonization, contamination, and infection.
2. Compare and contrast the spectrum of antimicrobial activity, pharmacokinetics, dosing, and adverse reactions of antibiotics on the NMH formulary.
3. Understand the physician’s role in limiting emergence and transmission of resistant pathogens.
4. Be able to formulate a differential diagnosis for fever in patients with:
   • prolonged mechanical ventilation
   • recent CVA
   • recent surgery (coronary artery bypass grafting, intraabdominal)
   • solid organ transplant
   • neutropenia
   • advanced HIV/AIDS
5. Be familiar with antimicrobial prophylaxis used for surgery.
6. Understand the microbiology of both community-acquired and nosocomial pneumonias including recognition of emerging resistance in CAP pathogens. Be able to utilize empiric antibiotic therapy. Understand the indications for bronchoscopy, CT scanning, and thoracentesis. Construct a differential for patients not improving with empiric therapy for pneumonia
7. List the typical pathogens responsible for IV catheter-related sepsis. Use empiric antibiotic regimens for specific pathogens. Understand the indications for catheter removal and echocardiography.
8. Be able to use the modified Duke criteria for the diagnosis of infective endocarditis. Compare the sensitivity of transthoracic and transesophageal echo in diagnosing endocarditis. Utilize appropriate initial empiric treatment as well as tailored treatment regimens for S. viridans, enterococci, S. aureus (left-sided and right-sided). List the indications for surgical valve repair.
9. Recognize the role of the following tests in diagnosing osteomyelitis: x-ray, bone scan, gallium scan, CT, MRI. Describe the role of ESR and CRP in monitoring response to treatment. Understand the significance of superficial wound swabs vs deep tissue or bonecultures to help identify an etiologic agent. Prescribe appropriate treatment regimens.
10. Understand the microbiology of cellulitis and other soft tissue infections. Recognize the clinical features of necrotizing infections. Utilize appropriate treatment regimens.
11. List the typical pathogens causing bacterial meningitis and utilize appropriate initial empiric antibiotic therapy. Recognize the clinical features of herpes simplex virus encephalitis and be able to use appropriate diagnostic testing.
12. Describe the different diagnostic testing available for Clostridium difficile colitis including toxin assay, culture, and endoscopy with biopsy.
13. Review the epidemiology and transmission of HIV and recognize the clinical features of primary HIV infection. Understand the significance of the CD4 lymphocyte count and the HIV viral load and understand the appropriate timing for prophylaxis of Pneumocystis carinii pneumonia, Mycobacterium avium complex, and toxoplasmosis. Describe the role of highly active antiretroviral therapy in treatment of HIV. Describe the clinical features and appropriate therapy of opportunistic infections acquired in HIV patients including PCP, cryptococcal meningitis, toxoplasma encephalitis, CMV retinitis, disseminated MAI.
14. Utilize appropriate antibiotic therapy in the febrile neutropenic patient.
15. Recognize the clinical features, risk factors, and utilize the appropriate diagnostic testing and therapy for opportunistic infections affecting bone marrow and solid organ transplant patients including cytomegalovirus, herpes virus, and invasive fungal infections. Understand the appropriate prophylaxis for prevention of HSV, bacterial, fungal, toxoplasma, and PCP infections.

Top References for General ID and Immunocomprised ID

General ID:

1. de Gans J, van de Beek D. Dexamethasone in adults with bacterial meningitis. EuropeanDexamethasone in Adulthood Bacterial Meningitis Study Investigators. N Engl J Med. 2002 Nov 14;347(20):1549-56
2. Chastre et al. Comparison of 8 vs 15 days of antibiotic therapy for ventilator-associated pneumonia in adults: a randomized trial. JAMA. 2003 Nov 19;290(19):2588-98
3. Weber JT. Community-associated methicillin-resistant Staphylococcus aureus. Clin Infect Dis. 2005 Aug 15;41 Suppl 4: S269-72
4. Hill DR et al. The Practice of Travel Medicine: Guidelines by the Infectious Diseases Society of America. Clinical Infectious Diseases 2006;43:1499-153
5. Mourad O, Palda V, Detsky AS. A comprehensive evidence-based approach to fever of unknown origin. Arch Intern Med. 2003 Mar 10;163(5):545-51
6. Spanakis, Aperis , Mylonakis. New Agents for the treatment of fungal infections: Clinical efficacy and gaps in coverage. CID Vol 43 (2006) pages 1060-1068
7. Thielman NM, Guerrant RL. Acute infectious diarrhea. NEngl J Med. 2004 Jan 1;350(1):38-47
8. Thwaites et al. Dexamethasone for the Treatment of Tuberculous Meningitis in Adolescents and Adults. N Engl J Med. 2004 Oct 21;351(17):1741-51
9. Pronovost P et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006 Dec 28;355(26):2725-32
10. Zimmerli W, Trampuz A, Ochsner PE. Prosthetic-Joint Infections. New Engl J Med 2004; 351: 1645-54.
11. Baddour LM et al. AHA Scientific Statement on Infective Endocarditis. Circulation 2005; 111: 3167-84.
12. Aslam S, Hamill RJ, Musher DM. Treatment of Clostridium difficile-associated disease: old therapies and new strategies. Lancet Infect Dis 2005; 5: 549-57. 
13. Lipsky BA et al. IDSA guidelines: Diagnosis and treatment of diabetic foot infection. Clin Infect Dis 2004; 39: 885-910.
14. Baddour et al. AHA Scientific statement on Infective Endocarditis Diagnosis, Antimicrobial Therapy, and Management of Complications – endorsed by IDSA Circulation. 2005;111:e394–e434
15. Mourad O, Palda V, Detsky AS. A comprehensive evidence-based approach to fever of unknown origin. Arch Intern Med. 2003 Mar 10;163(5):545-51 http://archinte.ama-assn.org/cgi/content/full/163/5/545 
    • The authors of this article did a MEDLINE database search for articles relating to FUO, especially regarding prevalence of particular causes and advantages/disadvantages of certain diagnostic tests. They found that in the 1990s, no diagnosis was found in 30% of patients with FUO. Infection accounted for 24.5%, inflammatory causes for 23.5%, and malignancy for 14.5% of cases of FUO. The authors recommend the following: once a patient is found to have FUO (fevers >38.3 C on several occasions and lasting longer than 3 weeks, with an uncertain diagnosis after 1 week of hospital investigation – the current definition requires only 3 days of hospital evaluation), medications should be discontinued if possible. No empiric antibiotic therapy should be attempted. Diagnostic “tests” to perform include 1) applying the Duke criteria for endocarditis, 2) CT of abdomen and pelvis, 3) Technetium scan, and 4) Liver Biopsy. Other recommended tests include 5) Ultrasonography to evaluate for DVT and 6) Temporal artery biopsy in elderly patients to evaluate for temporal arteritis (a cause in 16-17% of elderly with FUO). Review by Dr. Adam Romeiser.

   Collection by Dr. Mobola Campbell with assistance from Dr. Sarah Sutton and Dr. Maureen Bolon

Immunocompromised ID:

HIV:

1. Neil M.H. Graham, MD; Donald R. Hoover, PhD; Lawrence P. Park, MSE; Daniel S. Stein, MD; John P. Phair, MD, Mellors John W. MD; Roger Detels, MD; Alfred J. Saah, MD. Survival in HIV-Infected Patients Who Have Received Zidovudine: Comparison of Combination Therapy with Sequential Monotherapy and Continued Zidovudine Monotherapy. Ann Intern Med. 1996: 124 (12):1031-1038.
2. Bozzette S. A., Sattler F. R., Chiu J., Wu A. W., Gluckstein D., Kemper C., Bartok A., Niosi J, Abramson I., Coffman J., et al. A controlled trial of early adjunctive treatment with corticosteroids for Pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome. California Collaborative Treatment Group. N Engl J Med 1990; 323:1451-1457, Nov 22, 1990. (Available in the journal stacks at the Galter Library)
3. de Quiros J. C. L. B., Miro J. M., Pena J. M., Podzamczer D., Alberdi J. C., Martinez E., Cosin J., Claramonte X., Gonzalez J., Domingo P., Casado J. L., Ribera E., The Grupo de Estudio del SIDA 04/98. A Randomized Trial of the Discontinuation of Primary and Secondary Prophylaxis against Pneumocystis carinii Pneumonia after Highly Active Antiretroviral Therapy in Patients with HIV Infection. N Engl J Med 2001; 344:159-167, Jan 18, 2001.
4. El-Sadr W. M., Burman W. J., Grant L. B., Matts J. P., Hafner R., Crane L., Zeh D., Gallagher B.,Mannheimer S. B., Martinez A., Gordin F., The Terry Beirn Community Programs for Clinical Research on AIDS. Discontinuation of Prophylaxis against Mycobacterium avium Complex Disease in HIV-Infected Patients Who Have a Response to Antiretroviral Therapy. N Engl J Med 2000; 342:1085-1092, Apr 13, 2000.
5. Hammer S. M., Squires K. E., et al. The AIDS Clinical Trials Group 320 Study Team. A Controlled Trial of Two Nucleoside Analogues plus Indinavir in Persons with Human Immunodeficiency Virus Infection and CD4 Cell Counts of 200 per Cubic Millimeter or Less. N Engl J Med 1997; 337:725-733, Sep 11, 1997.
6. Katzenstein D. A., Hammer S. M., Hughes M. D., Gundacker H., Jackson J. B., Fiscus S., Rasheed S., Elbeik T., Reichman R., Japour A., Merigan T. C., Hirsch M. S., The AIDS Clinical Trials Group Study 175 Virology Study Team. The Relation of Virologic and Immunologic Markers to Clinical Outcomes after Nucleoside Therapy in HIV-Infected Adults with 200 to 500 CD4 Cells per Cubic Millimeter. N Engl J Med 1996; 335:1091-1098, Oct 10, 1996.
7. Pallela, et al. Declining Morbidity and Mortality Among Patients with Advanced Human Deficiency Virus Infection. N Engl J Med 1998; 338: 853-860, March 26, 1998.
8. Palella FJ Jr, Deloria-Knoll M, Chmiel JS, Moorman AC, Wood KC, Greenberg AE, Holmberg SD, HIV Outpatient Study Investigators. Survival benefit of initiating antiretroviral therapy in HIV-infected persons in different CD4+ cell strata. Annals of internal medicine. 2003;138(8):620-6.

Bone Marrow Transplant:

1. M A Slavin, A P Grigg, et al. A randomized comparison of empiric or pre-emptive antibiotic therapy after hematopoietic stem cell transplantation. Bone Marrow Transplant 2007 Apr 30
2. S N Wolff, J Fay, et al. Fluconazole vs low-dose amphotericin B for the prevention of fungal infections in patients undergoing bone marrow transplantation: a study of the North American Marrow Transplant Group. Bone Marrow Transplantation. 2000: 25 (8): 853-59.
3. I Bence-Brucklera, C Bredeson, et al. A randomized trial of granulocyte colony-stimulating factor (Neupogen) starting day 1 vs day 7 post-autologous stem cell transplantation. Bone Marrow Transplant. 1998: 22 (10): 965-9.

Solid Organ Transplant:

1. Sia IG, Patel R. New strategies for prevention and therapy of cytomegalovirus infection and disease in solid-organ transplant recipients. Clin Microbiol Rev. 2000;13:83-121.

Hematology/Oncology:

1. Hughes WT, Armstrong DA, Bodey GP, et al. 2002 Guidelines for the use of antimicrobial agents in neutropenic patients with cancer. Clin Infect Dis. 2002;34:730-51.
2. Kern, Winfried V. Risk assessment and risk-based therapeutic strategies in febrile neutropenia. Current Opinion in Infectious Diseases. 14(4):415-422, August 2001.
3. Freifeld A, Marchigiani D, Walsh T, et al. A double-blind comparison of empirical oral and intravenous antibiotic therapy for low-risk febrile patients with neutropenia during cancer chemotherapy. N Engl J Med 1999; 341:305–11.

  Collection by Dr. Michael Hoffman

For an extended list of references with direct article links, sign in to the Galter Health Library website at:

http://www.galter.northwestern.edu/guides/expand/resident-reading-lists