Contents:

• Overall Goal
• Infectious Disease Unit
• Teaching Environment
• Statement of Supervision and Responsibility

Overall Goal

Our goal is to develop infectious disease trainees as physician-scientists in patient care and research. During the first year, the trainee will have an in-depth education in clinical infectious diseases supplemented by infection control, hospital epidemiology, and hospital anti-infective formulary management. The second year will be research oriented.

The entire program will allow enough flexibility for the trainees to pursue infectious disease careers that may involve clinical care, hospital infection control, and clinical/translational research and/or basic science research. We believe our facilities, faculty, and resources offer a superb opportunity for this training.

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Infectious Disease Unit

The Infectious Disease Unit is made up of six full-time board-certified clinicians. Dr. Grace is the unit director. He has been at the Fletcher Allen since 1987. Dr. Alston joined the unit in 1993, Dr. Ramundo in 1995 and Dr. Kirkpatrick in 1999. Dr. Huston joined the faculty in 2003 and Dr Polish in 2004. In addition there are four infection control practitioners and a unit coordinator. The ID trainee will work closely with all members of the unit. The ID unit has a close working relationship with faculty from the Clinical Microbiology, Immunology and Serology Sections, Department of Microbiology and Molecular Genetics, and Pathology.

The Infectious Disease Unit's offices are housed in the hospital in close proximity to the patient care units, Infection Control, and the Department of Medicine's medical education department. The unit is responsible for all inpatient and outpatient clinical care, infection control and hospital epidemiology, antibiotic formulary management for the Pharmacy and Therapeutics Committee, infectious disease teaching of housestaff and students of the University of Vermont, and advisory work with the Vermont Department of Health (VDH). The Infectious Disease Unit has seen a steady rise in consultations from 517 during the academic year of 1987 to greater than 1100 consults yearly.

Research interests of the faculty include basic, clinical, translational, and infection control research.  Topics include nosocomial infections, blood culture utilization, HIV/AIDS epidemiology, anal HPV infection in HIV positive patients, Staphylococcus aureus enterocolitis, Clostridium difficile colitis, economic impact of informal consultations, enteric pathogen vaccine development, mucosal immune pathogenesis to Cryptosporidium infection, use of transgenic systems to develop novel anti-cryptosporidium drugs, and pathogenesis of amebic infections.

The clinical laboratory is fully equipped for routine aerobic/anaerobic bacterial identification and testing, mycology, mycobacteriology, chlamydiology, virology and parasitology, DNA probes and plasmid analysis, clinical immunology including flow cytometry and HLA phenotyping and serology.

The ID unit works closely with the Pharmacotherapy Department and the Pharmacy and Therapeutics (P&T) Committee of Fletcher Allen. The department has a full time infectious disease pharmacist. The Infectious Disease Practice Committee (IDPC) is a subcommittee of the P&T committee chaired by the ID unit director. Its purpose is to review the antibiotic formulary, develop guidelines for antibiotic use, review new antibiotics and perform quality control checks of antibiotic use. IDPC has developed and writes the University of Vermont College of Medicine/Fletcher Allen Health Care "Guide to Antimicrobial Therapy for Adults", The Green Book.

The Comprehensive Care Clinic (CCC) is the Infectious Diseases and HIV/AIDS clinic for the hospital. Clinic staff includes a full time family nurse practitioner, a clinical care nurse specialist, two clinic nurses, a social worker, dietitian, and support staff. The majority of patients have HIV/AIDS. A variety of other infectious diseases including osteomyelitis, endocarditis, FUO, prosthetic joint infections, tuberculosis evaluation, chronic pneumonia are also managed in the clinic. Home intravenous therapy and an international traveler's clinic are also coordinated through the out patient clinic. The unit coordinates four HIV specialty clinics in Vermont supported by Ryan White CARE Act Title III funding.

The Clinical Epidemiology and Infection Control Unit at Fletcher Allen has recently been incorporated into the infectious disease unit. Dr. Alston who serves as the hospital epidemiologist and chairman of the Infection Control Committee directs it. There are four infection control practitioners. The Infection Control committee is a multidisciplinary group made up of representatives from Medicine, Surgery, Pediatrics, Obstetrics and Gynecology, Pathology/Laboratory Medicine, Nursing, Facilities Management and Quality Assurance.

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Teaching Environment

The following areas provide the environment for the fellow to achieve the goals and objectives of the training program.

1. In-hospital clinical consultation: There are currently over 100 formal consultations per month. The fellow will present cases to the attending who will review all findings at the bedside and supervise the clinical care by the fellow. The fellow will have exposure to patients with immune compromised states and requiring intensive care in addition to a wide array of infectious disease illnesses and diagnostic problems. Consultations are received from all departments and subspecialties of Fletcher Allen.

2. Outpatient continuity of care clinic: The fellow will attend the out patient ID clinic (Comprehensive Care Clinic) weekly for their continuity of care clinic. He/she will follow their own patients, most of whom have HIV/AIDS for the full two years of clinical training. There will be on-site supervision by the attending staff.

3. Clinical Microbiology Laboratory: This is a one-month rotation. The fellow will spend 4 days each week in the clinical microbiology laboratory. He/she will be introduced to laboratory methods for aerobic and anaerobic bacteria, mycobacteria, viruses, parasites and fungi. 

4. Hospital Infection Control/Epidemiology: The fellow will learn the basic aspects of nosocomial infection surveillance and control by working directly with Dr. Kemper Alston and the four infection control practitioners. Outbreak investigation, occupational exposure, education, clinical indicators, quality improvement projects and an introduction to National Nosocomial Infections Surveillance (NNIS) System will be included. The fellow will also take part in the hospital infection control committee meetings.  In addition, the fellow will take the online IDSA/SHEA course on hospital epidemiology.

5. International Travel Clinic (ITC): Presently the ITC sees approximately 75 patients per month. The fellow will have the opportunity to participate in this clinic during elective months of the first year. All pre-travel vaccinations, prophylaxis and education are provided.

6. Case Conference: This occurs twice each month for a total of four case reviews. A full literature review of the topic will be presented. All ID attendings will participate and also present topics.

7. Journal Club: This occurs once per month. Three recent articles will be reviewed and critiqued for content, methodology, and conclusions. All ID attendings will participate and also present journal articles.

8. HIV/HCV conference: This is a monthly conference. Each conference has two presentations concerning updates, reviews and journal articles concerning either HIV/AIDS, HCV infection or mixed infections. Topics include clinical care, basic science, or epidemiology.

9. Research Conference: This is a once monthly conference. Either planned or active research by a fellow, attending of the ID unit, clinical staff, or invited guests will be presented. Other topics will include introduction to molecular techniques, introduction to statistics and review of other relevant research from other units.

10. Clinical Care Conference:  This is a once weekly conference to review challenging clinical inpatient and outpatient consultations. A total of 4 cases will be presented by the fellows and the in-service attendings during the session.

11.  Fellow Core Curriculum.  This is a weekly teaching session covering major infectious disease topics and will run over a 2 year period.

12. ID unit core lecture series: The fellow will participate in the core ID lectures given to the housestaff of the University of Vermont College of Medicine/Fletcher Allen. These lectures include antimicrobial agents, clinical microbiology, fever, endocarditis, urinary tract infections, pneumonia, tuberculosis, bone and joint infections, infections in the immunocompromised host, sepsis and septic shock and central nervous system infections.

13. Fletcher Allen GME Core lectures; This lecture series is to help the fellow become well rounded in patient care and clinical practice issues cultural diversity, physician impairment and recovery, clinical genetics, ethics and end of life decisions, errors in medicine, sizing up medical practice business, contract negotiations, pain management, domestic violence, and compliance. Workshops are scheduled quarterly.

14. Infectious Disease Practice Committee (IDPC): This is a multidisciplinary subcommittee of the Pharmacy and Therapeutics Committee. The fellow will participate in antibiotic guideline development, drug use evaluations (DUE), formulary revision and development of the Green Book.

15. Infection Control Committee: This is a multidisciplinary hospital based committee of the medical staff chaired by Dr. Kemper Alston charged with infection control and hospital epidemiology. The fellow will be an active member of the committee and participate in nosocomial infection surveillance, infection control policy development and quality improvement.

16. ID Unit Bi-monthly administrative meeting: Each month the entire staff of the ID unit meets to review issues regarding administration, the clinic and the fellowship. The fellow has opportunity to voice opinion and make suggestions. Topics include schedules, billing and finances, federal and state regulations, staffing, coordination of inpatient and outpatient, conferences, medication adherence, HIV outreach, referrals, home IV antibiotics, and research related issues.

17. Attendance at National Meetings: The fellow will attend one national ID meeting each year. The unit financially supports this. Fellows are expected to present results of the second year research project nationally.

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Statement of Supervision and Responsibility

Each patient seen by the ID fellow is also seen by the ID attending. This oversight includes a presentation of the patient by the fellow including past medical records, history, physical and laboratory data and review of all pertinent x-rays and Gram stains. The data is then confirmed by the attending at the bedside with the fellow including key historical and physical exam items. The differential diagnosis and approach to diagnostic testing and treatment are then reviewed with the resident. Daily follow-up rounds are held with the ID fellow. During this time each active patient is reviewed in detail with the attending. Data includes clinical course, new problems, results of diagnostic testing and response to therapy. Many of these patients are reviewed at the bedside daily by the attending with the fellow. The daily rounds usually take 6-8 hours.

All new and follow-up patients seen in the outpatient clinic are seen with an attending physician in the same detailed manner as for the in-patient consultations.

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