PRINCE GEORGE’S HOSPITAL CENTER
INTERNAL MEDICINE RESIDENCY PROGRAM
SECTION 14: INFECTIOUS DISEASES
This section has been reviewed and approved by the Chief, Division of Infectious Disease
Medicine as well as the Program Director, Internal Medicine Residency Program at Prince
George’s Hospital Center.
_____________________________
Chief, Division Of Infectious Disease
I.
______________________________
Program Director, Residency Program
Overview
Infectious disease medicine requires an understanding of the microbiology, prevention, and
management of disorders caused by viral, bacterial, fungal, and parasitic infections,
including the appropriate use of antimicrobial agents, vaccines, and other immunobiologic
agents. Important elements include the environmental, occupational, and host factors that
predispose to infection, as well as basic principles of the epidemiology and transmission of
infection. During the rotation, residents will become knowledgeable and proficient in treating
infections in the intensive care, nursing home, surgical including trauma, OB/GYN,
hematologic/oncologic, general medicine and HIV patients.
Residents learn about diagnostic and management approaches to patients with HIV/AIDS
and related opportunistic infections. Experience includes patients with early HIV infection
who have few or no symptoms and also patients with advanced HIV infection who manifest
the acquired immunodeficiency syndrome (AIDS).
By the end of their training the general internist should be able to provide appropriate
preventive (including optimal use of immunization and chemoprophylaxis), diagnosis, and
therapeutic care for most infections. He/she should also be able to evaluate symptoms that
may be caused by a wide range of infectious disorders.
II.
Principle Teaching Methods
It consists of frequent encounters with the attending physician regarding patient care. The
resident will discuss all patients with the attending physician and interpret clinical data to
formulate a differential and/or management options. The attending will assign reading topics
on a regular basis and review the material with the residents. This will include accepted
national guidelines used in the diagnosis and treatment of various infectious diseases. The
faculty will also critique the residents consult notes, examination and management plan.
Rounds will include short 15-30 minute discussions on current topics driven by patient
encounters and initiated by resident and completed by the attending physician on most
days. Latest information dealing with the topic as provided by literature search and pertinent
articles should be discussed.
The residents will also learn from the monthly lectures throughout the three years of their
training. The residents will also be required to review slides in Microbiology for one hour
every Wednesday 11:00 am to 12:00 noon under the supervision of Ms Harjinder Malhotra
in microbiology, and learn identification of:





Cocci and bacilli
Gram stains (15) to identify Gram postive and negative bacteria
India ink (5)
Malaria smear (1)
Wet mounts (5): ( in the ER laboratory)
The residents will be provided with a sign-in/attendance sheet that they must get signed by
microbiology supervisor to show successful completion of this requirement.
III.
Strengths and Limitations
The residents will be exposed to a broad range of clinical problems typical of a communitybased practice with emphasis on inpatient illness and care. The teaching faculty for the
rotation is committed to teaching and patient care with strong role model presentation. For
patients with exceptionally unusual clinical problems, the care may require transfer to a
tertiary referral center. Patients in the continuity clinic at Glenridge Medical Center also offer
some learning opportunities regarding prevention, screening and long term follow-up of
patients with HIV. The hospital does not have a transplant unit therefore exposure of
residents to organ transplant patients with opportunistic infections is limited.
IV.
Goals and Objectives
At the beginning of each academic year the residents will receive a didactic session on ID
emergencies. This will be followed by monthly lectures by ID faculty and will cover the
following topics:
 Lyme’s Disease
 Tuberculosis
 Rashes and other skin manifestations of systemic illnesses
 Meningitis and interpretation of CSF findings
 Endocarditis
 Travel medicine
 Skin and soft tissue infections
 Approach to antibiotic therapy
There will also be scheduled lectures on HIV related topics to cover management of HIV
and its related infections and medications in a systematic manner.
Legend of Learning Activities
Learning Venues:
1. Direct Patient Care/Consultation
2. Attending Rounds
3. Core Lecture Series
4. Self Study
Evaluation Methods:
A. Attending Evaluation
B. Direct Observation
C. Nurses’ Evaluation
D. In-training Examination
Competency: Patient Care
Demonstrate the ability to perform history &
physical exam, interpret ancillary tests to make
diagnostic and therapeutic decisions.
Competency: Medical Knowledge
Understand the pathophysiology, evaluation,
and management of microbiological diseases
(bacterial, viral, mycobacterial, parasitic, fungal,
and rickettsial).
Understand the pathophysiology, evaluation,
and management of HIV and AIDS related
infections.
Understand the pathophysiology, evaluation,
and management catheter related infections,
endocarditis, and pneumonia,
Understand the pathophysiology, evaluation,
and management central nervous system
infections.
Understand the pathophysiology, evaluation,
and management GI related illnesses.
Understand the pathophysiology, evaluation,
and management of surgical infections.
Understand the pathophysiology, evaluation,
and management septic and critically ill patients.
Understand the pathophysiology, evaluation,
and management immunocompromised patients
such as transplant patients.
Understand the pathophysiology, evaluation,
and management febrile neutrapenia and other
hematological/oncological infections.
Understand the pharmacodynamics and
pharmokinetics of antimicrobial agents.
Understand the pathophysiology, evaluation,
and management of sexually transmitted
diseases.
Competency: Professionalism
Treats patients, team members, and primary
caregivers with respect.
Shows compassion to patients, families, and
colleagues.
Actively participates in consultations and rounds.
Attends and participates in all scheduled
conferences.
Competency: Practice Based Learning
Evaluates own performance and uses medical
literature to address gaps in medical knowledge.
Incorporates feedback into improvement
activities.
Learning Venues
1,2.3
Evaluation Methods
A,B
Learning Venues
1,2,3,4
Evaluation Methods
A,B,D
1,2,3,4
A,B,D
1,2,3,4
A,B,D
1,2,3,4
A,B,D
1,2,3,4
A,B,D
1,2,3,4
A,B,C,D
1,2,3,4
A,B,C,D
4
D
1,2,3
A,B,D
1,2,3
A,B,D
1,2,3
A,B,D
Learning Venues
1,2
Evaluation Methods
A,B,C
1,2
A,B,C
1,2
Attendance sheet
A,B
Learning Venues
1,2
Evaluation Methods
A,B,D
1,2
A,B
Competency: System Based Practice
Understands the barriers to optimal care of
patients with HIV.
Understands the need for teamwork with
multiple caregivers, social work, and case
management.
1,2
A,
1,2
A,B,C
V. Educational Content
1. Central Nervous System
 Brain abscess
 Encephalitis
 Meningitis- all types
2. Cardiovascular system
 Endocarditis: acute, subacute, prosthetic valve
 Pericarditis
3. Critical Care Unit
 SIRS
 Sepsis,
 septic shock syndrome
 Nosocomial Infections
 Ventilator Associated Pneumonia
4. Fever of unknown origin
5. Fungal
 Histoplasmosis
 Cocciidioidomycosis
 Cryptococcosis
6. Gastrointestinal
 Biliary tract infection
 Gastroenteritis
 Infectious diarrhea
 Liver abscess
 Peritonitis
 Viral hepatitis
7. Genitourinary
 Cervical cancer (HPV)
 Cervicitis, vaginitis
 Common sexually transmitted diseases: gonorrhea, chlamydia, trichomonas,
herpes simplex, syphilis)
 Pelvic inflammatory disease
 Prostatitis, epididymitis
 Urethritis
 Urinary tract infection
8. Infection in the immunosuppressed patient
9. Lyme Disease
10. Malaria
11. Respiratory
 Acute epiglottitis, pharyngitis
 Empyema
 Pneumonia (community and nosocomial), bronchitis
 Sinusitis
 Upper respiratory infection
12. Rheumatologic/musculoskeletal
 Osteomyelitis
 Septic arthritis
13. Rocky Mountain Spotted Fever
14. Skin Infections
 Cellulitis
 Folliculitis
 Ulcers
 Viral exanthema
15. Tuberculosis
 Active infection
 Positive tuberculin skin test
16. Viral
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Cytomegalovirus
Herpes simplex infection
Influenza
Mononucleosia
Varicella zoster infection
17. HIV Infection
i. AIDS-defining Malignancies
 Kaposi’s sarcoma
 Non-Hodgkin’s lymphoma
 Squamous cell carcinoma (cervix or anus)
ii. Cardiovascular Complications
 Cardiomyopathy
 Myocarditis
 Pericarditis
iii. Dermatologic Complications
 Bacillary angiomatosis

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H. zoster
Kaposi’s sarcoma
Molluscum contagiosum
Scabies
Seborrheic dermatitis
iv. Endocrine Complications
 Hypoadrenalism
 Hypogonadism
 Lipodystrophy
v. Gastrointestinal Complications
 Diarrhea
 Esophageal candidiasis
 Esophageal ulcer disease
 Hepatomegaly, hepatitis, jaundice
 Wasting syndrome
vi. General Management
 Evaluation and management of early disease
 Advance directives evaluation
 Assessment of alternative health practices
 Assessment of social support systems
 Monitoring progression to AIDS
vii. Ongoing Staging
 Diagnosing AIDS-defining opportunistic infections
 Functional assessment
 Mental status evaluation
 Nutritional assessment
 Referral to case-management agencies
 Palliative and terminal care
 Pregnancy counseling (pretest, post-test, risk factors)
viii. Gynecologic Complications
 Cervical dysplasia/neoplasia
 Pelvic inflammatory disease
 Vaginal candidiasis
ix. Hematologic Complications
 Anemia
x. Infectious Diseases (see also Preventive Measures and Specific Organ-based
Complications)
 Cytomegalovirus disease
 Mycobacterial disease
 Pneumocystis carinii pneumonia
 Syphilis (diagnosis, treatment)
xi. Neurologic Complications
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Central nervous system mass lesions
Cryptococcal meningitis
Dementia
Myelopathy
Myopathy
Neurosyphilis
Peripheral neuropathy
Polyneuropathy
Wasting Syndrome
xii. Ocular Complications
 Conjunctivitis
 Iritis
 Keratitis
 Retinitis
xiii. Oral Complications
xiv. Pregnancy Counseling
 pretest, post-test, risk factors
 HAART therapy during pregnancy
xv. Ongoing Staging
 Diagnosing AIDS-defining opportunistic infections
 Functional assessment
 Mental status evaluation
 Nutritional assessment
 Referral to case management agencies, palliative and hospice care
xvi. Preventive Measures
 Antibiotic prophylaxis: Pneumocystis carini pneumonia, Toxoplasmosis,
Mycobacterium Avium Complex
 Immunizations
 Transmission of HIV
xvii. HAART therapy
 Side effects, indications and contraindications of various medications
 Drug Interactions
xviii. Ordering and Understanding Tests
 HAART sensitivity testing- genotype and phenotype
 CD4 lymphocyte counts
 Cerebrospinal fluid cell count, chemistry, VDRL, cryptococcal antigen,
cytology
 Computed tomography, magnetic resonance imaging of the central nervous
system
 ELISA, polymerase chain reaction, and immunoblotting techniques
 Induced sputum stain for Pneumocystis carinii



VI.
Polymerase chain reaction ELISA and Western blot for detection of infectious
diseases
Syphilis serology and dark-field microscopy
Toxoplasma serology
Recommended Reading
Residents are expected to pursue directed reading of standard texts and journal articles
pertinent to the clinical problems they encounter. On a case by case basis residents should
refer to:
 MKSAP
 Up To Date
 MDConsult
 Mandell GL, Bennett JE, Dolin R (eds): Principals and Practices of Infectious
Diseases (5th ed). Philadelphia: Churchill Livingstone, 2000
The residents should also read the following articles during their rotation.
1) Schacker T, Collier AC, Hughes J, Shea T, Corey L. Clinical and epidemiologic features
of primary HIV infection. Ann Intern Med. 1996 Aug 15;125(4):257-64.
2) Hammer SM, et al. Treatment for adult HIV infection, 2006 recommendations of the
International AIDS society- USA Panel. JAMA. Aug 16,2006; 296 (7): 827843
3) Skiest Daniel J. Focal neurological disease in patients with acquired immunodeficiency
syndrome. Clinical Infectious Diseases. 2002; 34: 103-15
4) Hirsch HH, et al. Immune reconstitution in HIV-infected patients. Clinical Infectious
Diseases. 2004;38: 1159-1166
5) Dajani AS, Taubert KA, Wilson W, Bolger AF, Bayer A, Ferrieri P, Gewitz MH, Shulman
ST, Nouri S, Newburger JW, Hutto C, Pallasch TJ, Gage TW, Levison ME, Peter G,
Zuccaro G Jr. Prevention of bacterial endocarditis. Recommendations by the American
Heart Association. JAMA. 1997 Jun 11;277(22):1794-801.
6) Such J, Runyon BA. Spontaneous bacterial peritonitis. Clin Infect Dis. 1998
Oct;27(4):669-74.
7) Lew DP, Waldvogel FA. Osteomyelitis. N Engl J Med. 1997 Apr 3;336(14):999-1007.
8) Caputo GM, Cavanagh PR, Ulbrecht JS, Gibbons GW, Karchmer AW. Assessment and
management of foot disease in patients with diabetes. N Engl J Med. 1994 Sep
29;331(13):854-60.
9) Lipsky BA, et al. Diagnosis and treatment of diabetic foot infections, IDSA guidelines.
Clinical Infectious Diseases. 2004; 39:885-910
10) Quagliarello VJ, Scheld WM. Treatment of bacterial meningitis. N Engl J Med. 1997 Mar
6;336(10):708-16.
11) Tunkel AR, et al. Practice guidelines for the management of Bacterial Meningitis- IDSA
guidelines. Clinical Infectious Diseases. 2004;39: 1267-84
12) Kelly CP, Pothoulakis C, LaMont JT. Clostridium difficile colitis. N Engl J Med. 1994 Jan
27;330(4):257-62.
13) Lowy FD. Staphylococcus aureus infections. N Engl J Med. 1998 Aug 20;339(8):520-32.
14) Mermel LA, et al. Guidelines for the management of intravascular catheter-related
infections. Clinical Infectious Diseases. 2001;32: 1249-72
15) Bartlett JG, Dowell SF, Mandell LA, File Jr TM, Musher DM, Fine MJ. Practice guidelines
for the management of community-acquired pneumonia in adults. Infectious Diseases
Society of America. Clin Infect Dis. 2000 Aug;31(2):347-82.
16) 1998 Guidelines for Treatment of Sexually Transmitted Disases: US Dept of Health.
MMWR: 47 (RR-1): Jan 23, 1998
http://www.cdc.gov/mmwr/preview/mmwrhtml/00050909.htm
PRINCE GEORGE’S HOSPITAL CENTER
INTERNAL MEDICINE RESIDENCY PROGRAM
MICROBIOLOGY ATTENDANCE SHEET
RESIDENT NAME_____________________________________
GRAM STAIN
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