GENERAL OBJECTIVES:The specialty of infectious diseases concerns itself with human illness initiated by microorganisms and other pathogens. These diseases traverse the usual boundaries of organs and systems and thus any region of the body may be involved.

Only candidates certified in Internal Medicine or Pediatrics may be eligible for the Certificate of Special Competence in Infectious Diseases.

During the course of residency in infectious diseases in both inpatient and outpatient settings, residents must acquire clinical competence in the management of infections together with a sound background in the basic sciences of microbiology, immunology, pharmacology, and epidemiology. In order to function effectively as consultants to other disciplines, including non-medical, residents must also acquire the appropriate microbiology diagnostic skills and a highly developed ability to interpret data originating from a clinical microbiology laboratory. Those wishing to pursue a career in academic infectious diseases must also acquire research and educational expertise.

SPECIFIC OBJECTIVES:

Knowledge:

At the completion of residency, residents must demonstrate:

1. Knowledge of the consequences of host/pathogen interactions and the mechanisms involved in the pathogenesis of infectious diseases.
2. Knowledge of etiology, pathogenesis including natural history, pathology, clinical features, diagnosis, prevention and treatment of the following infections.
   1. common as well as less common infectious diseases due to all categories of infectious and toxigenic organisms, including viruses, chlamydia, bacteria, mycobacteria, rickettsiae, fungi, protozoa, helminths, prions and arthropods
   2. sexually transmitted diseases
   3. travel-related infections
   4. nosocomial infections
   5. infections in special hosts, including HIV-infected patients, transplant recipients, burn patients, patients with congenital immunodeficiencies and other immunocompromised patients
   6. maternal infections as they affect the mother and fetus, and infections in the neonate
   7. infections in the elderly
   8. infectious diseases as they present in surgical and gynaecologic patients
   9. infections associated with a foreign body
   10. emerging pathogens
3. Knowledge of microbiology and the related technology to include:
   1. the principles of molecular biology, microbial genetics, microbial physiology, microbial structures and taxonomy
   2. theoretical knowledge in all practical areas of diagnostic microbiology including: bacteriology, virology, parasitology and mycology
   3. knowledge of human normal flora and factors which affect it, such as body site, age, antimicrobial agents, environment, disease states and diet
   4. the microbiologic basis of tests used to monitor therapy including susceptibility testing
   5. the laboratory aspects of infection control
4. Knowledge of the principles and practice of infection control to include:
   1. understanding the duties and responsibilities of the infection control practitioner and hospital epidemiologist
   2. recognition and investigation of outbreaks
   3. reporting requirements of outbreaks to local public health authorities
   4. management of sporadic nosocomial infections, including the principles and methods of surveillance
   5. economic implications of infection control
   6. principles of prevention and implementation of infectious control interventions, including educational strategies
   7. occupational health
   8. role of infection control committees in the hospital setting
5. Knowledge of the clinical and diagnostic laboratory approach and differential diagnosis of complex problems in which infections may play a role, such as:
   1. fever of unknown origin
   2. systemic inflammatory response and multiple organ dysfunction syndromes
   3. pulmonary infiltrates of uncertain etiology
   4. post-operative fever
   5. illness in travellers
   6. recurrent illnesses or syndromes mimicking infection
   7. recurrent or relapsing infections
6. Knowledge of the principles of communicable diseases, epidemiology and public health and their application in the prevention and control of infection in the community to include:
   1. the ecology of microorganisms, including normal flora
   2. transmission and public health consequences of specific communicable diseases
   3. maintenance of sanitation
   4. principles of vector control
   5. the interaction with public health authorities at local, provincial, federal, and international levels
7. Knowledge of immunological and other host responses to include:
   1. details of humeral, cell mediated and phagocytic responses to colonization and invasion in the normal and abnormal host
   2. pathogenetic mechanisms both specific and non-specific including the more important cytokines and humeral factors by which the host prevents, diminishes or exacerbates disease
   3. principles and practice of prevention of infection by immunization and chemoprophylaxis. this should include the indications, contraindications, efficacy, effectiveness, adverse effects of:
      1. passive and active immunization
      2. chemoprophylaxis including surgical perioperative chemoprophylaxis
      3. environmental and behaviour factors
8. Knowledge of therapeutics applicable to infectious diseases to include:
   1. antimicrobial classification
   2. general principles of pharmacokinetics in the normal and abnormal host
   3. formulary management, pharmacoeconomics and the role of pharmacy and therapeutics committees
   4. mechanism of action and microbial resistance
   5. drugs toxicity and major interactions
   6. clinical indications and use
   7. the role of immune modulators and hematopoietic growth factors
9. Knowledge of the history of microbiology and infectious diseases with awareness of major changes that have occurred in disease epidemiology, pathogenesis and disease prevention during the past century.
10. Knowledge of the breadth and depth of the medical literature related to infectious disease.
11. Knowledge of the essential steps involved in answering research questions by clinical and basic research as well as knowledge of the process involved in presenting the findings of this work.
12. Knowledge of teaching techniques and the related evaluation strategies to assess the effectiveness of teaching.
13. Knowledge of ethical issues as they apply to the clinical practice of infectious diseases, research involving human and non human subjects, relationships with industry and confidentiality including ethical issues related to investigational protocols and diseases such as HIV.
14. Knowledge of the cost-effectiveness of various strategies of care and quality assurance.
15. Knowledge of key differences in communication strategies in relation to the intended audience.

Skills

At the completion of residency, residents must demonstrate:

1. Based upon sound clinical and microbiology knowledge, the ability to facilitate an effective informed interaction between clinical areas and the laboratory that would not only enable the clinician to appropriately interpret test results including those used to monitor therapy but also to identify deficiencies and limitations in the performance of various laboratory tests.
2. The appropriate and effective use of the laboratory in the diagnosis and treatment of infections, including:
   • appropriate selection, collection, and transport of specimens
   • role of rapid diagnostic tests
   • utility and cost effectiveness of tests
   • principles behind tests
   • sensitivity, specificity and predictive value of tests
   • limitation of tests
   • interpretation of results
   • quality control issues with respect to tests
3. Technical microbiology skills to include:

a.       appropriate skills in all practical areas of diagnostic microbiology including bacteriology, virology, parasitology, and mycology

b.      ability to perform and interpret commonly applied rapid diagnostic laboratory examinations

4. Skills to be applied to the area of infection control to include:

 .        the ability to effectively act as a supervisor and consultant in the area of infection control

a.       the ability to effectively and actively function on hospital infection control committees

b.      the ability to organize and implement an infection control program to investigate outbreaks of infection in health care settings

c.       the ability to effectively communicate principles of infection control to health care workers, patients, and general public

5. Appropriate skills in the interpretation and/or understanding of the significance of commonly used laboratory tests that are not only related to the microbiology and infectious diseases laboratory but to other disciplines that impinge on the differential diagnoses of complex problems such as:

 .        fever of unknown origin

a.       systemic inflammatory response and multiple organ dysfunction syndromes

b.      pulmonary infiltrates of uncertain etiology

c.       post-operative fever

d.      illness in travellers

e.       recurrent illnesses or syndromes mimicking infection

f.        recurrent or relapsing infections

6. Appropriate skills in the application of knowledge of communicable diseases to the prevention, investigation and control of disease outbreaks and the ability to act as a consultant, interacting with different levels of the health care system in disease prevention and control.
7. The appropriate and effective use of laboratory and other tests to evaluate the competency of the immune system and the characterization and extent of any immunologic defect.
8. The ability to effectively communicate with families, colleagues and the public about the merits of vaccines, including new ones and to deal effectively with issues and concerns related to immunizations; practical issues related to frequently used vaccines including reporting of adverse events and optimizing opportunities for updating immunizations.
9. The ability to choose among antimicrobial agents in an effective manner to facilitate the following:

 .        optimizing clinical outcome and compliance

a.       minimizing side effects

b.      minimizing costs

c.       limiting antimicrobial resistance

d.      managing patients with resistant organisms

e.       managing patients with evidence of antimicrobial toxicity

In addition, the resident should be able to perform simple drug use evaluations and antibiotic audits as part of the functions of pharmacy and therapeutic committees.

10. The ability to conduct searches of the medical literature on subjects related to infectious diseases, to critically evaluate the literature and to maintain competence and ongoing learning. The ability to assess historical information on a particular subject matter including but not confined to traditional MedLine literature searches.
11. Participation in clinical or basic research during the course of the residency training in order to develop the potential for a research career and to facilitate collaborative interaction with colleagues involved in basic or clinical research. Clinical research is defined as research involving human subjects or experimental studies of direct clinical relevance, the results of which are reported at local or national meetings and are suitable for publication in a scientific journal. Acceptable research projects include:

 .        analysis of a contemporary clinical problem using acceptable statistical methods as required

a.       supervised participation in an ongoing project in experimental medicine or basic science

b.      laboratory-based epidemiology projects

12. The ability to teach the relevant aspects of infectious diseases, microbiology and infection control to colleagues, patients, and allied health personnel.
13. The ability to identify the essential cost components in various strategies of care.
14. The ability to exhibit exemplary behaviour for a consultant and to articulate the pros and cons of decisions by colleagues and primary care physicians in a fair and professional manner.
15. The ability to present and defend submissions to an ethics review board.
16. The ability to work with industry in an ethical, non compromising fashion.
17. The ability to effectively communicate verbally and in writing at different levels with patients, families, allied health personnel, colleagues, as well as other medical and non medical personnel. The ability to work skilfully with public health and cultural liaison workers to optimize care for communicable diseases such as tuberculosis.
18. The ability to provide written consultations which are legible and effective in influencing care for both inpatients and outpatients.
19. The sensitivity and compassion to deal effectively with dying patients and the ability to work effectively with community and hospital palliative care teams.
20. The ability to deal effectively and compassionately in a culturally sensitive manner with patients and families from different ethnocultural backgrounds.

Attitudes

At the completion of residency, residents must demonstrate:

1. An appreciation of the application of research methodology.
2. An appreciation of the value of quality assurance methods and evaluation as applied to clinical and laboratory practice.
3. An appreciation of the importance and application of the principles of bioethics and demonstrated ability to apply these principles in clinical settings, eg. consent for testing for HIV.
4. An appreciation of the importance of sending accurate and timely consultative reports and of handling telephone inquiries concerning infectious diseases from colleagues, physicians, the media, and the public.
5. An appreciation of the role and importance of each member of the health care team.
6. An appreciation of the need to develop and carry out an ongoing program of self education ,academic meetings, seminars, journal clubs, reading programs and the need to give and receive constructive criticisms.
7. An appreciation of the importance of confidentiality concerning patient information and the skills needed to ensure this.
8. An appreciation of the value of and the legal requirements for reporting of diseases, adverse drug and vaccine reactions and the skills needed to carry this out.
9. An appreciation of sensitivity issues relating to the role of culture and social background on differences in health perceptions, values, beliefs, and behaviours.

PAEDIATRICS INFECTIOUS DISEASES:

CONTENT AND ORGANIZATION OF THE RESIDENCY PROGRAM:

There must be an organized program of rotations and other educational experiences, both mandatory and elective, designed to provide each resident with the opportunity to fulfill the educational requirements and achieve competence in the specialty.

The content and organization of each accredited program in pediatric infectious diseases must be consistent with the specialty training requirements.

In addition to offering the components noted in the specialty training requirements all accredited programs in pediatric infectious diseases should offer community-based learning experiences.

Residents must be provided with increasing individual professional responsibility, under appropriate supervision, according to their level of training, ability, and experience.

RESOURCES:There must be sufficient resources including teaching faculty, the number and variety of patients, physical and technical resources, as well as the supporting facilities and services necessary to provide the opportunity for all residents in the program to achieve the educational objectives and receive full training as defined by the specialty training requirements in infectious diseases.

In those cases where a university has sufficient resources to provide most of the training in pediatric infectious diseases but lacks one or more essential elements, the program may still be accredited provided that formal arrangements have been made to send residents to another accredited residency program for periods of appropriate prescribed training.

Learning environments must include experiences that facilitate the acquisition of knowledge, skills, and attitudes relating to aspects of age, gender, culture, and ethnicity appropriate to pediatric infectious diseases.

1. Teaching Faculty

There must be a sufficient number of qualified teaching staff to supervise residents and provide teaching in the basic and clinical sciences related to infectious diseases. This requires a minimum of two full-time university staff specializing in pediatric infectious diseases. The director of the program must be certified in infectious diseases or have other acceptable qualifications.

2. Number and Variety of Patients

The number and variety of patients available to the program on a consistent basis must be sufficient to meet the educational needs of the residents.

3. Clinical Services Specific to Pediatric Infectious Diseases
   1. Clinical Infectious Diseases

It is essential that there be adequate numbers of patients in whose management the service participates. It is essential that there be adequate and well supervised consultation experience for all residents.

1. The following areas of infectious diseases are considered essential:

Clinical Experience

• acute infections (i.e., bacteremia, pneumonia, meningitis, gastroenteritis)
• burn wound sepsis
• common parasitic diseases
• diseases of travel and immigration
• infections associated with medical devices
• infections in neonates
• infections in the immunocompromised host, including patients with HIV infection
• infective endocarditis
• nosocomial infections
• osteomyelitis and septic arthritis
• sexually transmitted diseases
• systemic mycoses
• tuberculosis
• urinary tract infections
• wound infections

The residents must have the opportunity of assuming responsibility for patients over a sufficiently long period to observe the history of disease and the benefits and complications of therapy.

There must be an adequate number of pediatric patients available for teaching to provide experience with these main types of infectious diseases. The minimum acceptable number of supervised consultations per year is 300.

2. Residents must have exposure to adult infectious diseases that is separately and specifically identified. This training should be undertaken within an accredited adult infectious diseases residency program. If this is not available at the same university, the only two acceptable alternatives for the adult component of the pediatric residency program are:
   • Alternative same university adult infectious diseases experience which requires:
     • At least one full-time adult infectious disease specialist whose qualifications are acceptable to supervise the resident's clinical adult training.
     • An adequate patient number to provide a minimum of 200 adult consultations per year.
     • Clinical exposure to a broad range of adult infectious diseases including AIDS.
     • Supplementation of the clinical exposure with lectures, reading, and discussions to encompass areas where clinical material is not available.

or

• Training in an accredited adult infectious disease program at another university.
1. Ambulatory

Organized pediatric out-patient clinics must be available for the investigation and treatment of infections not requiring hospitalization (including diseases of travel and immigration, tuberculosis, and sexually transmitted infections) as well as for post-discharge follow-up. There should be a regularly scheduled clinic at least one-half day per week.

3. Consultation

There must be a consultation service to provide experience in elective and emergency consultations in patients with infectious diseases.

4. Community Learning Experiences

The program should offer community learning experiences particularly in areas of sexually transmitted diseases, TB, travel medicine, public health and HIV.

5. Epidemiology

Residents must understand and be able to utilize the principles and methods of epidemiology as applied to infectious diseases and, wherever possible, participate in the investigation of an epidemic.

6. Hospital Infection Control

Residents must become familiar with the methods and problems related to hospital infection control activities, attend meetings of the hospital infection control committee, and participate fully for at least one month in all aspects of the hospital infection control program.

7. Laboratory Component of the Program

Each resident must gain an adequate experience in diagnostic microbiology and spend a minimum of 6 months full-time in an accredited residency program in medical microbiology. Pediatric residents must spend a minimum of one month in routine diagnostic virology during their diagnostic microbiology training. This training must be undertaken under the direct supervision of a specialist certified in medical microbiology, or with acceptable qualifications. The following areas of laboratory training are considered essential:

1. General Microbiology
   • routine techniques including use of different culture media, specimen collection and primary inoculation, and various staining techniques.
   • bench experience and familiarity with special isolation and identification techniques related to urine, respiratory secretions, blood, tissue and body fluids, and enteric and anaerobic bacteriology.
   • antibiotic susceptibility testing and assays for antibiotic levels.
2. TB, Fungi and Routine parasitology
   • specimen collection, transport and media for fungi and mycobacteria.
   • rhodamine staining for AFB and antibiotic sensitivity testing for mycobacteria.
   • identification of common fungi including candida, aspergillus, cryptococcus; fungal serology and antigen detection.
   • stool examination for ova, trophozoites, and larvae; concentration techniques; string test; special stains and serology.
3. Virology, Mycoplasma and Chlamydia
   • virus isolation for herpes viruses, respiratory viruses, and enteric viruses.
   • virus serology including EBV, hepatitis, HIV, measles and rubella
   • chlamydia and mycoplasma isolation and antigen detection systems.
4. Special Techniques
   • quantitative bacteriology, rapid diagnostic techniques, ELISA, immunofluorescence, DNA probes, and electronmicroscopy.
5. Infection Control and Nosocomial Pathogens
   • role of microbiology laboratory in infection control and surveillance.
   • infection control unit organization and function.
   • epidemiology and laboratory investigation for nosocomial outbreaks, including biotyping, phage typing, and plasmid analysis.
3. Supporting Services - Clinical, Diagnostic, Technical
   1. Liaison with other Specialties and Subspecialties

There must be ongoing liaison with a teaching service in medical microbiology. Hospitals with a major role in the infectious diseases program should also be engaged in medical teaching including pediatrics.

2. Supporting Facilities and Services

Comprehensive diagnostic services coordinated with the teaching program must be available in pathology, immunology, radiology, and nuclear medicine.

3. Intensive Care Units

Adult or pediatric and neonatal intensive care units are required to provide experience in the collaborative care of severely ill and injured patients with infections.

4. Emergency Departments

Facilities must be available for residents to develop expertise in the initial diagnosis and management of all types of emergencies involving infectious diseases.

ACADEMIC AND SCHOLARLY ASPECTS OF THE PROGRAM:

The academic and scholarly aspects of the program must be commensurate with the concept of a university postgraduate education. The quality of scholarship in the program will in part, be demonstrated by a spirit of enquiry during clinical discussions, rounds, and conferences. Scholarship implies an in-depth understanding of basic mechanisms of normal and abnormal states and the application of current knowledge to practice.

1. Organized Scholarly Activities

Organized scholarly activities such as journal clubs, research conferences and seminars must be a regular part of the program. The program should include regularly scheduled tutorial activities, seminars, teaching rounds, and journal clubs. Active participation by residents in both the planning and production of conferences is essential.

2. Basic and Clinical Sciences Relevant to Pediatric Infectious Diseases

The academic program must include organized teaching in the basic and clinical sciences relevant to the specialty. A coordinated educational program must be provided in the scientific basis of infectious diseases. This should include: the structure, physiology, and genetics of microbes; pathogenetic mechanisms; host response to infection; mechanism of action, pharmacology, the toxicology of antimicrobial agents; and epidemiology of infectious diseases.

3. Biomedical Ethics

The academic program must ensure that residents gain an understanding of the basic principles and practice of biomedical ethics as it relates to pediatric infectious diseases.

4. Communication Skills

The program must ensure that residents learn effective communication skills for interacting with patients and their families, colleagues, co-workers from other disciplines and students. Clearly defined educational objectives for teaching these skills and mechanisms of formal assessment should be in place.

5. Patient Care Team

Residents must be given opportunities to develop effective skills in collaborating with all members of the patient care team.

6. Teaching Skills

Residents must be given opportunities to develop effective teaching skills by teaching junior colleagues and students, as well as through conference presentations, clinical and scientific reports, and patient education.

7. Management Skills

Residents must be given opportunities to develop skills in management as applied to infectious diseases such as efficient practice and records management and the ethical use of health care resources. Residents should also be prepared for their role as a health care advocate.

8. Quality Assurance/Improvement

The program must provide residents with opportunities to gain an understanding of the principles and practice of quality assurance/improvement. Opportunities should be provided for residents to participate actively in such programs in their hospital departments.

9. Research Opportunities for Residents

There must be a faculty member with the responsibility to facilitate the involvement of residents in research and other scholarly work. The academic program must provide the opportunity for residents to learn biostatistics and the critical appraisal of research methodology and medical literature. Such teaching must include issues related to age, gender, culture, and ethnicity in research protocols and data presentation and discussion. Residents should learn the design and interpretation of research studies, the evaluation of investigative methods, and analysis of data. Residents should have the opportunity to participate in clinical or basic research studies under the direction of a member of the division, be expected to complete the project, and submit an abstract or manuscript to a peer reviewed meeting or journal. This research project may be a quality of care study, an investigation of an outbreak, the design and implementation of a therapeutic study, or any basic science study that has been designed and carried out by the resident. A case report does not satisfy this requirement.

10. Faculty Research

A satisfactory level of research and scholarly activity must be maintained among the faculty identified with the program.

11. Life-Long Learning

All programs must promote development of skills in self-assessment and self-directed life-long learning. To promote this end, the program should provide opportunities for residents to attend conferences outside their own university.