1.

Inpatient Facilities - Experience

The Infectious Diseases Fellowship Training Program at Case Western Reserve University (CWRU) utilizes the major affiliated teaching institutions of CWRU, including University Hospitals of Cleveland (UHC), the Cleveland Veterans Administration Medical Center (VAMC), and MetroHealth Medical Center MHMC). Although fully integrated, each institution offers unique experiences and programs.

Trainees are primarily involved in acute care of infectious diseases problems. However, through their assigned ambulatory experiences, chronic/continued care of patients is a substantial emphasis.

Trainees are assured of experience in evaluating and treating a variety of infectious disease cases by way of the phenomenal numbers and breadth of clinical material at the three institutions. The trainee is exposed to cases from every area of the hospital and all services except Pediatrics. Pediatric infections are discussed at case conference and selected fellows may choose to do rotations on the Pediatric ID Consultation Service as an elective.

2.

Ambulatory Care Facilities - Experience

Ambulatory Care Facilities Utilized in the Program

University Hospitals of Cleveland

The John T. Carey Special Immunology Unit (SIU). The SIU provides ambulatory care to over 700 HIV infected persons. Fully staffed with its own nurses, clinical assistants, clerical personnel, and attending physicians, the SIU shares space with the NIH-sponsored AIDS Clinical Trials Unit and together they provide comprehensive, state-of-the-art and experimental treatment for HIV-infected persons.

Travelers' HealthCare Center (THC). The THC provides advice and immunizations for international travelers, as well as patient care for those who become ill. The Travelers' HealthCare Center has over 1,500 outpatient visits annually and meets Tuesday and Thursday afternoons at UHC and Friday mornings at UHC and Chagrin Highlands.

Infectious Diseases Ambulatory Practice. This practice meets on Tuesday and Wednesday mornings at UHC and Friday mornings at UHC and Chagrin Highlands to provide ambulatory follow-up care for patients seen on the inpatient consultation service, as well as referral patients with particularly challenging infectious diseases problems. Areas of interest include: orthopaedic infections, chronic infections (such as tuberculosis, Lyme disease and chronic fatigue syndrome), transplant-associated infections, and pulmonary and enteric infections.

Veterans Administration Medical Center

Infectious Diseases Clinic. This clinic meets twice a week and presently follows approximately 120 patients, most of whom are HIV-infected. The clinic is staffed by a nurse practitioner, a clinical psychologist, and a nurse coordinator, in addition to a medical director, 2 additional faculty, fellows, residents and medical students.

MetroHealth Medical Center

Infectious Diseases Clinic. This clinic meets two half-days per week and is staffed by 3 faculty members and a nurse practitioner. The clinic provides outpatient management for persons with HIV infection and is the second largest provider of care to AIDS patients in the city of Cleveland.

Tuberculosis Clinic. The Cuyahoga County Tuberculosis Clinic, which receives referrals from throughout the eastern United States including patients immigrating into the Cleveland area. The TB clinic meets daily and has approximately 12,000-14,000 patient visits per year. The clinic is supported by nurse clinicians and attendings in Infectious Diseases and Pulmonary Medicine.

Lorain City STD Clinic

This clinic meets once a week treating patients with sexually transmitted diseases on a first-come, first serve basis. The clinic is staffed with nurses who see patients in consultation with the physician, and a nurse who does HIV testing and counseling. This site has become popular as an ambulatory rotation for medical residents.

In years 2, 3 and 4 of training, fellows choose an outpatient clinic (from among their 1st year ambulatory block rotation) for their continuity experience. They're scheduled to see patients ½ day/week with on-site attending physicians. Attending physicians, who have ultimate medical-legal responsibility for these patients, will serve as mentors for trainees.

3.

 Educational Program

Supervision of trainees in diagnostic microbiology stains and interpretation occurs during inpatient and outpatient experiences and during the mandatory clinical microbiology rotation. Aspiration of abscesses or, in rare circumstances, transtracheal aspirations, are always supervised by on-site attending physicians.

Faculty (attending physicians) conduct rounds at least six times per week. Work rounds (prerounds) are performed daily by fellows as well as residents and medical students under the supervision of fellows. Each case is discussed in detail and seen with the attending on a daily basis.

Fellows assume more responsibilities with time and experience. This involves direct patient care, medical decision-making regarding diagnostic and therapeutic issues, and education of colleagues, residents and medical students. Fellows are committed to scholarly research projects in conjunction with faculty mentors resulting in national presentations and published manuscripts. As detailed above, our program has three tracks. Requirements for board certification exist for all, but research experiences differ.

Trainees select cases for presentation weekly at the clinical case conferences held at all three institutions. Annotated references are provided and salient features of the cases are discussed in the context of "classic" and most recent literature. Fellows also prepare cases for discussion for joint subspecialty conferences. Fellows are responsible for the curriculum of the weekly didactic conference (supervised by the conference faculty advisor) which is a three-year rotating conference serving as a basis for board review for the trainees.

4.

Related Disciplines

Exposure to other subspecialties and departments occurs frequently on the clinical services related to direct patient care activities. Joint conference with pulmonary medicine is in effect. Joint fellowship in infectious disease and geriatrics and pediatrics infectious diseases have been established. Research is often performed in an interdisciplinary manner with contacts in the basic sciences or other clinical subspecialties/departments.

5.

Research

The Division of Infectious Diseases and Geographic Medicine at the three participating hospitals have ample space (>25,000 square feet) fully equipped for basic studies of the immune responses to infectious agents and molecular biology of infectious pathogens. A modern Biosafety Level 3 facility has been established in the Division of Infectious Diseases at Case Western Reserve University School of Medicine for research on biohazardous agents. Forty-seven faculty participate in the NIH-supported training program in Infectious Diseases & Geographic Medicine and Infectious Diseases & Pulmonary Medicine. Postdoctoral trainees choosing the basic research or physician scientist track will conduct research in these facilities under the direction of a faculty mentor. In addition, the trainee may work on collaborative projects with faculty from basic science departments, or other clinical departments/divisions. There are five major basic research programs available in the training program; retrovirology (HIV/HTLV), mycobacteria (M. tuberculosis/M. avium), parasitic infections (filariasis, malaria, schistosomiasis, leishmaniasis and giardiasis), bacterial host defense, and antimicrobial resistance. Clinical and epidemiologic research is also extensively carried out at the 3 institutions of the Program. Areas of emphasis include nosocomial infections, sepsis, immunocompromised hosts, antimicrobial trials (phase II and III), travel medicine, population-based studies, outcome analysis and pneumonia.

Scholarly research is mandated for each of our subspecialty residents including those in the clinical track. Supervision of fellows during research time is crucial and is the responsibility of the Fellowship Program Director, the Research Training Grant Director when applicable, and other selected faculty members in a mentoring committee format. Research activities in the clinical track will focus upon HIV infection, nosocomial infections, health services research, outcome analysis, novel antimicrobials, and epidemiologic studies. Examples of current research projects by clinical track fellows in the Division include: 1) a population-based study of invasive group A streptococcal disease in Cuyahoga County with evaluation of risk factors and predictors of outcome; 2) an epidemiologic and molecular analysis of vancomycin-resistant Enterococcus in Northeast Ohio; 3) studies of preventative therapy for tuberculosis in Uganda in HIV-infected individuals; 4) a longitudinal evaluation of the epidemiology, predictive factors and differences in geriatric and younger patients with Enterobacter bacteremia; 5) a multicenter review of Lactobacillus bacteremia; 6) the clinical and virological effect of corticosteroids in HIV-infected persons; 7) predictive factors for Clostridium difficile diarrhea in HIV-infected patients; 8) risks for central nervous system thrombotic events in HIV-infected patients; 9) the evolving epidemiology of deaths in HIV-infected persons; 10) Streptococcus intermedius-milleri infections and predictors of acquisition and outcome; 11) epidemiological risks for VRE bacteremia on a Hematology-Oncology ward; 12) the spectrum of infections in fetal cord blood stem-cell transplantation; 13) non-group A streptococcus associated necrotizing fasciitis; and 14) the evolving epidemiology of group G streptococcal infections.