PGY-2 Specialty Residency in Infectious Diseases

UCSF School of Pharmacy & UCSF Medical Center

Residency Syllabus 2014-2015

Program SummaryThe School of Pharmacy at the University of California, San Francisco, offers a one-year Postgraduate Year Two Infectious Diseases (PGY-2-ID) specialty residency. The primary responsibility of the resident includes participation in the Antimicrobial Stewardship Program and clinical activities with the General Infectious Disease, Transplant Infectious Disease, and Pediatric Infectious Disease consult services at UCSF Medical Center and the National AIDS/HIV Clinical Consultation Center (the “Warmline”). The resident will also have ambulatory care experiences in the UCSF HIV Clinic and Travel Medicine and Vaccination Clinic. Elective clinical opportunities in infectious diseases at other area hospitals and non-infectious diseases services at UCSF Medical Center are available. Research opportunities are diverse, including epidemiology, clinical trials, and antimicrobial control studies. Presentation of research efforts at major infectious diseases or pharmacy meetings is an expectation. The resident will also have numerous opportunities for teaching, including didactic lecturing, leading a therapeutics conference section and student preceptorship while on rotation.

PersonnelResidency DirectorConan MacDougall, PharmD, MAS, BCPSAssociate Professor of Clinical PharmacyDepartment of Clinical Pharmacy, UCSF School of Pharmacymacdougallc@pharmacy.ucsf.edu415-502-9573

Residency Administration and OversightDepartment of Clinical PharmacyLisa Kroon, PharmD Professor of Clinical PharmacyChair, Department of Clinical Pharmacy, UCSF School of Pharmacy

UCSF Medical Center Department of Pharmaceutical ServicesDaniel Wandres, PharmDChief Pharmacy OfficerUCSF Medical Center

Other Key PersonnelKatherine Yang, PharmD, MPHHealth Sciences Associate Professor of Clinical PharmacyDepartment of Clinical Pharmacy, UCSF School of Pharmacy

Alexandra Hilts-Horeczko, PharmD, BCPSClinical Specialist, Infectious DiseasesUCSF Medical Center

Dominic Chan, PharmD, BCPSClinical Specialist, Infectious DiseasesUCSF Medical Center

Betty Dong, PharmDProfessor of Clinical PharmacyDepartment of Clinical Pharmacy, UCSF School of Pharmacy

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Cathi Dennehy, PharmDHealth Sciences Clinical Professor of PharmacyDirector of PGY-1 Residency ProgramsDepartment of Clinical Pharmacy, UCSF School of Pharmacy

Catherine Liu, MDAssociate Clinical Professor of MedicineDivision of Infectious Diseases, UCSF School of MedicineDirector, Infectious Diseases Management Program

Brian Schwartz, MDAssociate Clinical Professor of MedicineDivision of Infectious Diseases, UCSF School of MedicineDirector, Travel Medicine and Vaccination Clinic

Conditions of EmploymentPeriod of Appointment:July 5, 2011 - July 4, 2012

Stipend: Approximately $50,000 per year (paid monthly)

Benefits:PROFESSIONAL LEAVE: 1-2 weeks (to attend professional meetings)VACATION: 10 working daysINSURANCE: Health and professional liability insurance

Residency ExperiencesClinical ExperiencesRequired Clinical ExperiencesBlock experiencesUCSF Medical Center Adult General Infectious Diseases Consultation ServicePreceptors: Conan MacDougall, Pharm.D., Dominic Chan, Pharm.D., BCPS, Kathy Yang, Pharm.D., Alexandra Hilts-Horeczko, PharmD, BCPS

UCSF Medical Center Adult Transplant Infectious Diseases Consultation ServicePreceptors: Conan MacDougall, Pharm.D., Dominic Chan, Pharm.D., BCPS, Kathy Yang, Pharm.D., Alexandra

Hilts-Horeczko, PharmD, BCPS

UCSF Children’s Hospital Pediatric Infectious Diseases Consultation ServicePreceptors: Conan MacDougall, Pharm.D., Dominic Chan, Pharm.D., BCPS, Kathy Yang, Pharm.D., Alexandra

Hilts-Horeczko, PharmD, BCPS

Longitudinal experiencesUCSF Medical Center Antimicrobial Stewardship Program

Preceptors: Conan MacDougall, Pharm.D., Dominic Chan, Pharm.D., BCPS, Kathy Yang, Pharm.D., Alexandra Hilts-Horeczko, PharmD, BCPS

National AIDS/HIV Clinical Consultation CenterPreceptor: Betty Dong, Pharm.D.

Elective Clinical ExperiencesBlock experiencesSan Francisco General Hospital Adult Infectious Diseases Consultation Service

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Preceptor: Daniel Deck, Pharm.D.

Veterans Affairs Medical Center Adult Infectious Diseases Consultation ServicePreceptor: Daniel Maddix, Pharm.D.

UCSF Medical Center Adult Hematology-Oncology ServicePreceptors: Larissa Graff, Pharm.D., Helen Wu, Pharm.D., Courtney Yuen, Pharm.D.

UCSF Medical Center Adult Critical Care ServicePreceptors: Fanny Li Pharm.D., Cindy Loffler, Pharm.D., Kendall Gross, Pharm.D., Megan Pintens, Pharm.D.,

Ashley Thompson, Pharm.D.

UCSF HIV ClinicPreceptor: Jennifer Cochoba, Pharm.D.

Other elective clinical experiences are possible on mutual agreement of the resident and the residency director.

Teaching ExperiencesRequired Teaching ExperiencesBlock experiences Clinical Pharmacy 131: Therapeutics of Infectious Diseases and Immunocompromised StatesServe as a conference facilitator and provide one lecture in a therapeutics course for third professional year pharmacy students.

Longitudinal experiencesCo-preceptor for UCSF APPE students in Clinical Pharmacy 175.03: Infectious DiseasesUnder the supervision of program personnel, precept third/fourth professional year pharmacy students undertaking advanced pharmacy practice experiences in Infectious Diseases.

Co-preceptor for UCSF PGY-1 residentsUnder the supervision of program personnel, precept PGY-1 pharmacy residents taking a rotation in Infectious Diseases.

One-time experiencesPharmacology 131: Anti-infectives and Anticancer DrugsProvide one lecture in a pharmacology course on anti-infectives agents for third professional year pharmacy students.

Elective Teaching ExperiencesOne-time experiencesProvide an update on an antimicrobial topic to the staff of the Microbiology Laboratory of UCSF Medical Center.

Other elective teaching experiences are possible on mutual agreement of the resident and the residency director.

Research ExperiencesRequired Research ExperiencesLongitudinal experiencesDesign, conduct, analyze, and summarize the results of a hypothesis-based study on a question related to antimicrobial use. The results should be disseminated via at least two of the following:-Meeting of the Infectious Diseases Management Program-Antimicrobial Subcommittee of the Pharmacy and Therapeutics Committee-Department of Clinical Pharmacy Research Seminar-Western States Residency Conference-An abstract submitted to a pharmacy or infectious diseases meeting-A manuscript submitted to a pharmacy or infectious diseases journal

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Block ExperiencesSatisfactorily complete Epidemiology 150.03, Designing Clinical Research for Residents and Students, including drafting of a research protocol.

Elective Research ExperiencesLongitudinal experiencesIn cooperation with program faculty, co-author a systematic or narrative review of a topic in infectious diseases pharmacotherapy for publication in a peer-reviewed journal.Other elective research experiences are possible on mutual agreement of the resident and the residency director.

Administrative/Operations ExperiencesRequired Administrative/Operations ExperiencesLongitudinal experiencesParticipate in the clinical/distributive operations of the Department of Pharmaceutical services as a licensed pharmacist.

One-time experiencesPrepare the institutional antibiogram for UCSF Medical Center by obtaining the relevant data, summarize it in a logical fashion, analyze the data for important trends, and present the summary data and conclusions at a meeting of the Infectious Diseases Management Program.

Revise the institutional antimicrobial dosing card for the UCSF Medical Center by incorporating user feedback and studies from the peer-reviewed and present the revisions at a meeting of the Infectious Diseases Management Program.

Perform a review of the utilization of a targeted antimicrobial and/or management of a particular infection, analyze the data, and present the summary data and conclusions at a meeting of the Infectious Diseases Management Program.

Elective Administrative/Operations ExperiencesParticipate in other departmental initiatives related to infectious diseases and/or antimicrobial utilization as appropriate opportunities arise.

Learning Objectives for the ResidencyThe UCSF PGY-2-ID program is primarily designed to prepare the resident to be an expert clinician in infectious diseases pharmacotherapy and secondarily to provide a foundation for future development as a researcher, teacher, and practice leader. The learning objectives below are designed to measure the resident’s progress in being able to perform in these roles. The resident will use the objectives for self-assessment and the residency director will regularly review progress together with the resident.

The objectives are organized by domain and ranked by level of mastery:I: early learning objectives (competency expected to be demonstrated after 4 months) II: advanced learning objectives (competency expected to be demonstrated after 8 months)III: expert-level objectives (competency expected to be demonstrated by completion of residency)

Fundamentals of Infectious Diseases PharmacotherapyPrinciples of Diagnostic Evaluation of Infectious DiseasesMicrobiological CharacterizationDescribe the process of identification of the following organisms from receipt of sample until final identification:Escherichia coli (I)Pseudomonas aeruginosa (I)Staphylococcus aureus (I)Staphylococcus epidermidis (I)Streptococcus pneumonia (I)Candida albicans (I)Aspergillus fumigatus (I)

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Antimicrobial Susceptibility TestingDescribe the process of broth microdilution and epsilometer-based susceptibility testing for aerobic bacteria. (I)

Define minimum inhibitory concentration (MIC) and minimum bactericidal concentration. (I)

Explain the concept of an antimicrobial susceptibility breakpoint and what methods are used to set breakpoints. (I)

For the following organism-drug combinations, state the broth microdilution susceptibility breakpoint. For organisms not listed below, be able to quickly find a given organism-drug breakpoint in appropriate references.Staphylococcus aureus – vancomycin (II)Streptococcus pneumoniae – penicillin, ceftriaxone (II)Escherichia coli – ceftriaxone, ceftazidime, ertapenem, ciprofloxacin (II)Pseudomonas aeruginosa – ceftazidime, piperacillin/tazobactam, meropenem (II)Candida albicans, glabrata, kruseii, tropicalis, parapsilosis – fluconazole, voriconazole (II)

Interpretation of Microbiologic Cultures, Laboratory Tests and Examination FindingsList five examples of situations in which recovery of an organism from a microbiologic culture may not be indicative of infection due to that organism. (I)

Describe the role of C-reactive protein, erythrocyte sedimentation rate, and serum procalcitonin in the diagnosis of infectious diseases and in monitoring response to therapy. (II)

Describe the utility of galactomannan and beta-D-glucan serum blood assays and list at least two reasons for false-positive results. (II)

Identify whether results from a cerebrospinal fluid analysis are suggestive of bacterial, viral, fungal, or mycobacterial central nervous infection. (I)

Identify whether results from a urine analysis are suggestive of a urinary tract infection. (I)

Explain the concept of differential time to positivity and identify whether the results for a set of paired blood cultures are suggestive of the catheter as a source of infection. (II)

Explain the differences between HPLC and bioassay in measurement of serum drug levels. (III)

State the desired therapeutic range for serum blood levels of the following antimicrobials:Vancomycin (I)Gentamicin, tobramycin (I)Amikacin (II)Voriconazole (II)Itraconazole (II)

Mechanisms of Antimicrobial ResistanceResistance Mediated by Drug-Modifying EnzymesFor the following beta-lactamases, identify beta-lactams that are hydrolyzed by the enzyme, whether the enzymes are inhibited by beta-lactamase inhibitors, location and mode of expression (chromosomal or plasmid, constitutive versus inducible), and typical organisms in which these are found.TEM-1, SHV-1 (I)Extended-spectrum beta-lactamases (I)AmpC (II)KPC (III)NDM (III)

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List three types of drug-modifying enzymes other than beta-lactams that contribute to antimicrobial resistance and the antimicrobials that they affect. (II)

Explain the mechanism of and implications for antimicrobial therapy of induction and stable derepression of AmpC. (III)

Resistance due to Altered Drug Concentration at the Target SiteList three examples of antimicrobial resistance (drug and organism) mediated by reduction of antimicrobial concentrations at the drug target (e.g. efflux). (II)

Discuss how porin channel loss and antimicrobial efflux contribute to differential carbapenem susceptibilities in Pseudomonas aeruginosa. (III)

Resistance due to Altered Drug TargetsList four examples of antimicrobial resistance (drug and organism) mediated by an alteration of the target of drug action. (II)

Discuss the functions of the mecA and pbp2x genes and how they are associated with antimicrobial resistance. (II)

Pathogens-For each of the pathogens listed below, be able to:-Identify the appropriate higher-level taxonomic grouping.-State the normal ecologic niche of the organism, including whether the organism can be found in humans who do not manifest symptoms of infection (e.g. colonization, latent infection)-List at least three infections that the organism is identified as being a common causative agent of and state any patient-, geographic-, or exposure-related risk factors for developing infection.-List at least five Category I antimicrobials with sufficient in vitro activity to be considered clinically useful against infections caused by the organism.-Given a patient with one of the common infections caused by the pathogen identified above, accounting for the severity of illness, site of infection, patient comorbidities, and concomitant medications, recommend an antimicrobial regimen including drug(s), dose, route, frequency, and duration.

Bacteria, Mycobacteria, and RickettsieaeStreptococcus pneumoniae, agalactidae, pyogenes (I)Viridans group streptococci (I)Enterococcus faecalis, faecium (I)Staphylococcus aureus, epidermidis (I)Clostridium difficile, perfringens (I)Peptostreptococcus (I)Escherichia coli (I)Klebsiella pneumoniae, oxytoca (I)Proteus mirabilis, vulgaris (I)Serratia marscesens (I)Citrobacter freundii (I)Acinetobacter baumanii (I)Pseudomonas aeruginosa (I)Enterobacter cloacae, aerogenes (I)Stenotrophomonas maltophilia (I)Haemophilus influenzae (I)Neisseira meningitidis, gonorrheae (I)Moraxella catarrhalis (I)Bacteroides fragilis (I)Chlamydophilia pneumoniae (I)Mycoplasma pneumoniae (I)Legionella pneumophila (I)

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Chylamydia trachomatis (I)Treponema pallidum (I)Mycobacterium tuberculosis (I)Mycobacterium avium (I)Enterococcus gallinarum, casseliflavus (II)Staphylococcus lugdunensis (II)Bacillus cereus (II)Clostridium botulinum (II)Corynebacterium jekeium (II)Lactobacillus (II)Gardnerella (II)Listeria monocytogenes (II)Propionibacterium acnes (II)HACEK group (II)Fusobacterium (II)Prevotella (II)Actinomyces (II)Nocardia (II)Burkholderia cepaciaSalmonella typhi, typhimurium, non-typhoidal (III)Shigella flexneri (III)Campylobacter jejuni (III)Bartonella henselae, quintana (III)Aeromonas hydrophila (III)Mycobacterium abscessus, fortuitum, chelonae (III)Borellia burgdorferi (III)Rickettsia rickettseae (III)

FungiCandida albicans, glabrata, kruseii, parapsilosis, tropicalis, lusitaneae (I)Aspergillus fumigatus, terreus, niger, versicolor (I)Cryptococcus neoformans (I)Coccidioides immitis (I)Pneumocystis jirovecii (I)Mucorales: Mucor, Rhizopus, Rhizomucor, Absidia, Cunninghamella (II)Fusarium (II)Scedosporium apiospermum, Scedosporium prolificans (III)Sporothrix schenckii (III)Penicillium marneffii (III)Alternaria, Bipolaris (III)

VirusesHerpes simplex virus (I)Cytomegalovirus (I)Varicella-zoster virus (I)Influenza virus (I)Human immunodeficiency virus (I)Respiratory syncytial virus (II)BK virus (II)Adenovirus (III)JC virus (III)West Nile virus (III)

Parasites and EctoparasitesToxoplasma gondii (I)

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Cryptosporidium parvum (II)Plasmodium falciparum, vivax, malariae, ovale(III)Taenia solium(III)Sarcoptes scabii (III)

Principles of Antimicrobial TherapyAntimicrobial Pharmacokinetics and PharmacodynamicsAntimicrobial Activity and Pharmacokinetic/Pharmacodynamic RelationshipsDefine bacteriostatic and bactericidal activity in terms of measurable tests and give four examples of clinical situations in which use of bactericidal agents is thought to be associated with significantly better outcomes than bacteriostatic agents. (I)

Define and illustrate the pharmacodynamically linked parameters of time above MIC (Time>MIC), peak to MIC (Cmax:MIC), and area under the curve to MIC ratio (AUC/MIC). (I)

Explain the concept of target attainment and for each of the pharmacodynamics parameters listed above, give one target value associated with improved clinical or microbiological outcomes for a drug:organism combination. (II)

Explain the technique of Monte Carlo simulation. (III)

Given a patient’s age, weight, height, gender, and serum creatinine, calculate dosing regimens for vancomycin, gentamicin, and tobramycin predicted to achieve appropriate serum drug levels for a particular infection. (I)

Antimicrobial Dosing for Abnormal Body Habitus, Drug Elimination, or Special SituationsRecommend an appropriate dose of an antimicrobial for an obese patient. (I)

Recommend an appropriate dose of an antimicrobial for a patient with acute or chronic renal failure who is not receiving dialysis. (I)

Recommend an appropriate dose of an antimicrobial for a patient receiving continuous or intermittent renal replacement therapy. (I)

For a patient with severe hepatic impairment, recommend an appropriate dosage adjustment for an antimicrobial or an appropriate alternative agent. (II)

Explain how the percentage penetration into the cerebrospinal fluid, serum drug levels, and organism MIC influence the selection of antimicrobial agents for infections of the cerebrospinal fluid. (III)

Antimicrobial Combination TherapyExplain three indications for use of antimicrobial combination therapy. (I)

Explain in vitro testing of the effects of antimicrobial combinations, including the fractional inhibitory concentration index and time-kill methodology. (III)

Alternative Routes of AdministrationProvide three examples of uses of antimicrobial agents administered as an inhalation and provide appropriate guidance for the appropriate administration of an inhaled antimicrobial. (II)

List three antimicrobial agents that are appropriate for intrathecal/intraventricular administration and recommend a dose/route/frequency/method of administration for each. (II)

Outpatient Antimicrobial TherapyIdentify intravenous antimicrobial agents that are practical for administration on an outpatient basis. (I)

Describe three different methods for administering intravenous antimicrobials to patients in a home care setting. (II)

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Provide a monitoring plan for patients receiving outpatient antimicrobial therapy. (II)

Adverse Effects and AllergyAllergy and DesensitizationDifferentiate between different types of allergic reactions according to their (putative) underlying mechanism, onset of response, severity of reaction, and management. (I)

Provide an estimate of the likelihood of a patient developing an allergic reaction to a particular beta-lactam agent given the patient’s history of allergic reactions to other beta-lactams. (I)

Provide a risk-benefit assessment of challenging a patient with an antimicrobial to which the patient may be allergic, based on the patient’s underlying disease, prior history of allergy, and the characteristics of the antimicrobial to be challenged with. (II)

Recommend an appropriate antimicrobial desensitization regimen including drug, dose, formulation (including recipe for preparation of doses), frequency of administration, and duration of desensitization as well as recommend the appropriate setting for the desensitization and any precautions necessary. (II)

Adverse EffectsFor a patient being treated with a single- or multidrug antimycobacterial regimen experiencing potential hepatotoxicity, based on laboratory parameters and clinical signs/symptoms, recommend appropriate management including continuing or discontinuing antimycobacterial drugs in appropriate sequence. (II)

Drug FeverIdentify patients in whose fever is consistent with a drug-induced etiology, rank the patient’s current medications according to likelihood of being the etiologic agent, and provide recommendations for managing the fever including withdrawal of likely offending agents, if appropriate. (II)

Pregnancy and LactationFor a given antimicrobial agent, be able to rapidly identify its FDA pregnancy category and its American Academy of Pediatrics recommendation for compatibility with breastfeeding. (I)

List antimicrobial agents that are FDA pregnancy category D or X and indicate under what circumstances, if any, they might be administered to a pregnant patient. (II)

Antimicrobial Agent Pharmacology-For each of the following agents listed below, be able to:-State the mechanism of action, whether the drug is generally considered bacteriostatic or bactericidal, and the pharmacodynamically linked parameter (Cmax:MIC, Time>MIC, AUC/MIC), if known.-List at least five Category I pathogens that the drug is generally considered to have sufficient in vitro activity against for clinical use (at least two pathogens for Category II and III antimicrobials).-List at least four common adverse effects (regardless of severity) and at least two severe adverse effects associated with the agent; if possible, provided recommendations for pharmacologic or non-pharmacologic methods to avoid or reduce the toxicity.-List at least three important laboratory or clinical monitoring parameters for each agent.-State all routes of administration in common clinical use, identify unusual drug distribution characteristics, and recommend whether the drug requires dosage adjustment in renal and/or hepatic dysfunction.-Identify whether a given second drug is likely to have a clinically significant pharmacokinetic or pharmacodynamics drug interaction with the agent, and if an interaction is likely, predict the consequences of that interaction.

Antibacterial AgentsPenicillin V, G, benzathine (I)Ampicillin, amoxicillin (I)Ampicillin/sulbactam, amoxicillin/clavulanate (I)

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Nafcillin (I)Piperacillin/tazobactam (I)Cefazolin (I)Cephalexin (I)Cefuroxime (I)Cefoxitin, cefotetan (I)Ceftriaxone, cefotaxime (I)Ceftazidime (I)Cefepime (I)Aztreonam (I)Ertapenem (I)Imipenem, meropenem (I)Vancomycin (I)Gentamicin, tobramycin (I)Azithromycin, clarithromycin (I)Doxycycline (I)Tigecycline (I)Linezolid (I)Nitrofurantoin (I)Clindamycin (I)ColistimethateTrimethoprim/sulfamethoxazole (I)Metronidazole (I)Ciprofloxacin (I)Levofloxacin (I)Moxifloxacin (I)Isoniazid (I)Rifampin, rifabutin (I)Pyrazinamide (I)Ethambutol (I)Penicillin procaine (II)Ticarcillin/clavulanate (II)Cefpodoxime (II)Cefixime, ceftibuten, ceftidoren (II)Ceftaroline (II)Telavancin (II)Dalbavancin (II)Tedizolid (II)Amikacin (II)Fosfomycin (II)Fidamoxicin (II)Dapsone (II)Minocycline (II)Quinupristin/dalfopristin (II)Streptomycin (II)Carbenicillin (III)Telithromycin, cethromycin (III)Chloramphenicol (III)Polymyxin B (III)Mupirocin (III)Methenamine (III)Tinidazole (III)Norfloxacin (III)Rifapentine (III)Rifaximin (III)

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Capreomycin (III)Cycloserine (III)

Antifungal AgentsAmphotericin B deoxycholate, lipid complex, liposomal (I)Caspofungin, micafungin, anidulafungin (I)Fluconazole (I)Voriconazole (I)Posaconazole (I)Flucytosine (I)Nystatin (I)Itraconazole (II)Terbinafine (II)Ketoconazole (III)Griseofulvin (III)

Antiviral AgentsAcyclovir, valacyclovir (I)Ganciclovir, valganciclovir (I)Foscarnet (I)Zidovudine (II)Lamivudine, emtricitabine (I)Abacavir (II)Tenofovir (I)Efavirenz (I)Darunavir (I)Atazanavir (I)Ritonavir (I)Maraviroc (II)Raltegravir (I)Oseltamivir (I)Zanamivir (I)Famciclovir (II)Cidofovir (II)Nevirapine (II)Etravirine (II)Lopinavir/ritonavir (II)Rilpivirine (III)Fomvirisen (III)Ribavirin (II)Peramivir (III)Amantadine, rimantadine (III)

Antiparasitic AgentsPentamidine (I)Pyrimethamine (II)Sulfadiazine (II)Atovaquone (II)Primaquine (II)Albendazole (II)Artesuante (III)Atovaquone/proguanil (III)Chloroquine (III)Quinine, quinidine (III)Mefloquine (III)

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Nitazoxanide (III)Paromomycin (III)Sodium stibogluconate (III)Ivermectin (III)Praziquantel (III)

Vaccines and Biologicals-For each of the following agents listed below, be able to:-Identify whether it is a live virus, inactivated virus, protein/toxoid, polysaccharide, or conjugated agent;-State at least two patient populations each agent is indicated in;-Identify patients in whom the agent would be contraindicated; -Provide at least two patient counseling points for patients on what to expect after administration, if applicable.Hepatitis A (III)Hepatitis B (III)Intravenous/Intramuscular Immunoglobulin (III)Cytomegalovirus immune globulin (III)Influenza (II)Meningococcal (III)Pneumococcal (II)

Therapeutics of Infectious DiseasesOrgan System InfectionsUpper Respiratory Tract InfectionsFor the infections listed below, based on a patient’s signs, symptoms, laboratory findings, comorbidities, and age, recommend whether to treat a patient with antimicrobials as opposed to symptomatic therapy alone, and recommend an appropriate regimen (drug, dose, route, duration).

otitis media (I)influenza (I)sinusitis (I)pharyngitis (I)

Recommend an influenza vaccine regimen (product, dose, route, and frequency) appropriate for a patient based on their age, comorbidities, allergies, history of vaccination, and social/occupational factors. (I)

Quantify the benefit of influenza antiviral treatment for a patient as a factor of the patient’s time to presentation, comorbidities, severity of illness, and certainty of influenza diagnosis. (II)

Describe the key influenza antigens, the determinants of antigenic variation, and the implications of antigenic variation for human immunity. (II)

List two pathogens associated with fungal sinusitis and describe typical risk factors for infection associated with each. (III)

Lower Respiratory Tract InfectionsRecommend an appropriate evidence-based antibacterial regimen (drug(s), dose(s), route(s), duration(s)), for treatment of a patient with pneumonia according to the following factors (I):

where and when infection was acquired (community, nursing home, early or late hospital stay)recent healthcare system exposuresite of treatment (outpatient vs hospital vs hospital-ICU)ageallergiespresence of comorbiditiesrecent antibiotic exposureinfecting organism (if known)

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Discuss the evidence supporting recommendations for duration of antimicrobial therapy for pneumonia and identify situations in which shorter-course therapy would be and would not be indicated. (II)

Provide appropriate recommendations for dosing of antimicrobials in cystic fibrosis accounting for the unique pharmacokinetic characteristics of this population. (III)

Urinary Tract InfectionsDifferentiate a complicated from uncomplicated urinary tract infection based on patient characteristics, and describe the implications for treatment (choice of drug, duration of therapy) of complicated versus uncomplicated cystitis. (I)

Differentiate cystitis from pyelonephritis based on clinical presentation, including signs and symptoms. (I)

Recommend appropriate antimicrobial therapy (drug, dose, route, duration) for patients with the urinary tract infections below based on patient characteristics, including presenting gender, signs/symptoms, comorbidities, allergies, epidemiology, and microbiology data (if available):Acute uncomplicated cystitis (I)Acute complicated cystitis (I)Acute pyelonephritis (I)

Skin and Soft Tissue InfectionsGiven a patient’s age, comorbidities, severity of disease, and local MRSA prevalence (if applicable), select an appropriate empiric antimicrobial regimen (drug, dose, route, frequency, duration) with appropriate monitoring for efficacy and toxicity for patients with:Impetigo (I)Cellulitis/erysipelas (I)Cutaneous abscesses (I)Necrotizing skin and soft tissue infections (II)

Describe the role of adjunctive protein synthesis inhibition in management of necrotizing skin and soft tissue infections and recommend an appropriate regimen for protein synthesis inhibition (drug, dose, route, frequency, duration) if indicated. (II)

Given a patient’s age, comorbidities, and severity of infection, select an appropriate empiric antimicrobial regimen (drug, dose, route, frequency, duration) with appropriate monitoring for efficacy and toxicity, as well as appropriate patient counseling on self-care, for patients presenting with diabetic foot ulcers that are:Uninfected (I)Infections of mild severity (I)Infections of moderate severity (I)Severe infections (I)

List one characteristic pathogen associated with infections due to the types of bites below and provide a recommendation for an empiric antimicrobial regimen that will include coverage for that pathogen:Human bites (II)Dog bites (II)Cat bites (II)

Bone and Joint InfectionsGiven a patient’s age, comorbidities, and route of infection, select appropriate and definitive empiric antimicrobial regimen (drug, dose, route, frequency, duration), recommend appropriate timing of antimicrobial treatment with regards to cultures, and give appropriate monitoring for efficacy and toxicity, for patients presenting with acute osteomyelitis that originates as:Hematogenous (I)Contiguous without vascular insufficiency (I)Contiguous with vascular insufficiency (I)

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State the most common pathogen in septic arthritis and provide an appropriate empiric regimen for an adult patient presenting with signs and symptoms of septic arthritis. (II)

For a patient with an infected prosthetic joint, recommend an appropriate antimicrobial regimen for each of the following management strategies:One-stage replacement of prosthesis (II)Two-stage replacement of prosthesis (II)Debridement with retention of prosthesis (II)

Identify circumstances in which chronic antimicrobial suppression is indicated for patients with osteomyelitis and/or prosthetic joint infection and recommend an appropriate antimicrobial regimen. (III)

Gastrointestinal Tract InfectionsGiven a patient’s age, severity of symptoms, comorbidities, and site of acquisition of infection, recommend an appropriate initial empiric antimicrobial regimen (drug, dose, route, frequency) for the treatment of the infections below as well as a monitoring plan for drug efficacy and toxicity:Primary peritonitis (I) Secondary and tertiary peritonitis and intra-abdominal abscesses (I)Cholangitis, cholecystitis (I)

Given a patient’s age, severity of symptoms, and comorbidities, recommend an appropriate antimicrobial regimen (drug/dose/route/frequency/duration) for initial treatment of Clostridium difficile-associated disease. (I)

Identify cases of intra-abdominal infection where empiric and/or definitive antibacterial therapy for Candida species and Enterococcus species is warranted, and recommend appropriate antimicrobial drugs. (II)

Describe the pathophysiology of pancreatitis, identify situations in which antimicrobial therapy is warranted, and provide recommendations for empiric antimicrobial therapy. (II)

List five common infectious causes of diarrhea and provide recommendations for management. (II)

Given a patient’s age, severity of symptoms, comorbidities, and treatment history, recommend an appropriate antimicrobial regimen (drug/dose/route/frequency/duration) for treatment of refractory or relapsed Clostridium difficile-associated disease. (II)

Cardiovascular InfectionsRecognize the signs and symptoms of, identify predisposing patient risk factors for, and list the most common organisms seen in infectious endocarditis; and recommend an appropriate empiric antibacterial regimen (drug(s)/dose/route/frequency) for a patient with suspected infective endocarditis pending organism identification. (I)

Given a patient with infective endocarditis due to a known pathogen, select a definitive drug regimen including drug(s)/dose/route/frequency and duration, along with appropriate monitoring parameters for efficacy and toxicity. (I)

Central Nervous System InfectionsFor each of the following patient categories, list the most common causative bacteria and recommend an appropriate empiric antibacterial regimen (drug(s), dose(s), route(s)):Neonatal meningitis (≤2 months of age) (II)Childhood meningitis (2 months to 2 yrs. old) (II)Adult meningitis (2 yrs to 50 yrs old) (I)Geriatric meningitis (> 50 yrs. old) (I)Meningitis in an immunocompromised patient (I)Nosocomial & postneurosurgical meningitis (II)

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Discuss the characteristic symptomatology, laboratory findings, and antiviral treatment of herpes simplex virus encephalitis (II)

Describe the anatomy of a ventriculoperitoneal cerebrospinal fluid shunt, list three common pathogens seen in infections of these shunts, and recommend an appropriate empiric antimicrobial regimen for a suspected infection of a ventriculoperitoneal shunt or external ventricular drain. (II)

List three bacterial, two parasitic, and one fungal pathogen commonly associated with brain abscesses, and provide an appropriate empiric antibacterial regimen for suspected bacterial brain abscess. (II)

Describe the anatomy of an epidural abscess, list the most common pathogen in epidural abscesses, and recommend an appropriate empiric antimicrobial regimen for a patient with suspected epidural abscess. (II)

Genital Tract InfectionsFor a patient with one of the infections listed below, given their age, comorbidities, allergies, and severity/stage of illness, recommend an appropriate empiric antimicrobial regimen (including treatment for potential co-infections if indicated) by giving the drug(s)/dose/route/frequency/duration of therapy and provide monitoring parameters for regimen efficacy and drug toxicity:Gonococcal urethritis and cervicitis (II)Chlamydial urethritis and cervicitis (II)Pelvic inflammatory disease (II)Syphilis: primary, secondary, tertiary, neurosyphilis (II)

SyndromesSepsisRecognize the signs/symptoms of the systemic inflammatory response syndrome (SIRS) and identify the subset of SIRS patients that have:Sepsis (I)Severe sepsis (I)Septic shock (I)

Based on a patient’s suspected underlying infection source, recommend an appropriate empiric antimicrobial regimen including drug(s)/dose/route/frequency and provide monitoring parameters for efficacy and drug toxicity; be able to recommend appropriate definitive therapy when/if a pathogen is identified. (I)

Febrile Neutropenia Describe how the risk of infection for patients undergoing myelosuppressive chemotherapy is associated with the level and duration of the patient’s absolute neutrophil count. (I)

For a patient identified as their first episode of febrile neutropenia, given their age, comoborbidities, current medications, severity of illness, and results of any current or prior microbiology tests, recommend an appropriate drug regimen, and give drug(s)/dose/route/frequency and provide criteria for monitoring for efficacy and toxicity. (I)

For a patient with febrile neutropenia who has not responded to antimicrobial therapy, given their age, comoborbidities, current medications, severity of illness, and results of any current or prior microbiology tests, recommend an appropriate drug regimen (adding/continuing/discontinuing drugs), and give drug(s)/dose/route/frequency and provide criteria for monitoring for efficacy and toxicity. (II)

Catheter-related Bloodstream InfectionsList the criteria that must be satisfied for a patient to be considered to have an uncomplicated bloodstream infection. (I)

Given the results of blood culture tests for a patient with a suspected catheter-related bloodstream infection, recommend whether to initiate/continue/discontinue/change therapy, and if treatment is chosen provide an

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appropriate definitive treatment regimen with drug(s)/dose/route/frequency and duration and appropriate monitoring parameters for efficacy and toxicity. (I)

Describe the antimicrobial lock technique, identify situations in which use of an antimicrobial lock is appropriate, and provide a drug/dose/route/frequency/method of administration for a patient with a staphylococcal catheter-related bloodstream infection. (II)

Special PopulationsInfections in Patients with Human Immunodeficiency Virus InfectionFor a patient with human immunodeficiency virus infection who is receiving antiretroviral therapy, identify whether the patient’s antiretroviral regimen meets minimum standards for appropriateness. (I)

For each of the opportunistic infections listed below, identify risk factors for development of a first episode of the infection (e.g. CD4 count, exposure history) and make appropriate recommendations for prophylaxis to prevent a first episode of the disease (drug/dose/route/frequency). Be able to identify circumstances in which this prophylaxis could be discontinued.Pneumocystis jirovecii pneumonia (I)Toxoplasma gondii encephalitis (I)Mycobacterium avium disease (I)

For each of the opportunistic infections listed below, identify the signs and symptoms of infection, and based on the patient’s age, comorbidities, severity of illness, and current medications, recommend an appropriate initial antimicrobial (and anti-inflammatory, if indicated) regimen, including drug(s)/dose/route/frequency/duration, and provide recommendations for monitoring for drug efficacy and toxicity. Identify patients for whom secondary prophylaxis would be indicated, give a drug/dose/route/frequency for secondary prophylaxis, and identify circumstances under which prophylaxis could be discontinued.Pneumocystis jirovecii pneumonia (I)Mycobacterium avium disease (I)Cytomegalovirus retinitis (I)Cryptococcal meningitis (I)Toxoplasma gondii encephalitis (II)

Infections in Patients with Hematopoietic Stem Cell TransplantsFor a patient undergoing hematopoietic stem cell transplantation, recommend an appropriate prophylactic regimen based on the patient’s type of transplantation and the depth and duration of neutrophil suppression. (II)

Infections in Patients with Solid Organ TransplantsFor the infectious complications of solid organ transplantation listed below, state the usual timing of the infection (<1 month, 2-6 months, > 6 months post-transplant), and given a patient’s age, comorbidities, history of present illness, and current medications, be able to recommend an appropriate prophylactic regimen, if indicated (drug/dose/route/frequency):Infections due to Candida spp. (I)Herpes simplex virus infection (I)Cytomegalovirus infection (I)Aspergillus infection (I)Pneumocystis jirovecii pneumonia (I)Cryptococcal meningitis (I)BK virus (II)

Infections in PediatricsName four antimicrobial agents that are generally avoided in pediatric patients (including relevant ages), state the rationale for their restriction, and explain under what circumstances benefits of the antimicrobials would outweigh their risks. (II)

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Provide an accurate dosage recommendation for all Category I antimicrobial agents for pediatric patients (preterm neonate through adolescent). (II)

Evaluate a child’s vaccination history, recognize any departures from the recommended vaccination schedule, and provide recommendations for catch-up vaccinations, if appropriate. (III)

Antimicrobial StewardshipPrinciples and Practice of Antimicrobial StewardshipAntimicrobial Stewardship StrategiesDescribe and provide an illustrative example of each of the following antimicrobial stewardship strategies:Formulary restriction and preauthorization (II)Audit and feedback (II)Educational interventions (II)Antimicrobial order forms (II)

State four ways in which computerized systems can aid in antimicrobial stewardship and for each provide one benefit the system provides and one challenge to implementation. (II)

Create a list of antimicrobials that would be candidates for an IV to PO conversion program and give an example of how such a program could be implemented. (II)

Practice of StewardshipGiven an order for an antimicrobial:Determine the necessary information to evaluate the order for appropriateness; (I)Access the appropriate information; (I)Accurately evaluate the order for appropriateness given the available information; (I)Document your assessment as appropriate, including interventions performed, if any. (I)

For antimicrobial orders that are not deemed appropriate:Prioritize orders according to acuity; (I)Determine the appropriate clinician to contact to discuss the order; (I)Concisely and professionally communicate your concerns to the clinician; (I)Manage disagreements with clinicians in a professional manner, including referral to other clinicians as appropriate; (I)

Practice ManagementReporting & Quality ImprovementPrepare an institutional antibiogram according to best practices and summarize its findings to a group. (II)

Define, compare, and contrast the antimicrobial utilization measures of days of therapy and defined daily doses. (III)

Prepare an antimicrobial utilization report according to best practices and summarize its findings to a group. (III)

Accessing, Evaluating, and Creating Evidence to Guide CareAccessing EvidenceRapidly access consensus guidelines for care of patients with a given infection. (I)

Rapidly determine the correct dose of an antimicrobial agent for an individual patient. (I)

Using the peer-reviewed literature, provide an estimate of the likelihood (e.g. percent susceptible, MIC90) that a given antimicrobial will have activity against a pathogen whose antimicrobial susceptibilities have not been determined. (II)

Evaluating EvidenceState and define the United States Public Health Service Levels of Evidence and GRADE evidence guidelines. (I)

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Define a randomized intervention trial, a cohort study, a case-control study, and a cross-sectional study. (I)

Define intention-to-treat analysis in the context of a randomized clinical trial and identify whether a given study followed intent-to-treat principles. (I)

Define confounding in the context of clinical research and discuss three ways it can be reduced. (I)

Define and differentiate between sensitivity, specificity, positive predictive value, and negative predictive value. (I)

Define a p-value. (I)

Explain the purpose of multivariable regression analysis. (II)

Compare and contrast superiority and noninferiority designs for randomized controlled trials and provide a rationale for the use of noninferiority designs. (III)

Creating EvidenceIdentify a question of suitable content and depth to serve as a research project and properly define the main study question/hypothesis. (I)

With the collaboration of program personnel, design a study appropriate to answer the study question(s). (I)

Summarize the peer-reviewed literature on a topic to sufficient depth to:write the background section for a research proposal; (I)submit a topic summary for peer-reviewed publication. (III)

Perform a power calculation to determine the necessary number of subjects for a study given a presumed effect size, power, and p-value. (II)

Gather study data in an accurately, securely, and in a manner that facilitates quantitative analysis (II);

Analyze study data using:Descriptive statistics; (II)Inferential statistics (III)

Summarize study results:as an abstract (II)as a poster (III)as a PowerPoint presentation (III)as a manuscript for submission to a peer-reviewed journal (III)

Sharing KnowledgeFormal Didactic Teaching to StudentsSketch out the conceptual relationships between environmental stimuli, sensory memory, working memory, and long-term memory. (II)

Write five behavioral learning objectives for a teaching session appropriate to the level of the learner (I).

Draft a classroom presentation designed to provide students the necessary information to demonstrate competency in the learning objectives. (II)

Incorporate at least two active learning strategies into a classroom presentation. (II)

Reflect on a completed teaching session, identifying at least three areas of achievement and at least three areas for improvement. (II)

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Experiential Teaching to Students and ResidentsProvide a constructive critique of a trainee’s patient presentation, providing specific suggestions for improvement. (II)

Summarize and lead a small group discussion of an infectious diseases topic, including preparation of a properly referenced handout. (II)

In collaboration with program personnel, complete a trainee evaluation form including narrative feedback. (III)

Presenting Information to Other Healthcare ProfessionalsSummarize and lead a small group discussion of an infectious diseases topic, including preparation of a properly referenced handout. (II)

Summarize the results of a research or clinical operations project, including preparation of a handout, and effectively respond to questions from the group. (III)

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