Monday, August 1, 2016

Rotation 2 - Infectious Diseases at UMHS

Posted by James Shen at Monday, August 01, 2016

I finished up my second rotation with the infectious disease consult service at UMHS, and it was definitely quite the experience. We have an excellent team of infectious disease pharmacists at the University of Michigan, and you will undoubtedly learn more about antibiotics, antifungals, stewardship, and other infectious disease related topics than at any other rotation. Make sure you review your bug-drug list, brush up on your pharmacokinetics, and put on your stewardship hats – because you will be in for a very challenging, yet rewarding rotation!

 Infectious diseases functions primarily as a consult service at UMHS, which means that we have no specific unit to which we are assigned to. Any patients that have complicated infectious cases are referred to our team, where we will review their antimicrobial regimen and determine if any adjustments need to be made. Throughout my time on the service, I was able to see many unique cases, including patients with HIV, mucormycosis fungal infections, gangrenous toes and fingers, gunshot wounds, amputated limbs, and more. Sometimes the infectious causes were obvious, whereas other times I really had to dig deep to find out what the true source of a patient’s infection was.

Morning Routine
A typical day on rotation would start with me working up patients in the morning that were assigned to our particular consult service, which would usually amount to around 15-20 patients per day. Some patients would remain on the service for weeks, and I got to know their cases in-depth as I followed up with them each day, whereas other patients came on the service and were signed off within hours. Once I had a solid grasp on several patients on the service, I would meet up with my preceptor to discuss each of the cases. Sometimes, a topic would come up that would warrant a further topic discussion for the next day, such as the use of linezolid with SSRIs, or the use of carbapenems in patients with penicillin allergies. After going through the patients with my preceptor, we would discuss if any changes needed to be made to their regimen based on their clinical status, culture results, or any other relevant factors. We would then start our afternoon rounds, which typically lasted from 1 pm until 4 pm.

Rounds were typically preceded by something called “Micro-rounds,” where the team would meet in the pathology lab and we would have a brief topic discussion about some microbiology topic. After that, we would head up to the floors to begin our actual patient rounds. The rounding team is large, and it typically consisted of at least one attending physician, an ID fellow, a medical resident, a medical intern, a fourth-year medical student, the fourth-year pharmacy student, and occasionally the ID pharmacist. Prior to entering the patient room, one of the team members would present the patient case to the attending, and we would then have a discussion about what we think needed to be done. Don’t be surprised if the team turns to you and asks for a dosing recommendation during this whole process - the team will take your dosing recommendations very seriously, so make sure you do the proper research beforehand about each of the patients on the service!

What else?
In addition to rounds, I attended various weekly meetings, which included stewardship meetings, weekly reports, and ID grand rounds. The weekly reports were my personal favorite. We would meet early in the morning, and one of the ID fellows or ID physicians would present 2-3 interesting, complex, or unsolved cases from the previous week. It was always interesting to hear the ID team’s thought process as they tried to narrow down a patient’s diagnosis, and discuss all the possible differentials that may be contributing to a patient’s clinical symptoms. I also attended various other meetings on and off throughout the rotation, including an infection control meeting (where we discussed environmental and non-pharmacological ways to reduce infection spread in the hospital), and a P&T committee meeting (where we discussed changing some of our ID guidelines).

Other student responsibilities during this rotation included monitoring patients on restricted antimicrobials (ex: fidaxomicin, meropenem, micafungin), and determining whether or not their use was appropriate. I also participated in ID stewardship, where I assessed patients that had S. aureus bacteremias, C. difficile infections, or HIV infections. Finally, I did a lot of reading of primary literature, and I gained a much better understanding of how to properly interpret, analyze, and critique the literature. I would often be assigned one or two landmark trials per week, and then I would meet up with my preceptor to discuss each of them in depth (ex: statistical analysis, inclusion/exclusion criteria, flaws in study designs, implications for practice, etc.)

 Overall, I learned a lot on this rotation about what it means to be an infectious disease specialist. This was a topic that I greatly enjoyed learning about in therapeutics, and I would highly recommend this for anyone that is interested in learning more about it. Even if you are not interested in pursuing a future career in ID, I think this rotation really gives you a solid foundation that will undoubtedly be useful for any future clinical rotations.

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