Outpatient Training and Clinics
Outpatient Training and Clinics
Outpatient clinical training at UVA provides opportunities for trainees to observe and manage adult and adolescent patients with a wide variety of infectious diseases, in nine different ambulatory clinics staffed by faculty members from the Division of Infectious Diseases. These rotations result in a well-rounded experience, ensuring trainees’ competence for longitudinal care of patients with a broad range of clinical infectious diseases.
Fellows oversee the care of patients with acute and chronic infections in the General Infectious Diseases Clinic (Non-HIV), Sexually Transmitted Diseases Clinic, and the Travelers Clinic, over seven months split between the second and third years of training. Trainees provide both short-term and longitudinal care for patients in these clinics, under the supervision of ID faculty members.
Beginning in their second year, trainees are assigned a half-day per week to attend their own HIV clinic, where they are responsible for the ongoing care of a panel of patients, under the supervision of ID faculty. The majority of fellows’ training in longitudinal patient care is provided through this experience.
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Infectious Diseases Clinics
Trainees spend one half-day per week caring for the needs of HIV-infected patients from Charlottesville and surrounding areas. The clinic provides care for approximately 750 HIV-positive patients. Under the direction of dedicated faculty, trainees assume primary responsibility for a panel of 50-60 patients including issues related to antiretroviral therapy, prophylaxis and management of opportunistic infections, and social and financial aspects of case management. Trainees are expected to participate in all aspects of longitudinal care, phone consultation, and direction of referral to other specialists for their patients when needed. Trainees may also provide assistance to the Inpatient Infectious Disease Service as required when one of their patients is admitted to the hospital. Generally, patients are seen for regular visits every 3-6 months, depending on their clinical status. There are also two nurse practitioners in the clinic who have their own patients.
The clinic receives significant funding from the federal Ryan White HIV/AIDS Program. These funds provide for additional on-site services such as Gynecologic care from an Ob/Gyn faculty nurse practitioner, mental health care (provided by faculty psychiatrists and psychologists, as well as a substance abuse counselor), and case management. These funds are also used for such things as dental care, nutritional support, transportation and outreach for our patients. The clinic also has a full-time social worker and full-time PharmD. The clinic provides for a walk-in clinic Monday through Friday that is staffed by the two clinic nurse practitioners.
Fellows will develop expertise in the diagnosis and treatment of complications of HIV representing the full range of opportunistic infections including PCP, CMV, MAC, PML, disseminated VZV; opportunistic malignancies, including lymphoma and invasive anal and cervical carcinomas; and complications of HAART including metabolic complications and the development of drug resistance.
The UVA Outpatient Infectious Disease Clinic is open three half-days weekly and receives patients from a variety of referral sources, including other medical and surgical teams within UVA, and surrounding community hospital and outpatient-based practices without dedicated infectious disease physicians. The clinic supports approximately 150-200 patient visits per month, and fellows are supervised by attending physicians from the Division of Infectious Diseases.
All manner of patients are seen in the clinic, reflecting the diverse population of the Charlottesville area and surrounding areas, as well as a large population of travelers from the University of Virginia and within the large immigrant population in the area (see Inpatient Training, Overview). Infections seen in this clinic include but are not limited to tuberculosis and other mycobacterial infections (including leprosy), brucellosis, ehrlichiosis, nocardiosis, invasive fungal infections such as histoplasmosis and aspergillosis, CMV infections, epidural and brain abscesses, and endocarditis, along with a host of more common infections including osteomyelitis, indwelling line and vascular graft infections, Lyme disease, and many others.
The UVA Transplant Infectious Disease Clinic is a part of our state-of-the-art transplant center, which provides comprehensive treatment for patients undergoing heart, lung, pancreas, kidney, liver, and islet cell transplants.
Held once weekly, the clinic serves patients in all stages of the transplant process. We are involved with pre-transplant evaluation when a concern for a previous infection or exposure, such as tuberculosis orStrongyloides, exists. We also evaluate patients with a history of infection caused by multidrug-resistant organisms, in order to assist their transplant team with planning peri-operative and post-operative antibiotics. We help to guide the management of post-transplant infections, including both nosocomial infections and those caused by opportunistic pathogens, and follow these patients in clinic longitudinally to monitor for medication side effects and resolution of the infectious process. Close contact with referring physicians and the patient’s entire transplant team allows for truly comprehensive care of the organ transplant recipient.
Traveler’s Clinic is attended by fellows on an elective basis. The clinic meets one half-day per week and focuses on the pre-departure needs of international travelers including adults and children who may be vacationers, business-related travelers, health-care workers, or travelers visiting friends and relatives. The Travel Clinic is staffed by Dr. Erik Hewlett (Director) and Drs. Richard Pearson and Tania Thomas.
Trainees have an opportunity to develop experience with vaccines regarding current national and international recommendations, importance of the traveler’s immune status, location of travel, and cost; prevention of malaria; prevention and management of traveler’s diarrhea; and approach to global infectious diseases and emerging pathogens.
Infectious Diseases’ Hepatitis C Virus (HCV) Clinic provides care for people diagnosed with HCV who are interested in pursuing immunotherapy. During the initial clinic visit, the patient is provided with education about HCV and its treatment, and providers stage and characterize the disease and make recommendations for treatment.
This is a fast-paced and exciting time for treatment and care of acute and chronic hepatitis C disease; fellows have an opportunity to learn about new HCV therapies and administer and manage them, as well as strategies for assessing and managing early-stage liver disease. Patients with cirrhosis are co-managed by, or referred to, the UVA Hepatology group. Cases of co-infection with HIV and HCV are also seen and managed in the HCV clinic.
ID fellows have many opportunities to broaden and deepen their knowledge and experience related to TB and NTM disease, particularly with regard to mechanisms of drug-resistance, host immunology, pharmacokinetics, and imaging of mycobacterial infection. Fellows participate in patient consultations as part of UVA’s Outpatient Infectious Diseases clinic; they have also participated in, and collaborated with, the state’s TB Control Program, and presented and published resulting research findings. Fellows may also have opportunities to work in non-UVA clinics, such as the busy Fairfax County TB Clinic in northern Virginia. In addition, ID fellows have completed the Southeastern National Tuberculosis Center’s “Comprehensive Clinical TB Course,” offered quarterly.
Virginia has a relatively high number of cases of tuberculosis (TB) and non-tuberculous mycobacterial (NTM) disease, compared to national statistics. ID faculty members Eric Houpt, Tania Thomas and Scott Heysell work as consultants to the Virginia Department of Health for complex TB cases, including cases of pediatric TB, and those with drug resistance or intolerance, or co-morbidities such as HIV or diabetes. UVA patients with NTM are often managed in collaboration with colleagues from Pulmonary Medicine–particularly those with specialties in cystic fibrosis–and from Thoracic Surgery.
Second- and third-year fellows may spend Friday afternoons in the Sexually Transmitted Disease Clinic at the Thomas Jefferson District Health Department., located in the City of Charlottesville. There they are directly involved in all aspects of STD management, including differential diagnosis, antimicrobial therapy, and public health issues. Special emphasis is placed upon the development of skills appropriate for the evaluation of these patients, including gynecologic examination and specimen processing, microscopic evaluation, and provision of topical dermatologic therapies for infections like HPV and molluscum contagiosum. Fellows are expected to become expert in the management of these infections, with consideration for cost containment and local antimicrobial-resistance patterns.
Clinic supervision is provided by Dr. Cirle Warren and Dr. Joshua Eby, UVA associate and assistant professors of medicine, respectively. Dr. Warren completed her research training at UVA, studying the role of lactoferrin as a marker of inflammatory genital infections; she has co-authored a chapter in the textbook Sexually Transmitted Diseases (edited by Holmes et al.). Dr. Eby also received his infectious diseases training at UVA, with a research focus in Bordetella pertussis and bacterial toxins.
Due to a growing aging population that requires increasing joint replacement, orthopedic infections are a growing problem. By 2030, it’s estimated that the total number of hip arthroplasty (THA) and total knee arthroplasty (TKA) implantations done in the U.S. each year will approach 4,000,000. Assuming a risk of infections of 1 to 5% in all prosthetic joints, the number of THA and TKA infections is likely to increase proportionately. The UVa Musculoskeletal Infectious Diseases (MSK ID) clinic provides multidisciplinary expertise in diagnosing and managing musculoskeletal infections in collaboration with our colleagues in the Department of Orthopaedic Surgery who perform roughly 1000 joint replacements each year. Many of these operations occur in patients referred to UVa with pre-existing infections. The UVa MSK ID collaboration has led to participation in recent international consensus guidelines and other publications that have included ID fellows.
Complicated Clostridium difficile Clinic
The Complicated Clostridium difficile Clinic (CCC) is a component of UVA’s multidisciplinary Fecal Microbiota Transplantation (FMT) program. The FMT team includes Ann Hays, MD (Gastroenterology), Sheila Vance, PA (Gastroenterology), Glynis Kolling, PhD (Microbiology), Laurie Archbald-Pannone, MD (Geriatrics) and Cirle Warren, MD (Infectious Disease). The CCC provides care for patients with recurrent C. difficile infection (CDI) and screens patients for potential FMT. The clinic is open on Friday afternoons and is staffed by Ann Hays, Cirle Warren, Sheila Vance, and Deadra Boyd, RN. Trainees rotating in the clinic have a chance to experience the challenges of managing recurrent CDI; they also participate in patient and provider education, perform FMT screening, follow up on FMT and non-FMT patients, and participate in various translational and clinical research within the FMT program.