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2 Specialties Infectious diseases and tropical medicinePatients with chronic conditionsInfectious diseases practice involves working with somepatient groups with chronic conditions, even thoughmost of the activity concerns acute admissions. Thosewith blood-borne virus infections, notably HIV,hepatitis B and C, are frequently cared for in theoutpatient setting. There needs to be engagementbetween physicians and patients, along with other teammembers, to ensure the best long-term care andoutcomes. Difficult surgical infections, particularlyinvolving the musculoskeletal system, require long-termmanagement and close liaison with surgical colleagues.Some infectious diseases physicians also managepatients with CFS and again provide chronic care forthese individuals in a multidisciplinary team (MDT).The role of the carerCarers have an important role in managing manydiseases. The involvement of carers in the overallmanagement of those with HIV infection is oftenimportant. They can help ensure adherence to difficultdrug regimens and provide support. The same is truefor those who have to undergo difficult treatments forhepatitis C infections.Access to information, patient support groupsand the role of the expert patientInformation is provided in a variety of formsby infectious diseases units to increase patient awarenessand involvement. Patient support groups are very helpful,particularly in HIV disease where organisations suchas the Terence Higgins Trust provide invaluable supportand advice. Similarly, involvement of support groups forthose with hepatitis C or with CFS can help. The role ofthe expert patient is most useful in chronic conditions,such as HIV, but is more difficult for many of theacute conditions seen by infectious diseases physicians.Availability of clinical records/resultsPrompt access to records and results is an essential partof the practice of infectious diseases physicians asdecisions often have to be made in the acute setting.The use of information technology (IT) has improvedthe ability to access results and records. Imaging is animportant component of good infectious diseasesmanagement and this has been enhanced enormouslyby the availability of digital imaging accessibleelectronically. The electronic patient record will be amajor step to improving care. Many units now have theability to inform patients of results by email or textmessaging. This can be helpful for those with chronicconditions, such as HIV, but may also help those seekingtravel advice. Those units that provide an OPAT service(see above) usually provide patients with hand-heldrecords to facilitate their care in the community.4 Interspecialty and interdisciplinary liaisonMultidisciplinary team workingInfectious diseases physicians frequently work in MDTs.The complex cases and the numbers of vulnerablepatients require interactions with specialist infectiousdiseases pharmacists, specialist nurses, dietitians,occupational and physical therapists, and socialworkers. There are also close links with voluntaryorganisations, particularly those involved with HIV andwith drug addiction. Infections can complicate surgicalprocedures or may require complex surgery, so MDTclinics and rounds are essential for good outcomes. Inaddition, the management of CFS requires team workwith clinical psychologists.Working with other specialtiesThere are close working relationships betweeninfectious diseases physicians and clinicalmicrobiologists and virologists. There are also nowwell-established joint training programmes so thatfuture infection specialists will be accredited in bothinfectious diseases and medical microbiology. Infectiousdiseases specialists also interact closely withgenitourinary medicine (GUM) specialists (particularlyin the joint management of HIV infection) withhepatologists in the management of chronic hepatitis Band C infections and with respiratory physicians inmanaging TB. Due to the acute nature of the specialty,there are many times when infectious diseases specialistswork with other physicians in the acute sector,particularly those in acute general medicine. Manyinfectious diseases physicians, acting as acute physiciansthemselves, play a major role in acute medicine in theirtrusts. Surgical infections are an important problem soinfectious diseases physicians interact regularly withsurgeons to manage complex intraabdominal infectionsor musculoskeletal infections. There are few hospitalspecialties that do not require and seek advice frominfectious diseases physicians.Working with GPsGenerally speaking, there are no GPs working ininfectious diseases although there are many interactionswith GPs needing specialist advice to manage patients inthe community. Some GPs have a special interest intravel medicine and may provide these services in theC○ Royal College of Physicians 2013 147
Consultant physicians working with patientsNHS or the independent sector. Infectious diseasesphysicians are prominent in the development ofantibiotic policies, not only for the hospital but alsothose that are used in primary care. They help toeducateGPsintheappropriateuseofantibioticsinthecommunity, the interpretation of laboratory tests andthe prevention and management of healthcareassociatedinfections.Specialist activity beyond local servicesInfectious diseases physicians have taken on the burdenof providing clinical expertise and cover in the event ofbioterrorism. Each region has an infectious diseasesphysician named as the smallpox diagnostic expert(SDE), who has been vaccinated and trained in therecognition of this disease and its management in theevent of a new case emerging. These physicians are alsoinvolved in the planning for other outbreaks, includingpandemic influenza, in conjunction with the HealthProtection Agency (HPA) and public health physicians.Infectious diseases physicians play an active role innational bodies. As well as working at the Royal Collegeof Physicians (RCP), they serve on national committeessuch as the Joint Committee on Vaccinations andImmunisations (JCVI), the Expert Advisory Group onAIDS (EAGA), the Advisory Committee onAntimicrobial Resistance and Healthcare AssociatedInfection (ARHAI) and the National Expert Panel onNew and Emerging Infections (NEPNEI). Many havehelped with the development and running of theNational Travel Health Network and Centre which nowprovides excellent advice about travel medicine to thepublic as well as to health professionals.5 Delivering a high-quality serviceCharacteristics of a high-quality serviceCharacteristics of a high-quality service include: inpatient facilities and expertise 24 hours a daythroughout the year isolation rooms, including those with negativepressure ventilation same day access to outpatients for acute infectionsand travellers open access to those with HIV infection open access to those with accidental blood-bornevirus exposure clinical management that takes a holistic approach regular clinical liaison with themicrobiology/virology laboratory lead on the trust’s antimicrobial policy active promotion of appropriate antimicrobial usagein the hospital lead on the trust’s infection control policies and withthe team active promotion of best practice of infection control promoting safe intravenous antibiotic usage outsidethe hospital meeting recognised standards in clinical care meeting NHS targets for inpatient and outpatientwork.Maintaining and improving the quality of careLeadership role and service developmentInfectious diseases physicians often take leadership rolesin the hospital, in addition to having clinical leads intheir specialty. Many will serve on or chair antibioticcommittees or infection control committees in theirtrusts. They will frequently have leadership roles in theirregions for infection-related policies and links withprimary care trusts (PCTs) and with the HPA.Infectious diseases physicians have taken the lead indeveloping OPAT to facilitate patient discharge, whileproviding appropriate antibiotic therapy for seriousinfections. In addition, by supporting the developmentof standards for managing HIV and TB, they arecontributing to improvements in the service.Education and trainingMost infectious diseases physicians are involved inteaching medical students, both preclinical and clinical.In addition, because many have academic positions,there is wider teaching, both regionally and nationally.However, some of the new medical schools do not haveinfectious diseases physicians so not all students andtrainees get exposed to such teaching, which is a gap intheir training. Most infectious diseases physicians willact as trainers for junior medical staff. Some centreshave appointed new academic clinical fellows under theWalport scheme to continue to nurture academicmedicine and, particularly, academic infectiousdiseases. The physicians also teach other trainees,including nurses and ancillary workers. Infectiousdiseases physicians, as in other specialties, have beeninvolved in training foundation doctors and inacademic training schemes. In addition, recognising theneed to encourage trainees to learn about internationalhealth, our specialty is keen to allow trainees to spendtime abroad and to encourage trainees from developingcountries to be involved in research and to get someexperience in the UK.148 C○ Royal College of Physicians 2013
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AbbreviationsA&EAACsAMUsARCPCCGsCCS
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