Remember to ask. Senior doctors in infectious disease are usually friendly and approachable and would rather be asked than leave you to manage things alone.
Many inpatients on infectious disease wards will have underlying HIV or TB, though infectious disease units will also routinely manage those with more common infections such as cellulitis and gastroenteritis. Before starting it would be helpful to brush up on the management of common infections as well as the weird and wonderful.
Familiarise yourself with the common tests used to monitor patients with HIV, including viral load and CD4 count. There are also well described thresholds of falling CD4, where opportunistic infections such as Pneumocystis jirovecii pneumonia (PCP), Kaposi’s sarcoma, and cerebral toxoplasmosis can develop.
It is useful to develop a working knowledge of the diagnosis and management of TB, including isolation precautions before going on-call. You may be asked to give an opinion on a new diagnosis of TB by doctors in accident and emergency (A&E).
It is important to understand and respect the importance of confidentiality for patients with HIV. Concerns about confidentiality may mean that patients will not disclose their diagnosis to their usual GP. As a result they may present to an infectious disease unit ahead of a GP surgery with seemingly minor problems unrelated to their HIV. Don’t dismiss them as they may feel unable to access health care any other way. Always check with them first before communicating with their GP or another specialty.
A minority of complex inpatients stay on the ward for many months. Investigation, treatment, and recovery can seem to take much longer than on standard medical wards. Take the time to get to know your patients and be aware of the difficulties they face with long periods of isolation and hospitalisation. It can have a massive impact on social, professional, and financial aspects of their lives.
Don’t worry if you find new and unfamiliar drugs mind-boggling. There are many unfamiliar drugs in the antiretroviral drug category in particular. These drugs come in a variety of combinations and have important side-effects, drug interactions, and contraindications. Check the BNF and ask a senior colleague or pharmacist working in the department.
Respect isolation precautions. Units are mainly made up of side rooms some of which will be under negative pressure. Follow instructions and ask before entering, especially when seeing patients with newly diagnosed TB.
You may be asked to inform your local public health medical officer of a notifiable disease. A list of notifiable conditions can be found on the Health Protection Agency website and ask a ward clerk or manager for the forms that need to be completed.
Make yourself aware of needle stick injury protocols. You may be asked advice on this by other specialties or A&E.
You may be asked to perform an Ishihara test for patients starting TB therapy. This is a test of colour vision and involves showing the patient coloured dot diagrams. Find the charts on the ward and ask a colleague how to use them.
Improve your phlebotomy skills. Some patients, in particular those who have injected drugs, will be almost impossible to take blood from or cannulate. Take the opportunity to get some supervised experience taking blood from neck veins.
Intravenous drug users are at increased risk of a number of infectious diseases and are therefore frequent attenders to infectious disease units. Try and avoid frustration with their apparently chaotic behaviour, focus on improving their health without judgement or prejudice.
Have a high level of suspicion for malaria in all returning travellers with fever. It can mimic other infections and appear in travellers from affected regions up to 6 months (occasionally years) after return, even if prophylaxis was taken. Be wary of worsening anaemia (haemolysis in malaria), confusion (cerebral malaria), and low blood sugar in patients admitted to the ward.
Fever of unknown origin is a common presenting problem in infectious disease. Keep an open mind about the diagnosis and try and rule out common infections before jumping to a more exotic diagnostic conclusion. Remember, many pyrexias are not due to infection so also consider autoimmune conditions and neoplasm, in particular lymphoma.
Make yourself familiar with your department’s seasonal flu protocol. Infectious disease units are central to coordinating this and you may be asked to give advice to other specialties.
