IDSA News - May 2009
Vol. 19 No. 5
(Print All Articles)
IDSA Journal Club
This month: the role of toxin B in Clostridium difficile virulence, alcohol-based hand gels in child-care centers, native valve endocarditis, telaprevir as a treatment for hepatitis C, and rabies prophylaxis for bedroom bat exposure.
In this feature, a panel of IDSA members identifies and critiques important new infectious diseases studies in the current literature that have a significant impact on the practice of infectious diseases medicine.
The Killer B? Role of Toxin B in Clostridium difficile Virulence
Reviewed by Christopher J. Graber, MD
In contrast to previous studies, toxin B, rather than toxin A, is essential for the virulence of C. difficile, a finding that has implications for diagnosis, according to a study published in the April 30 issue of Nature. The investigators constructed isogenic mutant strains of C. difficile with interruptions in the genes for toxins A and B and used a hamster model of colitis to compare the virulence of each mutant strain to wild type.
Western blots demonstrated that no toxin was produced when its gene was interrupted; of note, toxin B mutants produced more toxin A than wild type. Cytotoxicity assays demonstrated the functionality of either toxin when the other one was mutated. In the hamster model, the hamsters inoculated and colonized with toxin A mutants had similar outcomes with regard to mortality compared to wild type (94 percent vs. 90 percent), while the hamsters colonized with toxin B mutants had markedly decreased mortality (21 percent). Fecal pellets from three of the hamsters that died after being colonized with toxin B mutants were analyzed to show that toxin B activity had been restored in all three, likely from the mutant strain at least partially reverting to wild type. This phenomenon was not seen in the toxin A mutants.
This study contrasts with prior animal studies showing that purified toxin A alone induces pathology and that toxin B is not toxic unless combined with toxin A. This demonstrates the importance of using natural infection models to study the relative impact of toxins on virulence. From a clinical standpoint, this study calls into question diagnostic strategies that rely on detection of toxin A (and not toxin B) activity, as it seems clear that C. difficile strains that only produce toxin B are capable of causing disease.
(Lyras D, et al. Nature 2009; 458:1176-81.)
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Is it Safe to Use Alcohol-based Hand Gel in a Day-care Setting?
Reviewed by Paul Pottinger, MD
Children in day-care centers are at high risk of transmitting and acquiring communicable infections, and alcohol-based hand disinfectants are proven to reduce the risk of many of these infections. However, many child-care centers have not adopted the use of these products because of concerns over ethanol toxicity to children. It is true that ethanol can be absorbed transcutaneously or via mucous membranes, and this has been described at least twice in exotic circumstances. But does this happen in common practice? A Finnish study published in the May issue of American Journal of Infection Control suggests that this is unlikely.
In the study, 82 children aged 3-7 years rubbed their hands with either 1.5 ml or 3 ml of 70 percent ethanol gel. Three independent observers recorded the number of times that children put their fingers into contact with their mouths, noses, or eyes within 15 minutes of applying the gel (average: 2.4 times, peak number: 30). Each child’s alcohol level was measured using a standard police-issue breath analyzer pre-application and again at 15 and 60 minutes post-application. All breath alcohol levels were undetectable.
This study’s major limitations are its relatively small size and its reliance on breath alcohol levels rather than blood levels. Nevertheless, it demonstrates the likely safety of this technology when applied in a very common setting. Skeptical parents and day-care workers may still raise concern regarding the toxicity of hand rub when swallowed in significant quantities, but the risk of this happening among average children seems remote. The implications of this elegant study have the potential to augment hand hygiene practices in a very high-yield setting.
(Kinnula, et al. Am J Infect Control 2009;37:318-21.)
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A Comprehensive Look at Native Valve Endocarditis: Health Care Contact is a Major Risk Factor
Reviewed by Nina Kim, MD
Nearly half of all health care-associated cases of native valve endocarditis are acquired outside of the hospital, according to a large international cohort study from the May 5 issue of the Annals of Internal Medicine.
This is the largest prospective study on native valve endocarditis (NVE) and emerges from data collected by the International Collaboration on Endocarditis Prospective Cohort Study (ICE-PCS), a global registry of endocarditis from 61 centers in 28 countries. Investigators included only those cases that met definite criteria for NVE according to the modified Duke criteria, with an identified place of acquisition and no history of injected drug use. Cases were considered nosocomial if signs and symptoms of endocarditis developed more than 48 hours after the patient was hospitalized. Cases were considered health care-associated (HCA) but non-nosocomial if signs and symptoms were present on admission or within the first 48 hours of hospitalization but the patient had extensive out-of-hospital contact with health care interventions (recent hospitalization in past 90 days, residence in nursing home, receipt of hemodialysis, chemotherapy, wound care or intravenous therapy). The remainder cases were considered community-acquired.
Of the total 1,622 patients who met criteria for definite NVE, 557 (34 percent) were health care-associated NVE and of those, a sizable minority, 254 (46 percent), were thought to have acquired their infection outside of the hospital. Like their nosocomial counterparts, non-nosocomial patients tended to be older and have comorbid conditions such as diabetes or cancer and were more likely to have persistent bacteremia and die than patients with community-acquired NVE. Many of the non-nosocomial HCA cases received hemodialysis (54 percent vs. 9 percent). A substantial proportion – 48 percent of nosocomial and 35 percent of non-nosocomial – of patients had undergone invasive medical procedures such as endoscopy or urologic or vascular manipulations within a few months of symptom onset. Staphylococcus aureus comprised the bulk of HCA cases (45 percent MSSA, 47 percent MRSA). Enterococci were responsible for 15 percent of cases.
Despite the limitations of hospital-based data entry and the potential for misclassification, this study provides an important contemporary examination of native valve endocarditis and emphasizes the emergence of outpatient health care contact as a major risk factor.
(Benito et al., Annals of Internal Medicine 2009; 150:586-594.)
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Telaprevir Shows Promise as Treatment for Hepatitis C
Reviewed by Ed Dominguez, MD
Hepatitis C virus (HCV) infection affects almost 200 million people worldwide. Although therapy is available by combining pegylated-interferon and ribavirin, HCV genotype 1 – the most prevalent genotype in North America and
Europe – is associated with sustained virological response (SVR) rates of less than 50 percent after a standard 48-week course of therapy. Phase 2B results of the Protease Inhibition for Viral Evaluation (PROVE) trial reported in the April 30 issue of The New England Journal of Medicine suggest telaprevir may be a useful addition to the protocol for the treatment of individuals with suboptimal response to the standard therapy.
An inhibitor of the NS3/4A HCV protease, telaprevir exhibited potent antiviral activity in Phase 1B trials; however, breakthrough resistance occurred with monotherapy. The PROVE trial is a multicenter randomized, placebo-controlled trial focusing on treatment-naïve individuals and consists of a
U.S. arm (PROVE1) and a European arm (PROVE2). PROVE1 was double-blinded and PROVE2 was partially double-blinded. Participants in PROVE1 were randomized into one of four arms: a telaprevir-peginterferon-ribavirin arm for 12 weeks (T12PR12); a 12-week telaprevir plus 48-week peginterferon-ribavirin arm (T12PR48); and a control group of 48-week peginterferon-ribavirin. Participants in PROVE2 did not have the T12PR48 arm but rather a 12-week telaprevir plus 12-week peinterferon without ribavirin arm (T12P12). The primary endpoint for both trials was SVR defined as undetectable viral load 24 weeks after completion of therapy.
In the PROVE1 trial, the T12PR24 and T12PR48 groups displayed SVRs of 61 percent and 67 percent, respectively, while the control group (PR48) had an SVR of 41 percent. In the PROVE2 trial, the T12PR24 group had an SVR of 60 percent compared with the PR48 group, which had an SVR of 46. In both trials, treatment-limiting side effects were rash and pruritus seen particularly in patients receiving telaprevir. Virological breakthrough occurred in 7 percent of telaprevir patients in PROVE1 and in 10 percent in PROVE2.
These results are cautiously encouraging, particularly in light of the suboptimal response to therapy in patients with HCV genotype 1, although neither study evaluated patients with cirrhosis. The optimal duration of therapy with a three-drug regimen remains uncertain, although it does appear that ribavirin is necessary (partly as it may minimize the breakthrough of telaprevir resistance). Investigators in PROVE1 developed a protocol to deal with the telaprevir rash, but unfortunately it was implemented near the end of the trial. Ameliorating this side effect will be imperative as Phase 3 trials are planned.
(McHutchison, et al. N Engl J Med 2009;360:1827-1838 and Hezode, et al. New Engl J Med 2009;360:1839-1850.)
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Bedroom Bat Exposure: Should We Continue to Recommend Prophylaxis for Rabies?
Reviewed by Sara E. Cosgrove, MD
Current recommendations for rabies prophylaxis after exposure to bats while sleeping should be reconsidered based on the rarity of acquisition of rabies by this route and the magnitude of resources required to provide prophylaxis to this group, according to a study in the June 1 edition of Clinical Infectious Diseases.
The authors calculated the number needed to treat (NNT) to prevent one case of rabies using the following formula: the percentage of the population exposed annually multiplied by the inverse crude incidence of rabies without intervention. They estimated the percentage of the population exposed annually via a random-digit-dial telephone survey in
Canada, which assessed bat exposure and uptake of post-exposure prophylaxis. Among 36,445 persons surveyed, five had direct bat contact without a bite, 34 had exposure to a bat in the room while sleeping (bedroom exposure), 41 had exposure to a bat elsewhere in the house with the bedroom door open while sleeping (bedroom access exposure), and 77 had other exposures without direct bat contact. Only two sought post-exposure prophylaxis; both had bedroom exposures.
The authors calculated the incidence of bat-associated rabies by dividing the number of cases with different types of exposure in the
Canada between 1990 and 2007 by the sum of the populations from each year. The NNT to prevent one human case of rabies ranged from ~59,000 (direct bat contact) to ~2.7 million (bedroom exposure) persons. In a sensitivity analysis, the costs to investigate potential exposures were never below 293 professional FTEs and 228,000,000 Canadian dollars.
This study confirms that the practice of post-exposure prophylaxis following bedroom bat exposure is costly and leads to overtreatment. However, it would be difficult to recommend a change in practice unless formal guidelines are modified, given the emotionally charged response that might result from the perception that potentially life-saving treatment is being withheld. The data provide reassuring information to patients regarding the low risk of rabies associated with bat exposure.
(De Serres, et al. CID 2009; 48:11, 1493-1499.)
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IDSA’s Role in the H1N1 Epidemic
As the influenza A:H1N1 outbreak continues to unfold, IDSA is playing an important role by bringing the perspectives of ID clinicians and scientists to the attention of key policymakers.
As the influenza A:H1N1 outbreak continues to unfold, IDSA is playing an important role by bringing the perspectives of ID clinicians and scientists to the attention of key policymakers.
We have been working with colleagues at the Society for Healthcare Epidemiology of America, our own Emerging Infections Network (EIN), and other groups to offer our expertise and support to the Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO), the National Institutes of Health (NIH), the Food and Drug Administration (FDA), the Council of State and Territorial Epidemiologists (CSTE), and other groups.
CDC and other agencies have done a tremendous job of developing recommendations guided by science, and consulting with clinicians and public health authorities at the local level.
IDSA has provided a forum for dialogue between policymakers and ID experts, which has been helpful to officials as they have diligently worked to issue guidance on appropriate interventions and precautions for physicians, institutions, and communities, and revise such guidance based on our expanding scientific knowledge about this novel virus.
The Society has played a role in the development of WHO’s protocol for rapid data collection in the developing world, as well as CDC’s guidance on important issues such as school closure and use of respirators. IDSA also has commented on FDA’s draft guidance to industry concerning the development of drugs for treatment and prophylaxis. We have brought to the table not only our members’ scientific expertise, but also our practical concerns about matters such as supplies of respirators, drugs, and other critical equipment, as well as the disruptive impact of closing schools and canceling community events.
Very clearly, the investments that the nation has made in pandemic preparedness and in the scientific understanding of the influenza virus are paying off. We’ve made huge improvements in surveillance, coordination, control, and treatment. But we can’t back off now—we need a sustained commitment. IDSA is advocating for increased funding to help replenish antiviral stockpiles, develop and produce needed vaccines, support global detection and surveillance, and aid state and local preparedness. Notably, federal officials have moved ahead to develop and prepare for potential commercial-scale production of a candidate vaccine for the novel strain.
Right now, the virus is spreading easily but appears to be causing mostly mild or less severe disease, akin to seasonal influenza. That could change, as more epidemiological data become available. We must be prepared and vigilant in monitoring potential mutations and the evolution of drug resistance. We have to watch carefully how this virus behaves as it moves into the southern hemisphere, where the traditional influenza season is upon us. We also need to be prepared for what happens in the
U.S. in the fall.
In the meantime, IDSA continues to offer our expertise to officials and to keep IDSA members informed. IDSA’s Pandemic Influenza Task Force, led by Andy Pavia, MD, FIDSA, and our Rapid Communications Work Group, headed up by Peggie Neill, MD, have played critical roles in these efforts.
For the latest guidance from CDC and other resources, see the IDSA H1N1 web page, which is updated regularly.
IDSA members can also sign up to receive e-mail alerts from CDC and FDA related to H1N1 and other timely issues. For the sign-up form, click here. (You must be logged in to access this link.)
IDSA’s EIN is a sentinel network that assists CDC and other public health authorities with surveillance for emerging infectious diseases and related phenomena. More information about EIN is available online.
H1N1 E-mail Alerts
IDSA offers two e-mail services to help members stay informed of updates from the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA). Content normally includes a range of topics, including new drug approvals and warnings. Recent alerts have focused primarily on H1N1 and included:
IDSA members can sign up for these services online. (You must be logged in to have access to this link.)
Is Your Facility Experiencing Antibiotic Shortages?
Report these to FDA and IDSA
ID Physicians Are Underutilizing Prolonged Service Codes
In these lean economic times, it is imperative that ID physicians get paid for their work. But the 2007 Medicare Utilization data (log-in required) reveal that ID physicians continue to underutilize a valuable billing opportunity: Prolonged Service Codes (99354-99357). These codes are time-based codes that can be billed in the inpatient or outpatient setting when you are engaged in additional face-to-face time with patients that goes beyond the usual Evaluation and Management (E&M) service codes.
You can use CPT code 99356 to report prolonged services with hospitalized patients who require an additional 30 to 74 minutes of face-to-face time (or floor/unit) time. To report each additional 30 minutes of inpatient prolonged service time, CPT code 99357 should be used. Use codes 99354-99355 to report prolonged services in the outpatient setting. Prolonged service codes should only be billed once per patient per day and should reflect the total amount of additional time spent with a patient on that day. Because prolonged services are add-on codes, modifiers are not needed.
For more information about billing and coding, visit www.idsociety.org/coding.htm.
IDSA Urges CMS to Include ID Physicians in Electronic Records Incentive Program
In a letter to the Centers for Medicare and Medicaid Services (CMS) IDSA urged that ID physicians should be eligible for incentive payments for switching to Electronic Health Records (EHR). The recently passed federal economic stimulus law states that “hospital-based eligible professionals” should not be eligible for such incentives, but CMS must determine what that means. IDSA urges CMS to adopt an inclusive definition of "eligible professionals" that would include ID physicians who, despite providing a large proportion of inpatient services, also have office-based practices where critical and cost-effective outpatient services are provided to patients with serious infections.
The American Medical Association (AMA) is offering free webinars to help physicians understand the health information technology (HIT) provisions laid out in the stimulus legislation. The series will lay out what these provisions mean for physicians and how they can receive up to $44,000 in incentive payments over a five-year period for the implementation and use of EHR.
The webinar series includes:
- Stimulus 102: Update on the Health Information Technology Provisions
June 9, 12 p.m. CST
- Stimulus 103: Real World Perspectives
July 14, 12 p.m. CST
To register for the webinar, or to view the HIT tools and resources AMA currently has available online, please visit the AMA website at: www.ama-assn.org/go/hit.
Obama’s Budget for Global Health Raises Concerns Among HIV/TB Advocates
The Center for Global Health Policy at IDSA released a detailed analysis of President Barack Obama’s $63 billion six-year global health budget proposal, raising concerns about FY 2010 funding levels for vital programs to fight global HIV/AIDS and tuberculosis.
The Center’s assessment shows that while some significant increases are promised for later years, the administration is proposing FY 2010 funding levels for HIV and TB that fall far short of what is needed to address the urgency of these diseases.
“These health emergencies will not wait until 2011, and, since both diseases are major drags on the global economy, it makes good economic sense to aggressively confront them,” said the Center’s director, Christine Lubinski.
In addition, while the administration called for a stronger emphasis on strengthening health systems in poor countries, there was no serious money in the budget for such an effort.
Read more about the Center’s take on the White House global health plan and catch up on other recent HIV and TB news at www.sciencespeaks.wordpress.com. Other recent postings include:
- Strong praise for the administration’s choice of Thomas Frieden, MD, to be the new director of the Centers for Disease Control and Prevention (CDC). Dr. Frieden’s experience of battling drug-resistant tuberculosis in
New York and mounting an aggressive campaign against HIV/AIDS bodes well for the CDC’s leadership on these deadly infectious diseases.
- A new look at the effectiveness of the President’s Emergency Plan for AIDS Relief (PEPFAR) and how the program might be preventing new HIV infections, albeit without lowering prevalence rates.
- A story about James Hakim, MD, chairman of the Department of Medicine at the
Health Sciences, who visited
Washington in May. The Center hosted Dr. Hakim for part of his visit and co-sponsored a discussion of
Zimbabwe’s health care system at the Center for Strategic & International Studies. The
Center organized Dr. Hakim’s talk and an ensuing visit to Capitol Hill as part of its efforts to bring the voices of developing country physician/scientists into the American foreign policy debate.
Call for Cases: Innovative HIV/TB Programs in the Developing World
As policymakers in
DC, make vital decisions on global health, IDSA’s Center for Global Health Policy wants to spotlight the work of physicians and scientists on the front lines of preventing and treating the twin epidemics of HIV/AIDS and tuberculosis in the developing world.
The Center is looking for compelling stories about what’s happening in research labs, clinical trials, and field programs to help inform decisions made at the White House and in Congress on spending and other key issues. The Center will use these stories to highlight innovative approaches to HIV prevention, TB control, and HIV/TB co-infection.
The Center is particularly interested in programs that merit scale-up. Submissions should be grounded in research, clinical practice, training, or program activity relevant to resource-poor settings that hold implications for U.S. government policy or practice.
Send information to email@example.com or IDSA, Attn: Global Health, 1300 Wilson Blvd., Suite 300, Arlington, VA 22209.
IDSA Tackles Antimicrobial Resistance, Pandemic Flu, Other ID Priorities
IDSA is strongly backing legislation that would tackle the problem of antimicrobial resistance. Earlier this month, Rep. Jim Matheson (D-UT) reintroduced the Strategies to Address Antimicrobial Resistance (STAAR) Act, which IDSA leaders played a significant role in drafting. The STAAR Act provides important solutions to contain the spread of antimicrobial-resistant "bad bugs" through better overall coordination and funding of federal activities. The bill would strengthen federal antimicrobial resistance surveillance, prevention and control, and research efforts, as well as enhance the collection of critical information on the use of antibiotics in humans and animals. If enacted, it would ensure that the Food and Drug Administration (FDA) has the flexibility to collect comparable and reliable data on antimicrobial sales and distribution, similar to what currently is employed in many European nations. IDSA has secured the endorsement of 25 organizations thus far and has created a webpage dedicated to the STAAR Act.
The Society also has weighed in on health care reform, pandemic influenza, and other important issues, including:
- IDSA responded by letter to the Senate Finance Committee’s proposals for health care reform. IDSA supports strengthening public health infrastructure and personnel needs, and appropriately incentivizing specialists such as ID physicians who play an important role in controlling outbreaks and epidemics and preventing health care-associated infections. The HIV Medicine Association (HIVMA) also submitted a statement to the Senate Finance Committee highlighting the model programs that many HIV clinics have developed for providing comprehensive, well-coordinated care and urged policymakers to integrate support for these programs into the reformed health care system.
- IDSA endorsed a bill introduced by Sen. Jeff Bingaman (D-NM) to strengthen the federal government's monitoring and reporting of infectious diseases—most recently the H1N1 influenza outbreak.
- IDSA joined with the Working Group on Pandemic Influenza Preparedness in urging Congress to procure emergency funding for pandemic influenza planning and response. Both the House and Senate approved additional monies:$1.85 billion in the House and $1.5 billion in the Senate
- IDSA submitted testimony to Congress on FY 2010 funding for federal infectious diseases programs at the Centers for Disease Control and Prevention (CDC), the National Institutes of Health (NIH), FDA, and other agencies. IDSA supports more funding for pandemic flu preparedness, including development of an H1N1 virus vaccine and replenishing and building the national stockpile of antivirals, masks, and other medical equipment. Other priorities include antimicrobial resistance, emerging infectious diseases, immunization of children, adolescents and adults, tuberculosis control, and HIV prevention. HIVMA also submitted testimony highlighting the vital need for increases in federal support for HIV prevention at CDC, HIV treatment through Ryan White, and HIV research activities through NIH after several years of near flat or decreased funding for these programs.
Members on the Move
Carlos del Rio, MD, FIDSA has been named Hubert Professor of Global Health and chair of the Hubert Department of Global Health at the Rollins School of Public Health at
University. Previously Dr. del Rio served as professor of medicine at
University’s infectious diseases division, where he will maintain an appointment, and chief of medicine at
Hospital. He is also co-director of the
Center for AIDS Research and director of the World Health Organization’s
Center on AIDS. Dr. del
Rio is on the Board of Directors for the HIV Medicine Association and is a member of the IDSA Education Committee.
Eric P. Goosby, MD has been nominated by President Barack Obama to be director of the Office of Global AIDS Coordinator (OGAC). Congress will hold confirmation hearings in June. If confirmed, Dr. Goosby will oversee the newly reauthorized President's Plan for AIDS Relief (PEPFAR), leaving his current position as CEO of the Pangaea Global AIDS Foundation in
San Francisco. Dr. Goosby is a member of the Scientific Advisory Committee for the Center for Global Health Policy at IDSA and a member of the Board of Directors for the HIV Medicine Association.
To submit an item for Members on the Move, contact Rebecca Dotson at firstname.lastname@example.org.
Welcome, New IDSA Members!
Beggs, Donald, MD
Bell, Heather, DO
Cummins, Nathan, MD
Dattwyler, Raymond, MD
Hammond, Sarah, MD
Hughes, Molly, MD
Reller, Megan, MD
Ritchie, Brett, MBBS
Avery, Lisa, PharmD
Strong, Maureen, PharmD
Bartels, Scott, MD
Climaco, Antonette, MD
Espinosa-Aguilar, Luis, MD
Hung, Whitney, PharmD
Kitchell, Ellen, MD
Krishnaswamy, Sushena, MBBS
Ostovar, Gholamabbas, MD
Person, Anna, MD
Qi, Mingli, PhD
Reno, Hilary, MD, PhD
Sheikh, Virginia, MD
Influenza A:H1N1 Symposium Added to the 47th Annual Meeting of IDSA
IDSA has added a new symposium that will focus on the recent outbreak of influenza A:H1N1 to the list of influenza sessions at the 47th Annual Meeting of IDSA in
Philadelphia. The symposium will take place on Thursday, October 29 from 2:45 to 4:45 p.m. Other influenza sessions that are on the schedule for the meeting are:
- Symposium: What's New in Seasonal Influenza?
- Friday, October 30, 4:15 – 6:15 p.m.
- Symposium: Influenza Pathogenesis: 1918-2009
- Saturday, October 31, 2 – 4 p.m.
- Meet-the-Professor: Protecting Vulnerable Infants from Influenza: Assessing Strategies
- Saturday, October 31, 7 – 8:15 a.m.
- Symposium: Complications and Resistance Patterns of Influenza
- Saturday, October 31, 5:30 – 7:30 p.m.
More information is available in the Preliminary Program that is now available online.
For more on the meeting and how to register, visit the Meetings section of the IDSA website.
Updated Career Development and Funding Resources Now Online
IDSA has updated the online resources for funding opportunities and career development resources for those pursuing a career in infectious diseases. Members and visitors can find national and international opportunities for students, fellows, transitional faculty, early faculty, full faculty, and mature faculty. For the updated list, please visit www.idsociety.org/researchfundingopportunities.htm.
If you know of other career development or funding opportunities that are not included on the site, please contact IDSA at email@example.com.
PIDS Co-Sponsors Review Course on Pediatric ID
PREP®:ID: A Comprehensive Review and Update of Pediatric Infectious Diseases will be held July 13-18, 2009 in
Chicago. This course is designed to enable participants to apply infectious disease updates and case presentations readily in their own practice settings. The course is ideal for those who are preparing to participate in the Subspecialty Certifying Examination in Pediatric Infectious Diseases or the Program for Maintenance of Certification™ (MOC). Participants can earn a maximum of 38.75 AMA PRA Category 1 Credits™.
PREP®:ID is sponsored by the
Academy of Pediatrics (AAP), the AAP Section on Infectious Diseases, and the Pediatric Infectious Diseases Society (PIDS).
Visit www.pedialink.org/cmefinder for more information.