Recommended Curriculum for Training in Pediatric Transplant Infectious Diseases

A working group representing the American Society of Transplantation, Pediatric Infectious Diseases Society, and International Pediatric Transplant Association has developed a collaborative effort to identify and develop core knowledge in pediatric transplant infectious diseases. Guidance for patient care environments for training and core competencies is included to help facilitate training directed at improving the experience for pediatric infectious diseases trainees and practitioners in the area of pediatric transplant infectious diseases.

Transplant infectious diseases (TID) has emerged as a subspecialty within infectious diseases over the past 2 decades. The core knowledge for TID practitioners encompasses unique issues, which have been previously explored and communicated as guidelines for subspecialty training in TID by the American Society of Transplantation Infectious Diseases Community of Practice Educational Initiatives Working Group [1]. These guidelines, however, do not address issues that may be specific for pediatric transplant patients or training in pediatric TID.
An increasing number of pediatric infectious disease specialists are focusing their careers on transplant infectious diseases. While published content specifications for general training in pediatric infectious diseases identify a basic level of knowledge relevant to transplant-related infectious diseases, the core knowledge and directed training necessary to effectively establish expertise in TID in children are not fully described. In an effort to provide directed guidance in pediatric TID, the American Society of Transplantation (AST), Pediatric Infectious Diseases Society (PIDS), and International Pediatric Transplant Association (IPTA) collaboratively established a workgroup to develop a core curriculum to augment the training in the field of pediatric TID. Differences from adult TID training guidelines include the need to recognize the role of physical and psychological growth and development, as well as evolving immunologic maturation in assessment of the pediatric organ recipient, the increased risk for primary infections and community-based infectious exposures after transplantation, and the complexity of immunization-related issues before and after transplant. The following document provides guidance and recommendations for the training for individuals seeking a basic level of competency as a general pediatric infectious diseases practitioner to evaluate transplant recipients as well as those who require greater knowledge and expertise to pursue a specialized focus in pediatric TID. It is not meant to be all encompassing, but provides a framework for practitioners at different levels. The document supports subspecialty (fellowship) training programs in recognizing the specific issues related to pediatric TID. An additional fellowship is not suggested by the document or its contents, although additional training may be sought by individuals who wish to pursue a career in this sub-subspecialty.

PATIENT CARE ENVIRONMENT
• Basic competency for trainees Many pediatric infectious diseases training programs provide exposure to solid organ transplant (SOT) or hematopoietic stem cell transplant (HSCT) populations; however, some programs have limited or no routine access to these patients. Many training programs have access to some but not all transplant types and will see patient volumes that vary widely by specific organ recipient type.
• If inadequate patient volumes (fewer than two transplant-related consults per month on average) exist within a specific institution, augmenting experience with directed case-based learning is recommended.
• Specialized focus on pediatric TID It is recommended to pursue training at a pediatric center with the following resources: • The presence of an HSCT and at least 2 types of SOT programs • Sufficient patient volumes in HSCT and SOT to provide clinical exposure to common opportunistic infections • Proximity to adult transplant centers to expand experience is supportive but not essential; rotations with available adult TID services are strongly recommended, particularly if pediatric TID is limited • Opportunity for mentorship from at least one individual with clear expertise in pediatric TID is strongly encouraged. • Access to didactics designed to augment both clinical and research education in pediatric TID. • Experience in working with laboratories with expertise in bacterial, fungal, and viral diagnostics and resistance testing is encouraged.

Medical Knowledge
General competency in medical knowledge of preventing, evaluating, and treating infections that occur after transplantation is expected for all trainees planning to sit for the American Board of Pediatrics Pediatric Infectious Diseases subspecialty or equivalent examination [2,3], as described in the current Content Outline [2]. However, an increased depth of understanding should be achieved by those who anticipate careers focused on pediatric TID. The main areas of medical expert knowledge that should be acquired during pediatric TID training are summarized below. Medical expert knowledge for SOT and HSCT overlap in many areas, but specific differences are highlighted. and OPOs to report potential donor-derived disease transmission events and the role of the pediatric TID specialist to help recognize these events and assure appropriate reporting • Understand the processes of consent, donor, and recipient selection (including issues of brain death and donation after cardiac death), allocation systems, and considerations regarding retransplantation and limited resource utilization

SCHOLARLY ACTIVITIES AND CLINICAL PRACTICE
Practice-Based Learning and Improvement ▪ The pediatric infectious diseases specialist is expected to demonstrate a lifelong commitment to reflective learning, as well as the creation, dissemination, application and translation of medical knowledge. Knowledge of the logistics and operational issues of the transplant process is essential. ▪ Competency for all pediatric infectious diseases trainees • All pediatric infectious disease trainees should be aware of the resources that are available. These include but are not limited to the American Society of Transplantation's ID guidelines [4], relevant approved guidelines from Infectious Diseases Society of America (IDSA) that specifically address immunocompromised hosts [5], and sections of HSCT guidelines related to TID [6]. ▪ Specialized focus on pediatric TID • For those individuals seeking to focus on pediatric TID, additional resources are available and should be sought out. Specialized textbooks and journals focused on transplantation in general and TID in particular are available. Reports of consensus conferences on specific issues in TID have been published and are available. An increasing number of online resources are also available through the academic transplant societies (http://www.myast.org/cop/infectious-diseasecop; http://www.tts.org), United Network for Organ Sharing (UNOS) (http://www.unos.org/donation/index. php?topic=professional_education), and other agencies and organizations. Currently, the AST provides to members an online question-and-answer curriculum, primarily with adult literature, that covers significant infectious events in the transplant candidate and recipient. In addition, participation in transplant-focused continuing education is recommended to develop and maintain an understanding of noninfectious issues in transplantation.

Systems-Based Practice
• All pediatric infectious diseases trainees should be aware of the complexity of transplant logistics.
• Specialized focus on pediatric TID: ▪ Specialists practicing pediatric TID should be exposed to and understand transplant logistics including the role of OPOs, UNOS/OPTN and its ad hoc Disease Transmission Advisory Committee, and National Bone Marrow Donor Programs (in Canada, the Stem Cell and Marrow Network). ▪ Participation in Quality Improvement efforts is recommended and may include collaborations on development, evaluation, or revision of protocols related to infectious diseases in transplantation.

HEALTH ADVOCACY
As health advocates, pediatric TID physicians use their expertise and influence to advance the health and well-being of individual patients, communities, and populations on issues relating to infections in organ transplantation. Key and enabling competencies for advocacy by pediatric TID specialists include, but are not limited to: • The ability to identify the determinants of health for the populations that they serve, and promote the health of individual patients, communities, and populations • The ability to address health needs and patient care issues at both the level of the individual patient and as they may affect communities of transplant patients • Given that all pediatric ID trainees may not be at a center with dedicated expertise in pediatric TID, mentorship opportunities with adult TID locally and/or pediatric TID from other institutions could be explored. • Individuals inclined to pursue academic pediatric TID and independent research after fellowship should be identified early, encouraged, and assisted with organizing the submission of an application for a National Institutes of Health K award or similar training grant mechanism on an appropriate timeline.
• Specific studies should be tailored to the interests of the individual fellow, and aimed at developing the skills required for independent research in that area (Table 1).
• Clinical, translational, outcomes-based, and health systems research training may include formal course work in Public Health or alternate scientific training programs (eg, Master's in Clinical Science), with or without completion of the requirements for a Master's Degree. • Although prospective cohorts or clinical trials typically represent stronger study designs, studies using existing data/specimens may be better suited to be pediatric ID trainee projects in light of time constraints (usually 2-3 years).
• Given the relatively small numbers of pediatric transplants performed at most centers, opportunities for multicenter or multidisciplinary collaborations for clinically oriented research should be considered whenever possible.

SUMMARY
This curriculum provides a guide for pediatric infectious disease training focused on specialization in pediatric TID.
As the field progresses, we realize that additional issues will emerge requiring updates to the curriculum as with any area in infectious diseases. In addition, development of pediatric-specific case-based learning and educational conferences is needed from the Pediatric TID community.