Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
What is the recommended fungal workup in an immunocompromised patient after 5 days of persistent fever?
For any patient with fevers, I focus significantly on any symptoms that a patient might have, like headache, diarrhea, and sinus symptoms, and work up a differential diagnosis based on possible pathogens in this area. If I am not finding anything, I would obtain a CT chest/abd/pelvis, as both invasi...
Do you routinely order MRI or perform lumbar puncture in patients with peripheral neuropathies secondary to Lyme disease to inform staging, duration, and modality of treatment?
The short answer is definitely no. If this is a true neuropathy, on examination, an MRI adds nothing (it will be negative). A lumbar puncture may be mildly abnormal (as with ANY neuropathy), revealing elevated protein and a small number of lymphocytes. This result does not change the treatment. I us...
How do you decide when to use streptococcal urine antigen as part of your workup for pneumonia?
Guidelines recommend only using it for severe CAP as defined by the ATS/IDSA guidelines.
When do you recommend limited or targeted respiratory pathogen testing versus a full respiratory pathogen panel in a patient presenting with URI symptoms?
I think we’re asking the wrong group of people. How infectious disease physicians use respiratory pathogen panels is not the same as how emergency medicine or urgent care clinicians use them. For stewards of diagnostics, especially ID providers, the test often doesn’t change management. In many sett...
Would you treat sacral osteomyelitis with a prolonged 6-week course of antibiotics in a patient who has undergone surgical debridement and placement of a negative pressure wound therapy device, but for whom flap coverage is not planned?
The decision to use prolonged IV antibiotics depends on many factors beyond the infection itself, including the depth and size of the wound, comorbidities, social support, and the patient’s willingness and ability to participate in wound care. I have seen ulcers heal without flap coverage, particula...
How do you approach the use of fidaxomicin versus vancomycin for initial Clostridioides difficile infection in immunocompromised patients, considering the lower recurrence rates but higher cost of fidaxomicin?
Whether immunocompromised or not, fidaxomicin has been demonstrated to be superior to vancomycin – not in resolution of the acute infection but in reducing the risk or recurrence by approximately one-half. In one study of hospitalized patients published in 2015, it was reported that, when taking int...
Do you use valacyclovir as stepdown therapy for HSV CNS infections including encephalitis?
I have done this in selected patients who could not or did not wish to remain in the hospital for the full 14–21 days of IV acyclovir. For HSV meningitis, stepping down to oral valacyclovir after clinical improvement is an accepted approach. HSV encephalitis is different: IV acyclovir for 14–21 days...
How do you use gut microbiome or gut microbiota analysis in your clinical practice, if at all?
While I am presented with microbiome analyses on a regular basis by patients, I do not believe that these are useful, as we are still not there when it comes to defining the "normal" microbiome. This indeed may vary tremendously between individuals depending on age, gender, diet, geographic location...
Do you use MRSA nares PCR to influence antibiotic selection for non-respiratory infections?
BLUF: Yes, I use a MRSA nares PCR for early de-escalation in the stable patient with a non-purulent, non-respiratory infection. Mergenhagen et al., PMID 31573026 retrospectively examined nearly half a million clinical cultures and compared them to MRSA nares results. Among all infections, the NPVs w...
Do you treat empirically for strongyloidiasis in asymptomatic returning travelers with unexplained eosinophilia despite negative stool studies?
I would not treat an asymptomatic returning traveler with unexplained eosinophilia empirically for strongyloidiasis. This parasitic infection is rare in travelers (unless they are long-term expatriates, and even then it is unlikely unless they have spent a lot of time barefoot in potentially contami...