Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
How would you manage a patient with HIV, re-infection of hepatitis C that has not yet been treated, chronic hepatitis B infection on BIC/FTC/TAF with undetectable HIV viral load but HBV viral load consistently >100,000 with normal ALT?
Your concern about HBV reactivation during DAA therapy is real and well-documented, as it can occur in up to 24 of HBsAg-positive patients during or after DAA therapy when not on HBV-active therapy. However, the solution per guidelines is concurrent HBV prophylaxis/treatment, not sequential treatmen...
For a patient on appropriate treatment for invasive aspergillosis, how do you determine if and when it is acceptable to reintroduce a TNF inhibitor that likely contributed to their acquisition of the infection but is considered essential for control of their inflammatory condition?
There is no established answer to this question. The reintroduction of a TNF inhibitor must be individualized based on the clinical situation of the patient under consideration. There are two critical questions. First, how much does the patient need the inhibitor”? The more the patient is dependent ...
What is your approach to symptom management in patients with infectious diarrhea?
When it comes to infectious diarrhea, I would consider a short course of loperamide for symptomatic relief, provided that my suspicion for C. diff colitis and/or dysentery is low. Antimotility agents in the setting of toxin-producing infectious diarrhea can increase the risk of toxic megacolon (in C...
Do you treat Stenotrophomonas maltophilia bacteremia with combination therapy and if so, what is your preferred combination of antibacterials?
Yes, I would use two agents, at least up front, as recommended in the 2024 IDSA guidelines (Tamma et al, PMID 39108079). The guidelines suggest two of the following agents should be used, unless the combination of ceftazidime-avibactam plus aztreonam is used instead: cefiderocol, TMP/SMX, levofloxac...
What approaches can we take to initiate therapy and improve survival rates in patients with HLH?
At our institution, we have comprised a multidisciplinary team to help treat these patients. The team or "HLH task force" as we like to call ourselves is comprised of a clinical immunologist, rheumatologist, dermatologist, critical care physician, hepatologist, BMT attending/hematologist, infectious...
Do you still offer nirmatrelvir–ritonavir to a vaccinated older adult with comorbidities and mild COVID-19 illness given recent trial data showing no reduction in hospitalization or mortality?
The Butler et al., PMID 42019019, paper published in the New England Journal of Medicine in 2026 reviewed 2 open-label trials from the United Kingdom and Canada (PANORAMIC and CanTreatCOVID) where higher-risk patients were randomly assigned to receive nirmatrelvir-ritonavir plus usual care versus us...
What is your approach to the management of asymptomatic bacteriuria in an elderly patient without clear urinary symptoms but with cognitive changes and falls?
Asymptomatic bacteruria does not cause altered mental status. Data suggests that when we attribute acute changes to it, we will be wrong about 85% of the time, thereby missing the true etiology. It is a difficult thing to educate staff of senior living facilities and families who have been told it w...
What is the optimal therapy for laryngeal candidiasis in pregnancy?
Thirty years ago, I was consulted on a woman in her 30s with candidemia after fetal demise from Candida chorioamnionitis. During the pregnancy, she had been treated several times with clotrimazole for Candida vaginitis. Given that repeated exposure, I guessed that her Candida isolate would be azole-...
Do you add empiric anti-MRSA coverage to the initial antibiotic regimen for a patient admitted with community-acquired pneumonia who has risk factors for MRSA but a negative MRSA nasal screen?
Thank you for this excellent and highly relevant clinical question. I approach this scenario by blending robust evidence-based medicine with fundamental principles of diagnostic reasoning. The short answer is generally no, you probably do not need to add empiric anti-MRSA coverage for a standard CAP...
What additional antibiotic coverage, if any, would you give to a patient with penicillin-susceptible Strep viridans prosthetic valve endocarditis on ceftriaxone who needs to undergo a dental procedure?
I'm a little baffled by the phraseology of "therapeutic endocarditis" because this implies to me the patient is on therapy for endocarditis and therefore is therapeutic on the ceftriaxone therapy. Additionally, the patient could be switched to penicillin as either is recommended as therapy in the 20...