Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
Under what circumstances would you initiate antibiotics in adults hospitalized with RSV and a suspected bacterial co-infection?
Bacterial co-infection in patients hospitalized with RSV ranges between 8% and 29% (Karlsen et al., PMID 41488696). The American Thoracic Society 2025 guidelines recommend prescribing empiric antibiotics to all hospitalized patients with clinical and imaging evidence of community-acquired pneumonia ...
How do you evaluate for an ascending UTI in a patient with a urostomy?
Evaluating for ascending UTI in a patient with a urostomy UA Generally low value; chronic pyuria/mucus makes results unreliable. Urine culture Essential; must be collected from a clean stoma catheterization or a fresh pouch, and not from the urostomy bag. Imaging (CT abdomen and pelvis wit...
Under what circumstances do you consider valacyclovir for the management of VZV disease of the CNS?
If the patient has encephalitis would use IV acyclovir and only transition to high dose valcyclovir (2 g every 8 or every 6 hs depending on weight) after improvement. Although there is PK data to support these high doses, I would not use it initially. Immunosuppressed patients have a higher likeliho...
What is your approach to antiviral treatment of HSV acute retinal necrosis?
Acute Retinal Necrosis (ARN) is a rapidly progressive syndrome usually caused by varicella-zoster virus (VZV)and herpes simplex virus 1 or 2 (HSV). The syndrome is rapidly progressive in the absence of antiviral treatment. PCR performed on aqueous or vitreous sampling is highly sensitive and strongl...
What do you prescribe for HIV post-exposure prophylaxis in patients who cannot swallow tablets and have no enteral tube?
We would prescribe cabotegravir and rilpivirine 600mg/900mg intramuscular x 1 injection to give 28 days of protection. IF there is a question of any resistance in the source patient, we would add lenacapavir 600mg po on days 0 and 1 as an oral loading dose plus lenacapavir 927 mg sq on day 0.
Would you consider transition to a cabotegravir/rilpivirine injectable regimen in a patient living with HIV who is well-suppressed on BIC/FTC/TAF since initial diagnosis in Colombia in 2022 at which time her viral load was in the 400s precluding genotypic resistance testing?
The clinical scenario as presented is somewhat ambiguous. If the patient is described as “well suppressed” on bictegravir/emtricitabine/tenofovir alafenamide, this typically implies consistent HIV RNA <200 copies/mL. A persistent viral load in the 400s, however, would suggest low-level virologic fai...
For how long would you treat a patient with latent TB before allowing them to proceed with a liver transplant?
There are a few ways to look at the answer to this question. If the individual is stable enough to complete the Latent TB Infection (LTBI) therapy without need for a liver transplant, then treat the LTBI to completion. If the individual may need the transplant during the treatment course, then start...
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...
Does your hospital or institution have an Antimicrobial Stewardship Program (ASP), which oversees ID physicians, and if so, does the ASP have the authority to refuse an antibiotic prescribed by an ID consultant?
We have ASP and the ID docs have a very collegial relation with our PharmD who are both ID pharmacists. They are very helpful and they do not block the ID consultants. When ID consultant recommends something that should not be done due to drug interaction for instance The pharmacist will call explai...
Do you routinely recommend IV systemic antibiotic therapy in additional to intravitreal antibiotic therapy for exogenous bacterial endophthalmitis?
Post-surgical (exogenous) endophthalmitis is an uncommon complication with the incidence ranging from 0.04%-0.3%, 0.019%- 0.54%, and 0.11% - 0.03% following cataract surgery, intravitreal injection, and vitrectomy, respectively (Soliman et al., PMID 32467482). Initial management of exogenous endopht...