Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
Do patients with a PEG allergy have a contraindication to receiving mRNA vaccines?
While early anecdotal reports suspected that PEG allergy may be linked to allergic reactions to mRNA COVID vaccines, subsequent research disproved this. Therefore, even patients with true IgE-mediated allergy to PEG (which is extremely rare) do not have a contraindication to receiving mRNA vaccines....
What is your approach to determining whether a patient who repeatedly tests positive for strep has reinfection or has asymptomatic carriage?
One of the biggest challenges is that there is no single test that reliably distinguishes recurrent Group A Streptococcus (GAS) infection from chronic asymptomatic carriage. My approach starts with the clinical history. Patients with true recurrent GAS typically have the classic syndrome, e.g., abru...
How do you approach a patient on anti-TNF with positive Quantiferon (previously negative) with negative chest x-ray and no symptoms?
Prior to routine screening for latent TB for patients receiving or about to receive TNF inhibitor therapy, there were reports of miliary TB developing after initiation of TNF inhibitors. Therefore, one cannot say that a negative chest x-ray and no symptoms means the patient is not at risk for develo...
How would you manage a patient with mild respiratory symptoms, imaging showing bronchiectasis, one AFB culture growing only mycobacterium avium complex, and a separate AFB culture growing only nocardia species?
I would recommend repeating at least two more acid-fast bacilli (AFB) sputa to see if Mycobacterium avium complex (MAC) repeatedly grows; ideally, they should be identified to the species or subspecies level, but I understand that can be hard to request. Admittedly, bronchiectasis alone (without nod...
Would you avoid using cephalosporins in a patient with a history of cephalosporin neurotoxicity in the setting of CKD?
I think there are a few problems or nuances involved in answering this broad question:First, other practitioners may use other IV cephalosporins, but we only use cefazolin, ceftriaxone, cefepime, and ceftazidime (as part of Avycaz).Second, the calculated CrCl often poorly correlates with the patient...
What is the preferred four-drug regimen for initial treatment of pan-susceptible tuberculous meningitis, given the need to achieve optimal CNS penetration?
I will defer to the guidelines for the specific regimen. One general issue I would like to address is the idea of "CNS penetration." Since we don't routinely do brain biopsies in humans to truly assess levels of antimicrobials in the brain/spinal cord/meninges, many people think that "CSF levels = C...
In light of recent measles outbreaks in the US, would you recommend an MMR booster for immunocompetent patients born before 1957?
I would not recommend a measles vaccine for a person born before 1957. This year has been chosen because people before born before 1957 have a very very high likelihood of having had measles because virtually all children got this highly contagious disease. On the other hand, there is no harm to get...
When do you add corticosteroids to the treatment of HSV encephalitis?
My practice does not involve adding corticosteroids to confirmed HSV encephalitis unless there is a significant concern for malignant edema and midline shift. We lack large randomized, placebo-controlled trials, therefore their role is uncertain as of yet.
What is your approach to work up and management of a patient with advanced HIV and poor adherence to therapy presenting with dysphagia and fever?
Having a sense of a recent CD4 value would help. After a thorough H&P to assess for localizing symptoms beyond the dysphagia and no available CD4 data, I would approach this patient as someone with a CD4 count of <100 and possibly <50. It is highly likely that they have candida esophagitis, for whic...
Do you routinely recommend diagnostic endoscopy for patients with persistent enterococcus bacteremia despite receiving adequate antimicrobial therapy and no clear nidus?
It depends. Did you do an echocardiogram to rule out endocarditis? Urine cultures were negative? Gallbladder ultrasound was negative? CT of the abdomen and pelvis with contrast was negative?Any other symptomatology that accompanied the recurrent episodes of enterococcus bacteremia that could help us...