Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
Do you use isavuconazole for treatment of moderate to severe histoplasmosis in patients with co-morbidities, acute or chronic renal failure, or other features that increase the risk of side effects of itraconazole or amphotericin?
No. I would not routinely use isavuconazole as initial therapy for moderate to severe histoplasmosis. For severe disease, liposomal amphotericin B remains the recommended first-line induction treatment, followed by step-down oral therapy, traditionally itraconazole. In patients with renal dysfunctio...
Do you recommend procalcitonin to help convince other providers to stop antibiotics in patients with pneumonia in whom a non-infectious diagnosis is strongly suspected?
I have looked at both of these studies in some depth. The de Jong et al., study, called SAPS, is perhaps the more impressive of the two, but regarding either or any study on so-called "biomarkers", even the RCT studies only make recommendations or give advice. And, more often than not, the doctors d...
Do you adhere to the standard 5-day minimum treatment duration for community-acquired pneumonia, or have you used shorter courses for certain low-risk patients?
This is a question addressing a shorter duration of antibiotic therapy than the current IDSA guidelines for community-acquired pneumonia (CAP) recommend. It has been the topic of several studies, for example, 3-day treatment (Richard T. Ellison III, MD, reviewing Dinh et al., PMID 33773631; Niederma...
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...
Under what circumstances would you choose the 1-month 1HP treatment over a 3-4 month regimen for latent TB?
I tend to favor the 1-month daily isoniazid–rifapentine regimen (1HP) in very specific clinical and programmatic contexts, rather than as a default option. Its main advantage is speed i.e. when there is a narrow window to complete latent TB treatment such as prior to imminent immunosuppression (e.g....
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 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 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-...
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...
How do you rule out spontaneous bacterial peritonitis in a patient with minimal ascites that is not amenable to paracentesis?
You can’t, unfortunately. You either need to keep looking for a good pocket (move patient to each side, etc.) or use clinical judgement and decide whether or not to treat empirically.