Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
Which patients with NNRTI resistance mutations who wish to simplify their HIV antiretroviral regimens do you consider switching to cabotegravir/rilpivirine?
Personally, I would be cautious of using cab/rilpivirine in any patient with virologic failure and NNRTI resistance. However, the K103N mutation (signature resistance mutation in patients treated with efavirenz and nevirapine) is not associated with resistance to rilpivirine; these patients were inc...
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.
How do you approach a patient who has anterior uveitis and is referred for evaluation of ocular TB with a positive Quantiferon gold (as part of their workup) in countries with low TB incidence?
It is a frustrating problem and is expected to increase without solid evidence. Until then, management should involve an interdisciplinary collaborative approach and a shared decision-making process.I see the following issues. I feel ophthalmologists follow the diagnostic criteria for TB uveitis us...
Would you give long term antistreptococcal antibiotic prophylaxis to a patient who presents with features of poststreptococcal reactive arthritis but who also meets criteria for Acute Rheumatic Fever?
Acute rheumatic fever should have prophylaxis. If no rheumatic heart disease, the recommendation is penicillin up to age 21 or for five years after the last episode. If heart disease is present, that recommendation is for life. In the setting of penicillin G benzathine shortage, the only option for ...
Do you routinely recommend IVIG for viral myocarditis?
I do not routinely recommend IVIG for viral myocarditis. If there is a case of immune-mediated myocarditis) - It may be recommended. In cases of severe COVID myocarditis in the past, use has been reported. However, it is not something that I routinely recommend.
What is your preferred dosing of IV ganciclovir for CMV disease in immunocompromised patients?
For treatment, I usually start with 5 mg/kg IV q 12 hr, and the dose is adjusted for renal function with the help of ID pharmacists. I can consider going to 7.5 mg/kg if there is a concern for very severe disease or low-level resistance, but to be honest, I don't think I've ever done that, given the...
What is your approach to deciding when to stop therapy for cutaneous Mycobacterium chelonae infections?
I have an ongoing case of M abscessus cutaneous infection, possibly acquired from a pedicure. This is a similar bug to M chelonea, but even harder to treat. Our approach was to gather the opinion of several experts through email communication. The conclusion was to treat for 6-12 months, and follow ...
Is there a role for empiric scabies treatment in itchy patients without clear clinical signs of scabies?
I have seen many astute clinicians miss scabies or consider it after months of treating for AD with biologics and other systemics (including myself). Though this is very rare my personal rule of thumb is to treat with oral ivermectin if at any point patient is not responding the way I expect to trea...
When do you consider extended courses of oseltamivir in immunocompromised patients?
For immunocompromised individuals with severe influenza, I recommend a 10-day course of oseltamivir based on AST ID-COP guidelines (Manuel et al., PMID 30817023). Practically speaking, this is any immunocompromised patient who is hospitalized due to influenza.
How would you manage a patient with strongly suspected Lyme arthritis and negative bacterial synovial fluid cultures who was started on empiric antibiotics against typical bacterial pathogens arthritis before arthrocentesis and collection of cultures?
In a patient with a high clinical suspicion for Lyme arthritis who has negative synovial fluid bacterial cultures after receiving empiric antibiotics for presumed septic arthritis, management should be guided by clinical probability rather than the culture results. Antibiotics given before arthrocen...