Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
What is your re-immunization strategy after auto SCT for patients with myeloma on dara/len maintenance?
We do the same vaccination sequence according to BMT/CTN, whether they are on maintenance dara or not. Here is our schedule Post autologous SCT vaccine Interval Date Vaccine Yearly Flu Vaccine 3-month post-transplant Pneumovax 20, Hib, hep A/hep B, polio, TDap, Shingrix 6 months post-transplant Pneu...
Under which circumstances is there a role for reduction in immunosuppression post-SOT in a patient with recurrent CMV viremia and/or disease?
While the decision regarding immunosuppression is always up to the primary transplant team, as the infectious disease consultant, I always inquire about the ability to reduce immunosuppression during episodes of CMV syndrome or disease even if it is a first episode. This becomes even more important ...
How long do you treat uncomplicated gram-negative rod bacteremia in solid organ transplant recipients?
My approach to the duration of therapy for GNR bacteremia in SOT patients depends on the source of the bacteremia, the available antibiotics, the patient's net state of immunosuppression, and the organism. There are situations where 7 days of therapy are adequate (One example: E.coli urosepsis in a ...
How does trimethoprim-sulfamethoxazole's efficacy against S. pyogenes influence your empirical treatment of skin infections in regions with high resistance rates?
I am a little confused by the question. Why would you use TMP/SMX monotherapy for SSTI? During the emergence of CA-MRSA, cephalexin with or without TMP/SMX had the same efficacy rates (Pallin). I agree with Dr. @Dr. First Last; linezolid is a great choice if MRSA is a concern. Cephalexin or cefadrox...
Do you prescribe linezolid to patients who are concomitantly on an SSRI?
Yes, cautiously, especially when LZD is the best or only option. Recent Eur J Clin Pharmacol July 2023 meta-analysis involving 84 publications found an observed rate of < .01%; another study Shi et al., PMID 37301313 found a similar rate (1/1743 persons, 0.06%). Holding an SSRI for a day or two prio...
Do you recommend to exchange nephrostomy tubes when a patient is diagnosed with a urinary tract infection in the absence of any overt signs of infection at the exit site?
This patient has asymptomatic bacteriuria by definition - apparently with occasional symptomatic UTI. I would not change the tube because of the ASB like I would not change a urethral catheter in the setting of ASB. And as noted the patient has already demonstrated continued ASB after changing the t...
How do you balance diagnostic stewardship and high value cost-conscious care when working up a patient with newly diagnosed HIV/AIDS admitted to the ICU with shortness of breath who most likely has PJP pneumonia or cryptococcal infection but is at risk of multiple other pathogens?
This is an excellent question, which is very based on the patient's clinical presentation as well as the resources you have available to you in your setting, particularly how long it takes for test results to come back. One aspect that should be considered in patients with advanced HIV is that they ...
Would you recommend avoiding intravesical (bladder) tobramycin administration in a patient with advanced chronic kidney disease?
Guess fear is absorption, build up, and toxicity. A single loading dose of an aminoglycoside is not to toxic level. Maintaining the level of risks ototoxicity, build up also nephrotoxicity. Would depend on absorption and residual GFR. Try a single loading dose, check levels after 12 or 24 hours to g...
Would you use immunotherapy in patients with HIV and a positive viral load?
Current guidelines do not recommend universal HIV screening before starting immune checkpoint inhibitors (ICIs). However, if HIV is known or suspected, patients should ideally be on antiretroviral therapy (ART) before initiating immunotherapy.Safety:Retrospective data from the CATCH-IT Consortium (E...
What is your approach to treatment of macrolide-sensitive localized bone/joint MAC disease?
Agree with the above answers. Obviously, no strong clinical studies on duration and outcomes. At NJH, we typically recommend: Aggressive debridement/resection, Treat with appropriate antimicrobial therapy (in macrolide-S MAC, then AZM/EMB/Rifamycin +/- IV AMK) for a minimum of 6 months total, but a...