Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
How has your approach to managing asymptomatic bacteriuria in kidney transplant patients changed in light of a recent meta-analysis showing no significant differences in pyelonephritis, symptomatic UTI, or graft loss between patients treated with antibiotics and those who were not treated?
The referenced meta-analysis has not dramatically impacted my approach to asymptomatic bacteriuria (ASB) in kidney transplant recipients (KTRs). The included trials clearly show no benefit (and possible harm) in treating ASB at time periods >2 months post-transplant. So we do not screen and we do no...
How do you approach patients who continue to experience pruritus and ongoing concern for persistent scabies despite having completed appropriate treatment?
Pruritus can not uncommonly continue in patients for 6 weeks or more after infestation is managed. High-dose antihistamines may be of some benefit. Consider if there is an ongoing untreated exposure that the patient has not thought of or cannot/will not share with you. Not all people infested with s...
Is there a role for nitazoxanide for treatment of norovirus gastroenteritis in immunocompromised patients?
There is no good-quality evidence supporting a role for nitazoxanide for treatment of norovirus gastroenteritis in immunocompromised patients. The efficacy of nitazoxanide in viral gastroenteritis is supported by a small manufacturer-sponsored randomized, double-blind trial in non-immunocompromised ...
Do you offer antibiotic therapy for patients with a chronic joint infection, with no plans for surgery, and with an open draining sinus tract?
I think this depends on (1) the organism, (2) the host - if he/she is immunocompromised or not, and (3) if the patient is symptomatic. Generally, if the patient has a draining sinus tract that is stable and is not causing any fevers, chills, leukocytosis, etc., then I would favor not treating, as tr...
How do you approach recommending ocular exams for asymptomatic candidemic patients considering the discordance between the IDSA and American Academy of Ophthalmology guidelines?
Endogenous endophthalmitis due to Candida sp. occurs in <1% of patients with candidemia. The IDSA 2016 guidelines for management of candidiasis outline evaluation and treatment of patients with endophthalmitis, with recommendations to perform a dilated ophthalmologic exam on all patients with candid...
Do you routinely recommend D-mannose or probiotics for patients with recurrent urinary tract infections?
I would like to add that estrogen is very helpful for postmenopausal women with recurrent UTIs-- and is underprescribed for this use. Data seems to be strongest for vaginal estrogen, but see for example, Tan-Kim et al., PMID 37178856 and Rosenblum, PMID 33927578.
Would you recommend switching from an integrase strand transfer inhibitor-based regimen to a different antiretroviral regimen, or would you instead add weight loss medications for a person with HIV experiencing weight gain that has not improved with lifestyle changes?
The data about weight gain attributable to integrase strand inhibitors is actually a bit controversial. Multiple studies have raised the concern for increased weight gain in patients treated with second-generation INSTIs (ADVANCE, NA-ACCORD), while others indicate more of an impact of tenofovir alaf...
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...
When would you consider checking JC virus prior to initiating biologic therapy?
JC is a ubiquitous virus with sero-prevalence in the adult population of 60-70% in most studies. The concern is that in those who harbor latent JC are vulnerable to reactivation and ultimately the development of Progressive Multifocal Leukoencephalopathy (PML). The drug natalizumab used to treat MS ...
What is your preferred third antimicrobial agent for a patient with treatment-naive pulmonary MAC without cavitary disease and strict contraindications to utilization of rifampin or rifabutin?
There’s no clear winner yet. Inhaled liposomal amikacin solution has good potential and the data is trending this way with earlier clearance shown but the long-term outcomes, I believe are still pending. I’m relatively unconvinced or underwhelmed by moxi but as a third drug in the seemingly rare occ...