Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
When do you use a carbapenem empirically to treat a patient with Acinetobacter infection?
I try very much to NOT start a carbapenem empirically, but really try for high-dose ampicillin/sulbactam. However, if the patient has MDR history, particularly with other ESBL gram negatives, I may consider starting with a carbapenem. It comes down a lot to the can-I-afford-to-be-wrong sick/not sick...
How do you counsel a patient diagnosed with HTLV after an abnormal blood donor screening, especially in light of new data that dolutegravir may reduce uncommon but severe neurological outcomes associated with infection?
We actually do not see many individuals with HTLV disease at present in the US. Having said that, HTLV is a retrovirus, so it is biologically plausible that integrase inhibitors (like dolutegravir) could reduce viral spread in the body. However, the key counseling message is: evidence is still emerg...
What is your approach to empiric treatment of achromobacter infections?
Achromobacter is a Gram-negative bacterium in the Burkholderia order. This pathogen is significant in immunocompromised patients, such as those with cancer or Cystic fibrosis, and is seen with bacteremia or causing pneumonia. They can also be associated with foreign device infections. Typically, the...
Would you consider leaving fever untreated in patients with sepsis to potentially enhance immune responses and antimicrobial efficacy?
In light of the review article attached (Tilanus et al., PMID 41113323), there is some data reviewed supporting that fever is actually therapeutic. Four articles are of special interest in the review. Two are from the 70s, before sepsis was defined as it is today. Two are in the last 15 years, but o...
Do you generally recommend device exchange/removal in patients with gram positive bacteremia in the setting of intra-aortic balloon bump or other mechanical circulatory devices?
I am assuming in this case that the patient has a mechanical circulatory support device such as an LVAD, IABP, or another implantable device, and has developed gram-positive bacteremia. No further details about the device type or clinical scenario are provided. In such cases, device removal is recom...
What is your approach to monitoring of inflammatory markers during treatment of native vertebral osteomyelitis?
As long as the patient is clinically stable and CRP is coming down, there is generally no need for follow up imaging. Key reference: Kowalski et al., PMID 16779743.Also, good to remember that ESR is a very expensive test which basically measures fibrinogen (may cost $500 or more since it has to be r...
Do you still recommend adjunctive corticosteroids for tuberculous meningitis in light of more recent data showing heterogeneity in clinical outcomes?
Though there is some disagreement in study results, a number of randomized trials and one meta-analysis support the benefit of mortality when steroids are used as adjunctive therapy for tuberculous meningitis. The use of steroids continues to be the recommendation of the WHO. In most situations, the...
Do you still use itraconazole for Aspergillus prophylaxis in heart transplant recipients, or have you transitioned exclusively to posaconazole?
We haven't used itraconazole for Aspergillus prophylaxis in heart transplant at my institution since I have been an attending (2021).
Do you recommend doxycycline over azithromycin as first-line treatment for outpatient community-acquired pneumonia in otherwise healthy adults, given rising macrolide resistance rates?
Yes - our county antibiogram shows >50% resistance of Streptococcus pneumoniae to azithromycin, and thus if there is a true concern for bacterial infection, I recommend doxycycline.
In what circumstances would you consider monotherapy for empiric treatment of unresectable nontuberculous mycobacterial lymphadenitis?
NTM lymphadenitis is rather uncommon, and I personally have little experience with it and did not see it much even at NJH. However, extrapolating from how I treat any NTM disease in general, I would shy away from monotherapy in any NTM disease, preferring at least two active agents. Perhaps one scen...