Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
Would you recommend antifungal treatment or observation without therapy in an immunocompetent patient with a pulmonary nodule who underwent malignancy workup and was found to have yeast forms consistent with histoplasma on GMS stain?
We have seen a number of patients who have had a lung biopsy for a solitary pulmonary nodule to exclude the diagnosis of cancer. When histoplasmosis is identified by pathology, we obtain a urine histoplasma antigen as well as a careful history and exam, and some lab tests for immunosuppression. If n...
Do you recommend routine neurosyphilis testing in patients being evaluated for dementia?
Syphilis is a rare cause of dementia without other evidence of neurological disease, at least in the US and most other industrialized countries. Of course, a careful neurological examination is required for all dementia patients, but the absence of other manifestations of neurosyphilis makes testing...
Would you use low-dose infliximab as adjunctive therapy in a patient with severe central nervous system tuberculosis?
I would not routinely use low-dose infliximab as adjunctive therapy in patients with severe central nervous system tuberculosis at this time. The biological rationale is understandable. Tumor necrosis factor–α plays a central role in the inflammatory cascade that drives tissue damage in tuberculous ...
Do you still use fever as a minor criterion when applying the Duke–ISCVID criteria for infective endocarditis given data suggesting diagnostic accuracy may improve when it is omitted?
Actually, I still use fever as a minor criterium. I have not really thought much about it and have no instances where culture-negative endocarditis has come up since the publication. In fact, no one in my division has even brought this up for discussion. Anyhow, I think this is a minor modification....
Do you use daptomycin interchangeably with staphylococcal beta-lactams for ease of dosing on discharge for patients with serious MSSA infections (endocarditis, bacteremias, etc)?
I don’t use daptomycin interchangeably with antistaphylococcal beta-lactams for serious MSSA infections, and I think doing so routinely is a mistake. For invasive diseases like endocarditis, prolonged or complicated bacteremia, and deep-seated foci of infection, the outcome data consistently favor b...
How would you manage a patient with viremia up to 400 copies/mL on CAB/RIL injections who was previously undetectable on BIC/FTC/TAF and with prior genotypic testing without drug resistance mutations?
We have definitely seen treatment failure with CAB/RPV, which unfortunately made using both classes of medications impossible. Assuming usual issues of adherence and attending appointments are not issues, I would review the administration technique, particularly if the patient has an elevated BMI or...
What is your preferred laboratory test to assess treatment response or infection resolution in patients with bacterial pneumonia?
I don't generally check a laboratory test to assess resolution. I go more by their improved clinical status and seeing them get back to baseline oxygen status. If I am trending a WBC or procal, I do like to see it trend down, but it's not the only lab I hang my hat on to decide if someone has resolv...
What is your approach to monitoring blood parasite smears in an immunocompetent patient with babesiosis?
In an immunocompetent person the response rate to the treatment of acute babesiosis is extremely high and if a person is clinically improving follow-up smears are probably unnecessary. However, I generally check one at 48 hours to confirm a decrease in parasite burden. If that is favorable and the p...
What minimum inpatient monitoring and discharge criteria should be required after single high-dose liposomal amphotericin B induction for HIV-associated cryptococcal meningitis when the patient has persistent intracranial hypertension requiring serial lumbar punctures?
If a patient has persistent ICH despite serial LPs, I would ask neurosurgery to place a lumbar drain. I would also continue the liposomal amphoB until the ICH came down. In addition, the CSF cell counts, glucose, and protein should be followed along with CSF CrAg/culture to confirm that all are impr...
How would you manage a patient with good adherence on darunavir/cobicistat/emtricitabine/tenofovir alafenamide with persistent viremia 300-400 copies/mL with genotypic resistance testing demonstrating isolated T97A INSTI mutation, L10L/V, I13V, E35D, M36I, and L89M protease inhibitor mutations and no RT resistance?
Complicated question and answer: Confirm and evaluate causes (do now) Repeat HIV RNA promptly (e.g., in ~2–4 weeks) to confirm persistence and trend. Medication reconciliation/interactions (common culprits even with “good adherence”): cation-containing supplements/antacids (relevant mainly to INST...