Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
How would you manage a patient with HIV, re-infection of hepatitis C that has not yet been treated, chronic hepatitis B infection on BIC/FTC/TAF with undetectable HIV viral load but HBV viral load consistently >100,000 with normal ALT?
Your concern about HBV reactivation during DAA therapy is real and well-documented, as it can occur in up to 24 of HBsAg-positive patients during or after DAA therapy when not on HBV-active therapy. However, the solution per guidelines is concurrent HBV prophylaxis/treatment, not sequential treatmen...
Under what circumstances would you choose the 1-month 1HP treatment over a 3-4 month regimen for latent TB?
I tend to favor the 1-month daily isoniazid–rifapentine regimen (1HP) in very specific clinical and programmatic contexts, rather than as a default option. Its main advantage is speed i.e. when there is a narrow window to complete latent TB treatment such as prior to imminent immunosuppression (e.g....
Do you still offer nirmatrelvir–ritonavir to a vaccinated older adult with comorbidities and mild COVID-19 illness given recent trial data showing no reduction in hospitalization or mortality?
The Butler et al., PMID 42019019, paper published in the New England Journal of Medicine in 2026 reviewed 2 open-label trials from the United Kingdom and Canada (PANORAMIC and CanTreatCOVID) where higher-risk patients were randomly assigned to receive nirmatrelvir-ritonavir plus usual care versus us...
What additional antibiotic coverage, if any, would you give to a patient with penicillin-susceptible Strep viridans prosthetic valve endocarditis on ceftriaxone who needs to undergo a dental procedure?
I'm a little baffled by the phraseology of "therapeutic endocarditis" because this implies to me the patient is on therapy for endocarditis and therefore is therapeutic on the ceftriaxone therapy. Additionally, the patient could be switched to penicillin as either is recommended as therapy in the 20...
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 would you manage a patient with necrotizing pneumonia due to a susceptible Pseudomonas aeruginosa strain who continues to have significant purulent secretions and worsening imaging while receiving cefepime?
I agree, not enough information here to make a firm recommendation, but often times these necrotic pneumonias will undergo significant liquefactive necrosis, and all of that dead lung and purulence has to come out through the mouth. I tell patients that they may have a worse cough for a while, and t...
How would you manage persistent Norovirus diarrheal infections in a kidney transplant patient that are not responding to a decrease in the patient’s maintenance immunosuppressive regimen?
This is a difficult situation and does not have a strong evidence based response. First, I would really make sure they are not on mycophenolate as this is really the main problem with chronic Norovirus for most patients. Next, I would see if there are any available clinical trials that the patient m...
Have you used oral vancomycin as prophylaxis for C difficile infection in patients admitted for allogeneic hematopoietic cell transplant?
Yes, but only in patients with a history of C difficile in the previous year and starting at the time of initiation of broad-spectrum antibiotics (e.g., for fever and neutropenia). We use 125 mg daily.We are aware this practice may be controversial. To my knowledge, there is only one randomized tria...
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?
Multiple concurrent OIs are common in individuals with advanced HIV and contribute significantly to morbidity. Because several infections can emerge simultaneously in the setting of profound immunosuppression, recognizing the likelihood of multiple coexisting pathogens is critical. Early identificat...
Do you regularly recommend an immunological workup for patients with suspected immunodeficiency or defer to immunology?
I defer after a very preliminary work-up based on the type of immunodeficiency expected. I try to direct the consult to a provider most likely to have expertise in the problem I suspect. Often, I suggest consulting with a provider at NIH.