Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
What is your approach to determining whether a patient who repeatedly tests positive for strep has reinfection or has asymptomatic carriage?
One of the biggest challenges is that there is no single test that reliably distinguishes recurrent Group A Streptococcus (GAS) infection from chronic asymptomatic carriage. My approach starts with the clinical history. Patients with true recurrent GAS typically have the classic syndrome, e.g., abru...
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...
How would you manage a patient with mild respiratory symptoms, imaging showing bronchiectasis, one AFB culture growing only mycobacterium avium complex, and a separate AFB culture growing only nocardia species?
I would recommend repeating at least two more acid-fast bacilli (AFB) sputa to see if Mycobacterium avium complex (MAC) repeatedly grows; ideally, they should be identified to the species or subspecies level, but I understand that can be hard to request. Admittedly, bronchiectasis alone (without nod...
What toxicity threshold would make you stop bepirovirsen while pursuing functional cure in a noncirrhotic patient with chronic HBV on suppressive nucleos(t)ide analogue therapy?
From the paper: "On the basis of a phase 2a randomized controlled trial assessing safety, tolerability, and antiviral activity of bepirovirsen, in which ALT elevations associated with HBsAg reductions were reported for NA-naïve patients, ALT increases were considered AEs of special interest. Class e...
Do you add empiric anti-MRSA coverage to the initial antibiotic regimen for a patient admitted with community-acquired pneumonia who has risk factors for MRSA but a negative MRSA nasal screen?
Thank you for this excellent and highly relevant clinical question. I approach this scenario by blending robust evidence-based medicine with fundamental principles of diagnostic reasoning. The short answer is generally no, you probably do not need to add empiric anti-MRSA coverage for a standard CAP...
For hospitalized patients with confirmed viral respiratory infections who clinically improve but remain PCR-positive, how long do you maintain isolation precautions?
This is a great question and one that routinely comes up for patients, their families, and staff. Precautions should be continued until symptoms improve and for a minimum of 14 days after the onset of signs and symptoms. This is especially important for patients who can spread virus to individuals t...
Do you continue voriconazole beyond the minimum recommended duration in a patient with invasive pulmonary aspergillosis who is clinically improved but has persistent radiographic abnormalities on CT?
The "recommended" duration is based on expert opinion, rather than trials. The immune status of the patient counts. When I was taught how to treat invasive aspergillosis at the National Cancer Institute (this was before voriconazole was available), the recommendation was to continue treatment until ...
Would you avoid using cephalosporins in a patient with a history of cephalosporin neurotoxicity in the setting of CKD?
I think there are a few problems or nuances involved in answering this broad question:First, other practitioners may use other IV cephalosporins, but we only use cefazolin, ceftriaxone, cefepime, and ceftazidime (as part of Avycaz).Second, the calculated CrCl often poorly correlates with the patient...
What is the preferred four-drug regimen for initial treatment of pan-susceptible tuberculous meningitis, given the need to achieve optimal CNS penetration?
I will defer to the guidelines for the specific regimen. One general issue I would like to address is the idea of "CNS penetration." Since we don't routinely do brain biopsies in humans to truly assess levels of antimicrobials in the brain/spinal cord/meninges, many people think that "CSF levels = C...
In light of recent measles outbreaks in the US, would you recommend an MMR booster for immunocompetent patients born before 1957?
I would not recommend a measles vaccine for a person born before 1957. This year has been chosen because people before born before 1957 have a very very high likelihood of having had measles because virtually all children got this highly contagious disease. On the other hand, there is no harm to get...