Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
Is it ever safe to use a biologic DMARD in a patient with RA who is on suppressive antibiotics due to a history of septic prosthetic arthritis?
I have used Orencia and HCQ as more immunomodulating with suppressive M/W/F antibiotics in a patient with UTI/Bactrim.
For how long would you treat a patient with latent TB before allowing them to proceed with a liver transplant?
There are a few ways to look at the answer to this question. If the individual is stable enough to complete the Latent TB Infection (LTBI) therapy without need for a liver transplant, then treat the LTBI to completion. If the individual may need the transplant during the treatment course, then start...
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...
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 recommend procalcitonin to help convince other providers to stop antibiotics in patients with pneumonia in whom a non-infectious diagnosis is strongly suspected?
I have looked at both of these studies in some depth. The de Jong et al., study, called SAPS, is perhaps the more impressive of the two, but regarding either or any study on so-called "biomarkers", even the RCT studies only make recommendations or give advice. And, more often than not, the doctors d...
When would you consider offering antiviral treatment to an immunocompetent patient with acute EBV infection?
There are currently no approved antiviral drugs for acute EBV infection. The data on acyclovir and ganciclovir do not support prescribing either for acute EBV infection in immunocompetent individuals. I do not use this approach in my clinical practice, and treatment in immunocompetent persons relies...
Would you give treatment to a male patient with subjective dysuria but no objective pyuria with Ureaplasma urealyticum detected by PCR from urine?
No treatment is indicated. First, dysuria alone in males is not an STD symptom; published research is clear that discharge is required to suspect urethritis. The absence of urine WBCs (i.e. no pyuria) is a pretty good substitute for examining for discharge - not perfect but makes urethritis unlikely...
How do you explain the use of an AI scribe to patients the first time it is used in their care?
I use an AI scribe in my outpatient clinic, and around 90–95% of my patients agree to it. I obtain consent at the start of each visit and make it clear that it's completely optional—that they can say no at the start or change their mind at any point in the visit, with no impact on their care. I also...
Do you routinely recommend antibiotic prophylaxis for routine dental cleaning in patients taking mycophenolate mofetil?
The most recent AHA and ADA guidelines continue to recommend antibiotic prophylaxis prior to dental procedures for patients at high risk of developing endocarditis (Goff et al., PMID 31728507). Additional recommendations from the ADA include avoiding routine dental care for the first 6 months after ...
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...