Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
What is your approach to a patient with undetectable MMR titers checked prior to or during immunosuppression and a history of MMR vaccination in childhood?
MMR titers are good correlates of protection. If any titer is undetectable it could be one of these situations: Primary failure. The components of the MMR have different efficacy. Two doses of appropriately given MMR will have 96+% against measles, but only 88% for mumps. Thus 1 in 10 appropriately...
Would you consider levofloxacin graded challenge, extended IV aztreonam, or an alternative treatment in a patient with reported anaphylaxis to penicillin, fluoroquinolones, and cefuroxime with cavitary pneumonia secondary to Klebsiella and Pseudomonas?
The first and most important thing would be to establish whether the patient had a true penicillin (as well as other antibiotic) allergy since >90% of patients who think they are sensitive to PNC really are not. If it is established that the patient does have a PCN allergy, consultation with ID is a...
Do you recommend boric acid for patients with recurrent candida vulvovaginitis?
Yes, this will be effective at 600 mg bid for 2-4 weeks. However, with recurrence, it is important to obtain a fungal culture to document species and susceptibility.
How would you manage a patient with well-controlled HIV on Biktarvy, who is interested in switching to injectable HAART but also has a history of a prior Hepatitis B Infection?
HBV is a common co-infection in people with HIV (PWH), due to shared transmission routes. Two large meta-analyses of studies published found a global a pooled prevalence of HBV infection among PWH to be between 7.6 and 8.4%, with a higher prevalence in less developed countries (10.4%) compared to mo...
Is there a specific criteria that you use to determine if a patient with respiratory symptoms should have a multiplex respiratory test performed?
If the patient is being admitted to the hospital, the information provided by this test can be useful with regards to antimicrobial stewardship (potentially avoiding antibiotic therapy or targeting it) and also with regards to infection control precautions. For outpatient scenarios, if respiratory s...
Do you routinely test for toxoplasmosis during workup of fever of unknown origin in an immunocompetent patient with significant cat exposure?
Not with evidence of scratches and/or lypmpadnopathy, which can be very impressive.Tangentially, what definition of FUO is being used?SMS
When do you consider PET/CT to evaluate for an occult source of infection in patients with persistent bacteremia if TTE/TEE does not show evidence of endocarditis?
Great question. Generally, I consider PET/CT to evaluate for an occult source of infection in patients with persistent bacteremia if TTE/TEE does not show evidence of endocarditis, in the following scenarios: Persistent bacteremia ≥72 hours. TEE was negative or nondiagnostic. No source identified o...
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 ...