Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
How do you approach perioperative antimicrobial prophylaxis in patients undergoing reconstructive surgery with myocutaneous flaps whom have recently been treated for active infection?
Generally speaking, if the patient has been fully treated, I do not give antimicrobial prophylaxis other than the guideline-based 1 dose of therapy prior to surgery. If a flap is planned, generally, I would like the patients to complete their course of therapy for active infection prior to flap plac...
What is the best approach to determine whether antiviral post-exposure prophylaxis for influenza is appropriate in an elderly immunocompromised patient who has been vaccinated?
This is purely a matter of clinical judgement. The studies showing the benefits of post-exposure prophylaxis did not use any laboratory data, but it is believed that starting prophylaxis within 48h of exposure is important. The risk of severe complications or death in the hypothetical is unknown, bu...
In addition to ampicillin, is there any benefit to the addition of either gentamicin or Bactrim when treating a patient with listeria meningitis?
There has been a lot of misinformation in the literature for decades about the treatment of Listeria bacteremia and meningitis/encephalitis. Some of this arose based on publications of in vitro studies that claimed that "PCN and ampicillin are bacteriostatic against Listeria." This was based on dete...
What is your preferred oral regime with duration for treatment of onychomycosis?
Back in the old days of the "toenail wars" between terbinafine and itraconazole, I was a speaker for both and learned that the pharmacodynamics of the two drugs favored pulsing for the latter but NOT for the former. Terbinafine does NOT leave the blood for weeks, unlike itraconazole (days), so if th...
Would you consider using long-acting injectable cabotegravir/rilpivirine for pregnant women with HIV?
At this time, long-acting injectable cabotegravir/rilpivirine (CAB/RPV) is not generally recommended during pregnancy due to limited safety data and unknown effects on the developing fetus. So far, there have not been any reported safety concerns regarding harm to the fetus for either long-acting in...
Do you recommend surveillance lumbar punctures for patients with Mollaret's meningitis after diagnosis or in between clinical episodes?
No. My focus with these patients is to establish the diagnosis, which is often difficult, with false-negative CSF PCR tests, and then do everything I can to prevent and alleviate the attacks. I see no role for surveillance LPs because either the patient is better clinically or they are not, and CSF ...
What factors should be prioritized when deciding the timing of CIED extraction in patients with high surgical risk or multiple comorbidities?
I'll do my best to respond, though the question isn’t entirely clear to me. If the intent is to determine which patients should be prioritized for CIED extraction, the key consideration is whether the benefits outweigh the risks. The most straightforward case is persistent bacteremia, especially in ...
Do you routinely consider FDG PET/CT imaging for workup of fever of unknown origin?
The landscape of FUO and IUO and our clinical approach to diagnosing its cause has changed significantly over the past several decades. More sensitive microbiologic screening for infectious etiologies, including syndromic molecular panels and next-generation sequencing are now clinically available a...
What is your approach to dental prophylaxis for patients on biologics?
My approach has been to not recommend antibiotics prior to routine dental care for patients on biologic therapy. I'm not aware of any compelling evidence or guidelines supporting preventive antibiotic treatment for such patients. Of course, there may be exceptions to this. Antibiotic prophylaxis mig...
What is your approach to anal pap screening among MSM with HIV, and if routinely recommend, starting at what age (assuming access to HRA)?
We taught our nurses and patients how to do self-collection, which cut down on the amount of time it takes. Multiple guidelines for HPV have been revised in the past few months based on more recent studies (although the emotional reaction to having multiple of my patients diagnosed with anal cancer ...