Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
Do you still use fever as a minor criterion when applying the Duke–ISCVID criteria for infective endocarditis given data suggesting diagnostic accuracy may improve when it is omitted?
Actually, I still use fever as a minor criterium. I have not really thought much about it and have no instances where culture-negative endocarditis has come up since the publication. In fact, no one in my division has even brought this up for discussion. Anyhow, I think this is a minor modification....
How would you manage a patient with viremia up to 400 copies/mL on CAB/RIL injections who was previously undetectable on BIC/FTC/TAF and with prior genotypic testing without drug resistance mutations?
We have definitely seen treatment failure with CAB/RPV, which unfortunately made using both classes of medications impossible. Assuming usual issues of adherence and attending appointments are not issues, I would review the administration technique, particularly if the patient has an elevated BMI or...
What is your preferred laboratory test to assess treatment response or infection resolution in patients with bacterial pneumonia?
I don't generally check a laboratory test to assess resolution. I go more by their improved clinical status and seeing them get back to baseline oxygen status. If I am trending a WBC or procal, I do like to see it trend down, but it's not the only lab I hang my hat on to decide if someone has resolv...
What is your approach to monitoring blood parasite smears in an immunocompetent patient with babesiosis?
In an immunocompetent person the response rate to the treatment of acute babesiosis is extremely high and if a person is clinically improving follow-up smears are probably unnecessary. However, I generally check one at 48 hours to confirm a decrease in parasite burden. If that is favorable and the p...
What minimum inpatient monitoring and discharge criteria should be required after single high-dose liposomal amphotericin B induction for HIV-associated cryptococcal meningitis when the patient has persistent intracranial hypertension requiring serial lumbar punctures?
If a patient has persistent ICH despite serial LPs, I would ask neurosurgery to place a lumbar drain. I would also continue the liposomal amphoB until the ICH came down. In addition, the CSF cell counts, glucose, and protein should be followed along with CSF CrAg/culture to confirm that all are impr...
How would you manage a patient with good adherence on darunavir/cobicistat/emtricitabine/tenofovir alafenamide with persistent viremia 300-400 copies/mL with genotypic resistance testing demonstrating isolated T97A INSTI mutation, L10L/V, I13V, E35D, M36I, and L89M protease inhibitor mutations and no RT resistance?
Complicated question and answer: Confirm and evaluate causes (do now) Repeat HIV RNA promptly (e.g., in ~2–4 weeks) to confirm persistence and trend. Medication reconciliation/interactions (common culprits even with “good adherence”): cation-containing supplements/antacids (relevant mainly to INST...
Do you switch patients living with HIV off of boosted protease inhibitor-based regimens if possible to avoid the increased cardiovascular risk associated with them?
Yes, I usually do, despite my deep respect for PIs, which turned the tide in the United States in the 1990s from a universally fatal condition into a chronic disease. Some studies, most prominently the D:A:D study, suggest that ritonavir-boosted darunavir may increase the risk of CVD; however, other...
Do you provide empiric doxycycline for Lyme Disease to asymptomatic patients after a tick bite who haven't developed Erythema migrans or are not sure it was an Ixodes tick?
I would base post-exposure prophylaxis upon local prevalence (unless the patient has a recent notable travel history). For example, Lyme disease is very rare in California due to the Ixodes tick's intermediate host being the Western Fence Lizard (long story short, something in their blood kills the ...
How would you approach management of multidrug resistant Streptococcus mitis bacteremia in a patient with prolonged neutropenia and prior severe allergic reaction to vancomycin?
I think it depends on what it is sensitive to. Fluoroquinolones might be an option. Linezolid might be an option.
Do you prescribe empiric antibiotics to patients with CAP who test positive for a respiratory virus?
I do not start antibiotics when there is a detected viral etiology. And I tend to stop them if they were started. Obviously, this changes if the symptoms worsen and/or I suspect a bacterial superinfection. Another caveat would be in a patient with underlying COPD where Azithromycin may play a role i...