Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
How would you manage an early postoperative spinal implant infection when intraoperative cultures while on antibiotics are negative, no frank purulence or other evidence of infection is observed during washout, but there were fascial defects and fluid tracking down to the hardware?
This is quite an interesting spread of responses. I avoid using the term “broad,” as it is not a meaningful concept in infectious diseases. Unfortunately, there are no randomized trials to guide our practice in PSI. The closest comparable evidence is likely from the DATIPO trial, where 12 weeks of t...
What is the interpretation of an IGRA with positive TB wells and negative nil and negative mitogen wells?
We don't see positive controls in most clinical assays. They are run, of course, but hidden from view. The mitogen well is the positive control in the IGRAs. The mitogen used QuantiFERON-TB Gold is, I believe, PHA or phytohemagglutinin. PHA turns on T-cells to indiscriminately. If I remember my mito...
What is your approach to a positive PPD or IGRA in a patient with well-controlled HIV without significant TB risk factors?
I would treat this patient for LTBI (after ruling out active disease); if the patient was hesitant to be treated, a second test could be done if it would increase their likelihood of adhering to the regimen; but I would urge treatment in any case as the stakes are high if untreated LTBI is present. ...
Is there any role for administering another course of recombinant zoster vaccine (Shingrix) in a previously vaccinated patient with RA, who is in clinical remission on JAK inhibitor but has had a breakthrough shingles infection?
Dr. @Dr. First Last has provided a very complete and literate response. However, the critical word is “likely”. As with most vaccines, both the strength and the duration of response to the zoster vaccine decline with worsening levels of immunosuppression. We have increasingly adopted the practice of...
What is the interpretation of two IGRAs with negative mitogen wells, in the absence of immunosuppression?
If I understand this case correctly, the patient is actively ill and the patient's doctors are considering tuberculosis as a possible etiology of the patient's illness. In that scenario, IGRAs and PPDs have a limited to no role. Epidemiology, family history, and other possible exposures do. In your ...
Are there instances when you use letermovir without the addition of acyclovir when managing a kidney transplant recipient for CMV prophylaxis?
I am assuming this question is about initial viral prophylaxis after transplant and exposure to induction immunosuppression. We have not used often letermovir as first line CMV prophylaxis outside of a research study, or during valcyte shortages. Cases where one might consider Letermovir as prophyla...
Do you have any concerns about using long-acting cabotegravir/rilpivirine in obese patients with HIV?
There have been concerns raised about adequate drug levels being maintained in patients with high BMI. One concern is that injections may be deposited in subcutaneous rather than intramuscular tissue. A recent computer modeling study also indicated subtherapeutic drug levels in patients with BMI >40...
How do you use gut microbiome or gut microbiota analysis in your clinical practice, if at all?
While I am presented with microbiome analyses on a regular basis by patients, I do not believe that these are useful, as we are still not there when it comes to defining the "normal" microbiome. This indeed may vary tremendously between individuals depending on age, gender, diet, geographic location...
Do you treat prosthetic joint infections after a two-stage revision arthroplasty with oral antibiotics for the full duration of therapy, assuming a susceptible oral option is available?
This is a hard one-I definitely think the data is there for PO, but until the IDSA recommendations change and the culture of practice changes it is hard to make the switch to doing a full regimen PO! I also think the accountability of IV antibiotics is useful -with the visiting nurse, weekly labs, i...
What is the recommended duration of therapy for Enterococcal bacteremia from a urinary source in patients with prosthetic valves assuming negative TEE and clearance of bacteremia?
I guess a few questions. How quickly did the blood cultures clear? How good was the quality of the TEE? What is meant by treatment of enterococcal bacteremia, a single agent or endocarditis regimen? How long was the patient sick before they came in? ESR? Hgb? I guess, peripheral stigmata can be look...