Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
Do you add gentamicin when treating prosthetic valve endocarditis secondary to viridans group Streptococcus with a penicillin-intermediate isolate (MIC >0.125 - <0.5)?
No, we do not treat patients with such infections with a combination of penicillin and gentamicin. For these infections, we treat with ceftriaxone alone. Monotherapy with ceftriaxone is a more reasonable option than a combination of penicillin and gentamicin because we have every reason to consider ...
What is your approach when cryptococcus serum or CSF antigen titers do not change despite treatment in HIV-positive patients with cryptococcal meningitis or invasive disease, but there is clinical improvement and cultures remain negative?
While cryptococcal antigen is an excellent diagnostic marker for this infection, with excellent sensitivity and specificity, it is not reliable for tracking response to therapy. An initially high CSF antigen level has been identified as a sign of poor prognosis in patients with AIDS, but multiple st...
Would you offer live vaccines (e.g., MMRV/measles) to patients on bispecific antibodies for multiple myeloma?
I agree with the answer here by Dr. @Dr. First Last. There are a lot of nuances, though. In regard to giving the vaccine safely and effectively, the best strategy is not to wait until patients have multiple relapses and are on bispecific therapy to vaccinate. Given the recent outbreaks of measles, i...
How long do you recommend that a patient wear a mask when resuming biologic infusions following a recent upper respiratory infection?
Patients who have acquired an upper respiratory tract infection in the COVID, RSV, influenza era should wear masks as long as they are deemed contagious. The CDC makes recommendations concerning the duration of masking and the type to use. For COVID the current suggestion is 10 days after the cessat...
How do you think about biologic use in patients with underlying HIV infection?
This is always a difficult problem, and a tough clinical call. However, over the years of seeing these people, I have come to realize that following their viral load and CD4 counts while looking for immunologic recovery allows us as Rheumatologists a lot of opportunities to treat. While I have class...
How do you approach management for patient's with HIV on ART with persistent low level viremia but no new resistance mutations identified?
The US Department of Health and Human Services describes the different levels of virologic response related to ART[1]: Virologic suppression: A confirmed HIV RNA level below the lower level of detection of available assays. Virologic failure: The inability to achieve or maintain suppression of viral...
Do you routinely discontinue atypical coverage in community-acquired pneumonia when PCR testing (i.e., respiratory pathogen panel) is negative for atypical organisms?
In community-acquired pneumonia (CAP), here is how I approach the decision to discontinue atypical coverage (e.g., azithromycin or doxycycline) when respiratory pathogen panel PCR testing is negative for atypical organisms (most commonly, Mycoplasma pneumoniae, Chlamydia pneumoniae, Legionella pneum...
How do you make decisions about decolonization for a chronic asymptomatic MRSA carrier?
Carriage of Staph aureus (either MSSA or MRSA, depending on environmental exposure) is the “baseline” state for 25 -35% of individuals, likely dependent on genetic factors, most of which have yet to be fully identified. It cannot be readily reversed over the long term, but can be transiently halted ...
In clinical practice, are you using single-dose liposomal amphotericin B for treatment of cryptococcal meningitis for patients living with HIV?
I have practiced in Dallas, Texas, at Parkland Hospital for nearly 20 years; unfortunately, we see at least 50 patients a year with cryptococcal meningitis and HIV. We have been using the standardized approach from the US DHHS guidelines that recommend at least a 14-day course of therapy of Ambisome...
Is there a role for routine LP in HIV patients with disseminated histoplasmosis even in the absence of CNS signs/symptoms?
I would not recommend routine LP in the absence of CNS symptoms as it is unlikely to change the management of the infection in someone who has disseminated disease. Prolonged therapy will still be used and as opposed to Cryptococcal meningitis where intracranial pressure management is critical, ther...