Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
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...
How long do you treat an isolated bacterial liver abscess which has either undergone percutaneous drainage or for which an indwelling drain is placed?
Until it's gone... Percutaneous drainage of liver abscesses is, in my experience, less effective than drainage of intra-abdominal abscesses, which isn't very effective. Neither type of abscess isn't, as I explain to other doctors and pts, a water balloon. Liver abscesses are more complicated than ot...
Under what circumstances would you initiate antibiotics in adults hospitalized with RSV and a suspected bacterial co-infection?
Bacterial co-infection in patients hospitalized with RSV ranges between 8% and 29% (Karlsen et al., PMID 41488696). The American Thoracic Society 2025 guidelines recommend prescribing empiric antibiotics to all hospitalized patients with clinical and imaging evidence of community-acquired pneumonia ...
What is your approach to antiviral treatment of HSV acute retinal necrosis?
Acute Retinal Necrosis (ARN) is a rapidly progressive syndrome usually caused by varicella-zoster virus (VZV)and herpes simplex virus 1 or 2 (HSV). The syndrome is rapidly progressive in the absence of antiviral treatment. PCR performed on aqueous or vitreous sampling is highly sensitive and strongl...
What do you prescribe for HIV post-exposure prophylaxis in patients who cannot swallow tablets and have no enteral tube?
We would prescribe cabotegravir and rilpivirine 600mg/900mg intramuscular x 1 injection to give 28 days of protection. IF there is a question of any resistance in the source patient, we would add lenacapavir 600mg po on days 0 and 1 as an oral loading dose plus lenacapavir 927 mg sq on day 0.
How do you differentiate between HIV associated neurocognitive disease (HAND) and other causes of neurocognitive impairment?
This is a great question. In the era of test and treat, where many people with HIV have never had significant immunocompromise, cognitive impairment due to HIV itself is now relatively rare. On the other hand, people with HIV experience conditions of aging about 10 years earlier than people without ...
Would you consider transition to a cabotegravir/rilpivirine injectable regimen in a patient living with HIV who is well-suppressed on BIC/FTC/TAF since initial diagnosis in Colombia in 2022 at which time her viral load was in the 400s precluding genotypic resistance testing?
The clinical scenario as presented is somewhat ambiguous. If the patient is described as “well suppressed” on bictegravir/emtricitabine/tenofovir alafenamide, this typically implies consistent HIV RNA <200 copies/mL. A persistent viral load in the 400s, however, would suggest low-level virologic fai...
Does your hospital or institution have an Antimicrobial Stewardship Program (ASP), which oversees ID physicians, and if so, does the ASP have the authority to refuse an antibiotic prescribed by an ID consultant?
We have ASP and the ID docs have a very collegial relation with our PharmD who are both ID pharmacists. They are very helpful and they do not block the ID consultants. When ID consultant recommends something that should not be done due to drug interaction for instance The pharmacist will call explai...
For patients with MSSA bacteremia and planned oxacillin at home via OPAT due to start the day after discharge, would you consider discharging after a one-time dose of ceftriaxone or daptomycin?
In a patient with MSSA bacteremia, I would not be comfortable sending a patient home after one dose of ceftriaxone or daptomycin to continue outpatient anti-staph IV antibiotics. Staphylococcus aureus bacteremia causes distant seeding in more than 1/3 of cases and has a mortality rate ranging betwee...
What has been your experience with tecovirimat for monkeypox?
I thought it worked well in 2 patients of mine with rectal Mpox. However, the clinical trial did not confirm this, and it was a lot of trouble to get TPOXX going with consent, investigational drug, etc so we have abandoned use here.