Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
What is your approach to a patient with undetectable MMR titers checked prior to or during immunosuppression and a history of MMR vaccination in childhood?
MMR titers are good correlates of protection. If any titer is undetectable it could be one of these situations: Primary failure. The components of the MMR have different efficacy. Two doses of appropriately given MMR will have 96+% against measles, but only 88% for mumps. Thus 1 in 10 appropriately...
Do you always stop dexamethasone at discharge for patients admitted with COVID requiring respiratory support (as done in the RECOVERY trial), or are there situations in which you will prescribe it to complete a 10-day course?
Great question. Generally, I don't continue dexamethasone if they are no longer wheezing or generally feeling back to their baseline. Sometimes, I will extend the course if the patient has been in the hospital several times for COPD, just to see if I can keep them out of the hospital longer. But the...
Is there a role for cefpodoxime for treatment of acute cystitis caused by an Enterobacterales isolate with resistance to cefazolin, but susceptibility to ceftriaxone?
Yes – “sort of”. This is a much more complex question than it initially seems. First some background. CLSI has established a surrogate cefazolin breakpoint to predict susceptibility of urine isolates of Escherichia coli, Klebsiella pneumoniae, and Proteus mirabilis causing uncomplicated infection to...
Is there any utility to trending Histoplasma serology titers to guide duration of therapy or treatment response for pulmonary histoplasmosis with negative urine antigen?
Serology unfortunately is not useful to monitor response to therapy as the fall in titers is often very slow. In immunocompetent individuals, titers will often take a few years to show a significant drop in the antibody titer after successful treatment. The treatment duration should be guided by the...
Does a low serofast RPR titer (such as 1:1 or 1:2) in the setting of a remote history of appropriately treated latent syphilis in a patient with now uveitis of yet unknown etiology referred from ophthalmology for possible ocular syphilis make a diagnosis of ocular syphilis less likely?
I err on the side of offering empiric treatment. As syphilis rates have risen over the past 20 years, so has the incidence of syphilitic uveitis (Mir et al., PMID 37991790), and the question posed, therefore, represents a not uncommonly encountered conundrum for infectious disease consultants. Syphi...
Do you prefer vancomycin or daptomycin for gram-positive coverage in culture-negative prosthetic valve endocarditis considering both Corynebacterium and Enterococcus are notable possible pathogens?
In recent years, we have transitioned from using Vancomycin to Daptomycin for the treatment of endocarditis, whether it involves a native or prosthetic valve or culture negative. This shift is primarily due to concerns about intolerance rather than Vancomycin resistance. Additionally, recent literat...
How long would you treat an upper urinary tract infection in a patient with acute obstructive pyelonephritis due to a kidney stone status-post urinary stenting without yet removal of the stone?
After treatment of an ascending urinary tract infection for 7 days, the infection will be treated. However, if the stone is large enough it may be colonized and cause recurrent infection. I would make my best efforts to get the stone removed as soon as possible and I would likely give the patient a ...
Do you recommend starting anti-fungal prophylaxis for patients on systemic antibiotics who have a peritoneal dialysis catheter that is only currently being accessed for once weekly flushes?
This is a unique situation which is for me a strictly hypothetical one, as I've not encountered this situation in my 38-year PD career. Nor am I aware of data to guide a response. On reflection, however, I would answer in the affirmative. Fungal peritonitis is a very serious infection which invariab...
What is your approach to monitoring of inflammatory markers during treatment of native vertebral osteomyelitis?
As long as the patient is clinically stable and CRP is coming down, there is generally no need for follow up imaging. Key reference: Kowalski et al., PMID 16779743.Also, good to remember that ESR is a very expensive test which basically measures fibrinogen (may cost $500 or more since it has to be r...
Do you consider the use of tocilizumab in patients with COVID pneumonia who have had an improvement in supplemental O2 requirements but have significantly elevated inflammatory markers after day two of remdesivir and dexamethasone?
I don’t use tocilizumab if the clinical condition is improving.