Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
Do you favor a certain NRTI to pair with dolutegravir and lamivudine in persons with HIV to minimize the risk of resistance to dolutegravir?
The data are strong to support DTG/lamivudine as a stand-alone regimen with low risk of resistance development as long as patients remain adherent, so there isn't necessarily a reason to add another NRTI. That said, the Beck et al., PMID 40898778 study would suggest that tenofovir is associated with...
What oral treatment options would you offer a patient with severe onychomycosis who is also on methotrexate for another condition?
I prefer pulsed terbinafine at 250 mg daily x1 week every other month. Dr. Zaias showed in a comparative study that pulsed terbinafine works as well as giving it daily for 3 months, and since the patient is only taking this for 1 week every other month, risks for hepatotoxicity are minimal.
What further evaluation do you pursue for patients who present with vague symptoms such as subjective fevers or intermittent night sweats, who have no pulmonary symptoms but have a positive IGRA?
Great question. Another scenario that is not uncommon is some degree of cough, sometimes for long periods of time, but no other symptoms. If their risk is higher for progression to active disease (e.g., immunocompromised; recent contact with an active case) I may do more than if the risk is low. My ...
Do you treat non-albicans strains of Candida on sputum culture or BAL in patients who are immunosuppressed?
I agree with these answers and do not treat either without biopsy.
Do you ever favor cefazolin over ceftriaxone for bacteremia with susceptible E. coli?
We do cefazolin often unless h/o ESBL or complicated infection or procedural history. It is our preferred abx for pyelo or intra-abdominal infection (we add Flagyl for intra-abdominal) and is driven by our local susceptibility data.
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 treat all HIV patients with positive screening tests. I consider HIV itself, regardless of CD4 count, to be the highest risk for reactivation disease. I believe there is data showing this risk to be higher even than organ transplant or cancer treatment patients. The problem, of course, is navigati...
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 ...