Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
How do you decide when to initiate antibiotics for superimposed bacterial pneumonia in patients with influenza?
Antibiotic therapy should not be routinely prescribed for patients with influenza and should instead be reserved for those with a specific clinical concern for secondary bacterial pneumonia. This diagnosis is best identified by clinical trajectory. Key triggers include initial improvement followed b...
When do you give systemic chemotherapy in addition to HAART to patients with AIDS-associated pulmonary Kaposi sarcoma?
The indications for systemic therapy in AIDS-associated KS would include progressive disease or worsening symptom burden despite adequate HAART. Occasionally, if the disease is bulky or visceral in distribution, that may favor a trial of systemic therapy for palliation.
How do you decide when to test for Legionella in patients with pneumonia, given periodic outbreaks and risk for delayed diagnosis?
Legionella testing is really a question of pretest probability, not a reflex order on every CAP admission, and that distinction matters practically, since the ATS/IDSA 2019 CAP guideline explicitly moves away from routine testing toward a targeted strategy.The clearest indication is severity. Any pa...
What is your preferred first-line treatment for chronic fatigue in patients with long COVID-19?
Assuming that a thorough workup for other causes of fatigue (anemia, thyroid dysfunction, sleep apnea, etc.) has been performed and is negative, no single medication has been proven by a randomized placebo-controlled trial to help chronic fatigue in PASC. Anecdotally, my colleagues who treat PASC ha...
How do you typically manage a patient with a single positive blood culture from two sets growing Candida species in a stable patient without prosthetic devices or material?
Candidemia is defined as the presence of Candida species in the blood, and even a single positive blood culture specimen is considered significant and warrants treatment as candidemia. Initial management should include: Initiating antifungal therapy with an echinochandin (micafungin, capsofungin, o...
How do you decide on the timing and number of blood cultures for suspected endocarditis given the differences in recommendations between the ESC guidelines and the Duke Criteria?
Concern about differences in recommendations regarding specifics of blood culture collection between the two guidelines should be alleviated if one understands that these are guidelines, not dictates. It would help to lay out general principles. First, the focus of infection in infective endocarditi...
How do you manage patients with scleroderma who present with finger ulcerations without other signs of soft tissue infection and MRI demonstrates potential concern for osteomyelitis?
I think this is a tricky situation. Sometimes there is bone damage from acro-osteolysis from the ischemic injury of the scleroderma itself, which can sometimes be difficult to distinguish from osteomyelitis. I would consider watching closely for other signs of deeper infection. You could also consid...
Do you recommend routine neurosyphilis testing in patients being evaluated for dementia?
Syphilis is a rare cause of dementia without other evidence of neurological disease, at least in the US and most other industrialized countries. Of course, a careful neurological examination is required for all dementia patients, but the absence of other manifestations of neurosyphilis makes testing...
Do you usually recommend a modified diet for Clostridioides difficile infection (CDI)?
Post-infection IBS is common after C. diff infection, and some of these patients have dietary intolerances. Other than avoiding foods that exacerbate these symptoms, I do not recommend any particular diet. I also do not recommend probiotics, in keeping with society guidelines.
How do you manage resistant infections that persist after stopping antibiotic therapy in patients with non-CF bronchiectasis?
It depends on what is meant by resistant infections; if this means multi-drug resistant bacteria that remain present after treatment ends and when symptoms have returned to baseline, there are many things to consider. First, has the person had many exacerbations before? Or do they have minimal sympt...