Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
How do you approach treatment of RA with methotrexate in a patient with treated Hepatitis C and normal liver function?
Active hepatitis C infection can be present in the setting of normal liver function tests. So, I always check for the viral load, especially if the hep C treatment was done more than a few years ago. Here, the old alpha interferon-based treatments achieved a cure rate no better than 30%. The newer a...
For which pediatric oncology patients do you start bacterial prophylaxis, inpatient or outpatient, and what is your antibiotic of choice?
Bacterial prophylaxis in pediatric oncology patients should be guided by the intensity of treatment, depth and duration of neutropenia, and individualized risk for invasive infection. Current evidence and expert consensus support targeted prophylaxis in children with the highest risk of life-threate...
How do you approach DMARD therapy in patients with rheumatoid arthritis and chronic hepatitis B?
Patients with hepatitis B core positivity, surface antigen positivity, and positive PCR for viral DNA, should be treated with entecavir prior to starting any DMARD. Given the DNA PCR is positive too, that indicates active viral replication and they may need treatment for a while before starting anyt...
When do you consider repeating CSF studies in a patient with suspected viral encephalitis but overall initially unrevealing CSF?
Definitely not an expert on this topic, but this situation does come up, particularly for HSV encephalitis! One question worth asking your lab is what kind of assay are they using to run this test. If it's a dedicated HSV PCR assay (e.g., Simplexa), then the sensitivity is going to be quite robust, ...
How do you approach ongoing screening for TB in patients with a history of treated latent TB, but who have ongoing use of DMARDs and/or biologics given Quantiferon testing and PPD can remain positive?
Interferon-release assays (such as Quantiferon) and PPD testing do not discriminate between infection, reinfection, and prior infection with TB. However, in most developed countries, the likelihood that a patient who has once been treated for LTBI becomes reinfected and develops LTBI again is low, i...
Is the combination of a negative BAL PJP PCR and normal fungitell enough to rule out PJP pneumonia in an at-risk non-HIV patient?
Yes
For how long do you treat an early spinal hardware infection secondary to MSSA after operative washout and retention of hardware?
This infection is a key research interest of mine and one I'm deeply passionate about. I typically treat with a 12-week induction regimen, preferably using antibiofilm-active agents—an approach adapted from the DATIPO trial for prosthetic joint infections (PJI). I generally do not recommend routine ...
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...