Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
How long do you continue antibiotics after cholecystostomy tube placement for acute cholecystitis?
The solution to questions regarding treatment duration invariably falls under the category of "it depends." For individuals with severe illnesses, particularly those with bacteremia, an extended treatment period ranging from 7-14 days might be needed. Conversely, for patients who show significant im...
Is there any role for prophylactic bronchial artery embolization in immunocompromised patients with invasive pulmonary aspergillosis?
Bronchial artery embolization is NOT without complications. Although the bleeding risk is very high in invasive pulmonary aspergillosis, empirical embolization is not well supported either by data or clinical practice. It probably should be a case-by-case decision.
Is there a risk of hepatitis C activation with rituximab in a patient who has a history of HCV treated with antivirals and who is in sustained viral response?
In general, the risk of HCV flare with immunosuppression in general including rituximab must be viewed as minimal for those who have achieved a sustained virologic response (Undetectable HCV RNA ≥12 weeks after treatment completion) and does not influence my therapeutic decision-making if the patien...
Do you routinely offer fungal prophylaxis for patients on BTK inhibitors?
We do not use antifungal prophylaxis for patients on BTK inhibitors. The risk of invasive fungal infection in patients treated with BTK inhibitors in recent large single institutional series have been 2 to 3%, without routine antifungal prophylaxis. The risk of fungal infection increases in patients...
How long do you continue surveillance with imaging and sputum cultures in a patient with NTM with no indications for treatment?
Since NTM lung disease typically develops over years, it is reasonable to monitor the patient with periodic HRCTs, even if the patient is relatively asymptomatic. I typically do this every 12 months in an otherwise stable patient. The reason for this is because we know that in up to 2/3 of patients,...
Would you recommend imaging of the brain and lungs to investigate potential disseminated disease in a recent heart transplant patient with a skin nodule that grew Rhizopus?
Yes. For any immune-compromised individual with Mucor on the skin or another organ, I look at the brain and the lungs.
For how long would you treat a patient with dematiaceous fungi growing on a native heart valve discovered at the time of valve replacement?
The first step is to determine whether the positive culture may be a contaminant, as it very well could be. Every valve sent for culture should have also been sent for histopathological examination. In a patient with fungal endocarditis, one should expect to find evidence of acute inflammation and t...
Do you manage antibacterials for enterococcal bacteremia differently in patients with severe immunosuppression?
No.
Which biomarkers or diagnostic tools do you prioritize to support the decision to start antifungal treatment in septic patients with no clear source of infection but at high risk for fungal infections?
In general terms we do not use biomarkers to decide to start antifungals in a septic patient. We use them to confirm or rule out the infection once the antifungals were started based on clinical suspicion/presentation. BDG in particular has very good negative predictive value for candidemia, but due...
How have the results of the BALANCE trial, which demonstrated the noninferiority of 7 days of antibiotics compared to 14 days for non-S. aureus bloodstream infections, influenced your practice?
Although one trial does not make a standard of care, we have been aware of this publication and have “kicked around” the possibility of instituting such a short course. Not ready to adopt this (yet), but we have chosen to transition from IV to oral therapy earlier and earlier. Not quite the same iss...