Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
Have you incorporated the use of steroids for patients with severe community-acquired pneumonia?
Yes, the evidence is pointing toward starting steroids (hydrocortisone at 200mg total daily dose) early (in the first 24 hours) in patients with severe CAP who do NOT have influenza. In septic shock caused by CAP, steroid recs follow the septic shock guidelines. Dequin et al., PMID 36942789 showed t...
Do you consider late latent syphilis adequately treated if a patient receives a 10-14 day course of IV ceftriaxone for another indication?
This is a great question and not uncommon scenario. First, I would emphasize the importance of accurately staging the patient as 'late latent' and be sure there are no current signs or symptoms concerning for neurosyphilis, ocular, or otic (even before the IV CTX was given). Having said that, the bo...
What infectious prophylaxis do you use for patients with newly diagnosed multiple myeloma?
Excellent question for sure. In order of controversial nature/lack of evidence/lack of consensus around evidence: 1) Antiviral prophylaxis - I don't think there's any controversy around this, particularly in patients on PIs and/or a CD38 mAb. We do use acyclovir even in patients who have received th...
What is your approach to antimicrobial prophylaxis in adult patients undergoing treatment for HLH?
We often use bactrim for pneumocystis prophylaxis if high dose steroids are used and discuss the use of possible fluconazole for antifungal prophylaxis on a case by case basis. However, we do not have a specific protocol for these patients.
How would you manage persistent Norovirus diarrheal infections in a kidney transplant patient that are not responding to a decrease in the patient’s maintenance immunosuppressive regimen?
This is a difficult situation and does not have a strong evidence based response. First, I would really make sure they are not on mycophenolate as this is really the main problem with chronic Norovirus for most patients. Next, I would see if there are any available clinical trials that the patient m...
How would you manage a patient with Crohn's disease on a biologic and presents with non-bloody diarrhea, normal-appearing mucosa on sigmoidoscopy but severe colitis on biopsy with a positive CMV stain?
A few key pieces of information help distinguish CMV colitis from other competing diagnoses in this frequently encountered conundrum. An experienced pathologist will usually be able to tell you: If the CMV immunohistochemistry stain has good controls and whether it is floridly positive or scant. Al...
How do you factor cerebrospinal fluid (CSF) antibody results when deciding on the diagnosis and treatment of racemose neurocysticercosis, given the uncertainties associated with CSF antibody testing?
Antibody testing using an enzyme-linked immunoelectrotransfer blot (EITB) is an excellent test. It actually performs better when done on serum than CSF. Therefore, I do not do it on the CSF. The sensitivity of serum is close to 100%. This is available through the CDC and some commercial laboratories...
What is the preferred antibiotic treatment regimen for vancomycin-resistant Enterococcus faecium endocarditis assuming susceptibility to both daptomycin and linezolid?
I would use dapto+ceftaroline or +ampicillin. Linezolid lacks cidal activity so less attractive for that reason.
How often do you see bony erosions in patients with Lyme arthritis?
There are three ways that Lyme disease can result in joint involvement. The most common is diffuse arthralgias (not a true arthritis) associated with the acute infection. This is self-limited and does not harm the joint. The second is an inflammatory arthritis that is similar to other infected joint...
What is your approach to counseling patients regarding re-initiation of anti-TNF therapy after completion of treatment for non-disseminated pulmonary histoplasmosis?
We published a retrospective study on this topic in 2015 (Vergidis et al., PMID 25870331). We concluded that resumption of TNF-alpha antagonist therapy may be considered in individuals treated for histoplasmosis who have no evidence of residual disease and undetectable Histoplasma antigen levels. We...