Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
How do you use CD4% in clinical practice in management of patients living with HIV?
Perhaps a slightly different perspective: The CD4 percentage is invaluable in specific scenarios. Since the absolute CD4 count depends on the total WBC count and the lymphocyte percentage, the CD4 count can vary widely based on context, while the CD4 percentage is typically the more stable and relia...
What additional treatment strategies would you recommend for a patient with a Mycobacterium chelonae and Mycobacterium abscessus infection following bilateral prophylactic mastectomies and implant insertion, who has undergone multiple surgeries and an extended course of IV antibiotics selected based on sensitivities?
I assume the implants have been removed. I have had no success trying to treat with retention of the implants (because the patients all want a trial of antibiotics first at the suggestion of the surgeon). If the implants are out, all you can do is continue long courses of antibiotics based on sensit...
What is your approach to vaccinations and titers for patients with myeloma, who are immunosuppressed and do not have appropriate antibody responses to vaccines?
It depends on the vaccine and prior immunization history. Not all vaccines require an antibody response to be at least partially efficacious. In addition, with any immunocompromised host, reduced effectiveness for all vaccines is expected, but is not a reason to not vaccinate. Serologic testing is h...
Have you incorporated the use of linezolid in lieu of vancomycin plus clindamycin for empiric treatment of necrotizing fasciitis?
Clindamycin (with beta-lactam) vs linezolid use debate exists for severe invasive GAS infections like necrotizing fasciitis cases. Both inhibit protein synthesis via the 50s ribosome subunit, inhibiting translation and, thus, toxin production. The concern is rising clindamycin resistance in GAS isol...
How do you approach restarting cDMARDS/bDMARDS in a patient with active RA after incidence of disseminated CNS VZV infection while on tofacitinib?
This is a complex problem for which any response clearly is not data-driven. Disseminated VZV is a profound illness and is linked to JAKi exposure. While the majority of VZV is 'mild' all complications are increased in this setting and dissemination is among the most serious and potentially fatal co...
Is it ever safe to use a biologic DMARD in a patient with RA who is on suppressive antibiotics due to a history of septic prosthetic arthritis?
I have used Orencia and HCQ as more immunomodulating with suppressive M/W/F antibiotics in a patient with UTI/Bactrim.
Are there instances when you do not recommend tunneled dialysis catheter exchange in patients on hemodialysis who are found to have bacteremia?
Generally, the answer is no. The only situation I would not recommend tunneled catheter exchange is if the patient has "run out" of catheter insertion sites and removal of the catheter poses the risk of not being able to place another tunneled catheter. That is also tempered by the organism causing ...
How do you approach biologic initiation in patients with inflammatory arthritis and repeatedly indeterminate Quantiferon?
This is an unusual but anxiety-inducing situation. Remember that an "indeterminate" Quantiferon is not an "intermediate" Quantiferon. It's not half-positive, it's uninterpretable. The result provides absolutely no reason to be more or less concerned that the patient has lTB, latent or otherwise. I a...
What patient-specific factors would influence your decision to initiate semaglutide therapy in patients with HIV-associated lipohypertrophy?
I would consider it if the patient had diabetes. But there is not much data on this question.
What is your approach to the use of Paxlovid for patients with risk factors for severe Covid-19 infection but who have received SARS-CoV-2 vaccines in light of the EPIC-SR trial findings?
Although EPIC-SR Trial may not have shown a significant benefit of paxlovid in standard-risk patients regardless of vaccination status, EPIC HR and real-world evidence have shown benefits in high-risk populations. Shared decision-making with the patient is always the best policy.Disclosure: I have r...