Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
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...
Do you treat subarachnoid neurocysticercosis with albendazole alone, or with the addition of praziquantel?
There are no controlled clinical trials for the treatment of subarachnoid neurocysticercosis. That leaves the question of one drug or two and the proper duration open. Since this is a potentially very bad disease, and both albendazole and praziquantel are generally well tolerated, I generally start ...
Do you routinely refer all patients with cutaneous leishmaniasis with a species associated with mucocutaneous leishmaniasis to ENT for comprehensive nasal/oropharyngeal evaluation, or do you refer only if mucocutaneous involvement is suspected based on careful clinical assessment and/or bedside exam?
Yes. Mucocutaneous leishmaniasis-associated Leishmania/Viannia species can involve any part of the oropharynx. This is often difficult to identify and often requires molecular testing. If molecular or culture testing of a skin lesion shows a Viannia species I would also do an oral exam via ENT. If t...
Does your institution have formal policies or work flows to reduce unnecessary IGRAs ordered for patients on biologics?
We have developed a multi-specialty working group to implement this as a lot of unnecessary testing is getting done. This will include having a 2-3 question screening pre start of biologics, and then annually to asses risk, that we hope will be incorporated into the visit or an order set.