Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
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.
Do you recommend lifelong antibiotic prophylaxis, or do you prefer a more selective approach based on risk factors in asplenic patients without a history of severe infections?
The advice is limited by the fact that there are no randomized controlled trials in adults on daily antibiotic prophylaxis post-splenectomy. There are trials in children with sickle-cell disease that do show a benefit, but it is not clear that these can be extrapolated to splenectomized adults. Furt...
For which patients could you consider direct oral amoxicillin challenge as opposed to skin testing for penicillin allergy de-labeling?
If a patient can be identified as low-risk by history they should be considered for either historical removal of the label of direct oral challenge. If the history is not compatible with allergy (e.g. they have a family history or have tolerated another drug like Augmentin), historical de-labeling i...
Do you use combination antibiotic therapy for treatment of bacterial endocarditis due to gram-negative bacilli?
The approach towards different might differ depending on whether the culprit organism belongs to the HACEK group or the nonHACEK group. The mortality rates per literature were approximately 2% for HACEK and 20-30% for the nonHACEK group. Combination therapy is usually not recommended for HACEK endoc...