Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
What steps do you recommend to ensure continued viral suppression and prevent drug resistance in an HIV patient on injectable cabotegravir and rilpivirine who misses their scheduled injection appointment by two weeks?
When the patient returns to clinic, I would check an HIV VL and CD4 count and simply restart the same ART (cabaneuva). If the VL comes back high then resistance testing should be performed and the ART can be adjusted.
Is history of GBS a contraindication for all future flu vaccines?
In my opinion, the answer is no. Numerous studies have been published about this topic. Based on a recent review (see below): The additional risk for GBS attributed to influenza vaccination is 1-2 cases per million of vaccinated individuals. The risk of GBS following influenza INFECTION is several o...
Would you transition from IV to oral antibiotics in a solid organ transplant recipient with uncomplicated gram-negative bacteremia?
Yes, I would in the right circumstances. The referenced article by Nussbaum et al., PMID 38195100 provides reasonable evidence that this is a valid approach. Particularly, if the patient's net-state-of-immunosuppression is not terribly high and the organism is susceptible to highly bioavailable oral...
Do you have a preference between Quantiferon Gold and T-spot TB for screening in patients starting immunosuppressive agents?
TSpot testing has better performance than Quantiferon Gold in patients with low lymphocyte levels, and/or on glucocorticoids (especially moderate to high doses). This is partially related to the way the essay is performed, and as such the Tspot is much less likely to result in an indeterminate or fa...
Do you give additional pneumococcal vaccines after a dose of PCV20 in patients with asplenia?
Assuming the patient otherwise does not have immunocompromising conditions other than asplenia, following age-appropriate vaccine schedules is appropriate. A dose of PCV20 appears to provide adequate protection. However, ongoing surveillance studies will be important to answer this question, and vac...
Have you applied the POET trial to clinical practice?
I do transition to oral therapy after clinical stability, resolution of systemic inflammatory response and blood culture negativity have been achieved. I have long operated on the principle that it doesn’t matter how (IV or oral administration) the antibiotic gets into the bloodstream as long as it ...
Given recent data for use of doxycycline as post-exposure STD prophylaxis, how have you applied its use in clinical practice?
Doxycycline as POST-exposure prophylaxis for bacterial STI prevention is the hottest thing in STI prevention. It's good at preventing syphilis and chlamydia (approximately 80%) and okay at preventing gonorrhea (approximately 50% depending on background resistance). Here is the landmark study:Luetkem...
What else do you consider in the differential diagnosis for pulmonary-renal syndromes if there is low clinical and serologic evidence of AAV, Goodpasture's or other rheumatologic disease (SLE, RA, APS, Scleroderma)?
Endocarditis can mimic vasculitis and can have pulmonary hemorrhage. You CANNOT miss that one. Sarcoidosis is I suppose a pulmonary renal syndrome. Renal vein thrombosis from MGN with a pulmonary embolus is I suppose a pulmonary-renal syndrome.
How have you adjusted your practice for treatment of syphilis in light of the penicillin G benzathine shortage?
Theoretically, there should be an ample supply of penicillin G benzathine. Per the CDC: "June 10, 2024: Pfizer noted that they currently have an available supply of 2.4 million Units/4 milliliter Bicillin." https://www.cdc.gov/std/treatment/drug-notices.htm If by chance for whatever reason there is ...
After a course of treatment for neurosyphilis, do you administer an additional IM dose of penicillin G one week after finishing the course of IV penicillin therapy?
Excellent question. This has been the topic of a never-ending (if somewhat behind-the-scenes) debate among syphilis experts for decades. In fact, it came up for discussion just a few days ago after a presentation on syphilis at IDWeek in Boston, the Infectious Disease Society of America's annual con...