Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
Are there clinical scenarios in which you would start empiric treatment for pulmonary TB without microbiologic confirmation?
Yes, there are a few situations. One of them being pauci-bacillary TB in which you catch TB very early on its course hence your micro/cultures will be negative. CT will demonstrate micronodules. This is a diagnosis of exclusion and requires the right clinical setting (high-risk patient, from an ende...
Would you treat a sputum culture positive for Aspergillus niger despite an atypical CT chest and a negative serum galactomannan in an immunosuppressed patient who is too high risk for bronchoscopy?
How do you apply the CDC PrEP guidelines for cisgender women, particularly when faced with underreported risk behaviors or uncertain partner HIV status?
This can be quite difficult, especially in places like where I live in Texas, where PrEP literacy is low. There is still a lot of education that needs to take place in the community about how HIV is still a threat that you can do something about, particularly for women. On a global basis, getting th...
In which patients do you prefer daily standard three-drug therapy for non-cavitary pulmonary MAC as opposed to three times a week dosing?
Generally, if non-cavitary disease I favor thrice weekly therapy. However, if widespread non cavitary disease or immunosuppressed, I may choose daily dosing.
Do you use oral fosfomycin as a treatment option for uncomplicated cystitis due to ESBL producing E coli?
Fosfomycin is one of the first-line drugs for uncomplicated UTI listed in the Infectious Diseases Society of America (IDSA) UTI treatment guidelines (these guidelines are currently being updated). It is the only single-dose drug approved for UTI and is an effective option. It does have activity agai...
When treating pancreatic body/tail lesions that result in significant dose spread to the spleen, what is your threshold to offer pneumococcal, hemophilus influenza, and meningococcal vaccines?
A really great question, and one that we don’t necessarily have a lot of data for guidance. There are some guidelines out there, though, that I think can be helpful to consider. The first is the recent guideline from ASCO on the vaccination of adults with cancer (Kamboj et al., PMID 38498792). In li...
Do you recommend routine use of Evusheld for pre-exposure prophylaxis for patients on immunosuppression?
The use of monoclonal antibodies as passive immunity for pre-exposure prophylaxis is an exciting development for vulnerable patients, including immunosuppressed patients (either primary or through medications such as for autoimmune diseases), cancer patients, and organ transplant recipients. Evushel...
For how long do you recommend treatment for latent tuberculosis prior to initiation of anti-TNF therapy?
Some recommendations call for completing a course of treatment for latent TB prior to starting a biologic but I find most patients and referring specialists are intolerant of that strategy. This reference: Yeo et al., European Respiratory Journal 2014 is a good example of data supporting a shorter w...
How do you approach the evaluation of patients referred for chronic lyme disease and counsel patients regarding this entity?
"Chronic Lyme disease" is a term that needs careful definition before one can accurately evaluate and treat a patient. Is this chronic symptomatology with physical findings in a patient who actually had documented infection with B. burgdorferi in the past? Or are there no objective findings, no phys...
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.