Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
Which immunosuppressed patients with SLE would benefit from antibiotic prophylaxis to prevent pneumocystis pneumonia?
Starting PCP prophylaxis in patients with lupus is controversial. We typically start lupus patients on PCP prophylaxis if they have underlying ILD and are on doses of steroids of 20 mg or higher. I also consider starting PCP prophylaxis in lupus patients while they are receiving cyclophosphamide and...
Are there particular concerns related to the use of B-cell depletion therapies such as rituximab for rheumatic disease during the COVID-19 pandemic?
The attendant depletion of CD20+ B cells associated with treatment with rituximab likely results in impaired development of host immunity to previously unrecognized microbial pathogens. This has, therefore, been of concern in the context of the Covid-19 pandemic due to potential greater adverse outc...
Are you recommending the mRNA COVID-19 vaccines to your patients with immune mediated inflammatory diseases?
This is THE question at the moment for providers of patients with immune mediated inflammatory diseases. For now, we are merely extrapolating as patients with active IMIDS were censored from trials (Pfizer & Moderna). Organizations like the American College of Rheumatology are moving quickly to clos...
How does a history of splenectomy alter how you counsel patients on the infection risk of TNF inhibitors or other biologics?
In general, a history of splenectomy would lead to an increased concern regarding infections with parasitemia and encapsulated organisms (particularly Strep. pneumoniae, Haemophilus influenzae type b, and Neisseria meningitides). However, I would not consider prior splenectomy an absolute contraindi...
How would you manage an active rheumatoid arthritis patient on suppressive antibiotic therapy for ocular HSV who has abnormal liver function tests?
As an ophthalmologist, I will answer this selectively. The choice of immunomodulation for RA in the setting of liver dysfunction, I would defer to rheumatology (I do know that there are plenty of appropriate options that minimize risk to the liver). As far as the ocular HSV, I have many patients wit...
How would you manage methotrexate therapy in an active rheumatoid arthritis patient undergoing treatment for latent TB with rifampin?
There are no easy answers as both rifampin and INH combined with methotrexate are associated with enhanced hepatotoxicity. Monotherapy regimens, while generally well tolerated can cause hepatotoxicity leading to dose modification/interruption in about 5-10%. All approved regimens can be tried depen...
When are you recommending bone marrow transplant recipients receive the SARS-CoV-2 vaccine?
The CIBMTR and EBMT data indicate a 20-30% mortality in transplant patients. Risk factors are age >50, male, and <12 months from HSCT. Unfortunately, the complexity of immunological recovery after transplant makes inferring the likelihood of response to a new vaccine formulation impossible. In gener...
Is there a role for regular hepatitis and TB screening in patients on chronic immunosuppressive therapy in the absence of new risk factors or exposures?
Unless there has been an interval introduction of new risk factor for TB or hepatitis B, there is no need to screen annually and baseline testing is adequate.
How would you approach chronic isolated severe non-cyclic neutropenia with negative bone marrow and rheumatologic work-up?
My preference would be to use G-CSF at the lowest effective dose, i.e., the dose that maintains the ANC >1000. The risk of inducing leukemia is low in individuals with idiopathic, chronic neutropenia, but it is positively correlated with the G-CSF dose. There are also other side effects like bone pa...
How do you approach the timing of COVID-19 vaccination for patients with multiple sclerosis on B-cell depleting therapies?
B-cell depleting agents can interfere with a patient's ability to develop an adequate humoral response. With regards to the infusions such as rituximab and ocrelizumab, I recommend holding off on getting SARS-CoV2 vaccinations until at least 3 months and up to, at minimum, 2 weeks prior to the next ...