Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
How would you approach the use of JAK inhibitors in a patient with stable RA who is now starting treatment for pulmonary MAC infection?
Unfortunately, I would stop the JAK inhibitors, particularly in the induction antibiotic phase. Maybe treating the MAC may improve the inflammation overall and the arthritis. Once a month or 2 of antibiotics you can consider a trial of restart the JAK and see how the lungs do.
What is your approach to BK hemorrhagic cystitis not responding to cidofovir?
BK hemorrhagic cystitis can range from completely asymptomatic infection (with positive BK viremia and viruria by PCR) or grade 0 to massive macroscopic hematuria requiring instrumentation for clot evacuation and urinary obstruction requiring bilateral nephrostomy tubes for urine diversion (grade 4)...
How do you approach the workup for a patient with persistently elevated inflammatory markers (CRP and ESR) whose history and exam do not point to a clear cause?
Our hematologist/oncologist referred just such a patient. No evidence of malignancy, but elevated CRP &ESR. I did an “internist’s” workup as I would for dermatomyositis, starting with the most important and therefore most thorough aspect: taking a full and very “invasive” history, followed by a comp...
When would you consider percutaneous mechanical aspiration of vegetation in right-sided endocarditis?
Percutaneous options for right-sided endocarditis is a growing field. We have utilized it at our institution with the AngioVac in complex ACHD (Eilers et al., PMID 36448943); others have utilized Inari (Whitbeck and Chambers, PMID 35880845 and Bisleri et al., PMID 33155779). Some have even ventured ...
Do you utilize post-vaccination IgG titers to detect common variable immunodeficiency in patients who are about to start or are actively on B cell depleting therapy?
I have checked M-M-R, Td, and pneumococcal titers in patients with hx of infection and low Ig levels to see if they are making an immunological response. If any of these immune titers are low or the immunization is “due” by routine schedules, I recommend immunization and repeat testing in 6 weeks. T...
What is the optimal timing for Zoster vaccine administration for a patient who recently recovered from herpes zoster infection and is now planning to start B-cell depletion therapy?
This is a complicated question that must balance two competing factors. First, in general, most experts counsel waiting, approximately one year after zoster before vaccination in attempt to take advantage of endogenously boosted immunity and a low rate of recurrence within 12 months. On the other ha...
For patients on PrEP, is there a role for HIV RNA PCR screening in addition to 4th generation antigen/antibody testing?
Absolutely (if possible)! Particularly in the setting of injectable PrEP, the medication can suppress viral replication even if HIV is not prevented. Unusual results can be observed, with either positive viral loads or positive antigen/antibody tests. PCR screening would also give the shortest windo...
Do you use letermovir as CMV prophylaxis in solid organ transplant patients?
Letermovir is now FDA-approved for CMV prophylaxis in high-risk (D+/R-) kidney transplant recipients, and the data in the primary study that led to this approval (Limaye et al., PMID 37279999) is quite convincing that it works well in that population. Outside of this specific indication we have used...
Are there any non-beta-lactam antibiotic options for treatment of neurosyphilis in non-pregnant adults?
Doxycycline is a consideration. There are no conclusive data, but a few anecdotal reports are supportive -- the most recent (in a brief PubMed search) cited below. On the other hand, there is at least one case report (also cited) of a patient treated with doxycycline who subsequently re-presented wi...
How would you approach immunomodulatory treatment for systemic lupus associated protein losing enteropathy (PLE) in a patient whose clinical course has been complicated by significant infection?
Lupus protein-losing enteropathy (LPLE) is a rare manifestation of systemic lupus erythematosus (SLE). Therefore, the medical evidence for the "best treatment" of LPLE is only based on anecdotal reports, case series, and retrospective reviews.Although the easy way out would be to say that a SQ or IV...