Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
Do you still recommend adjunctive corticosteroids for tuberculous meningitis in light of more recent data showing heterogeneity in clinical outcomes?
Though there is some disagreement in study results, a number of randomized trials and one meta-analysis support the benefit of mortality when steroids are used as adjunctive therapy for tuberculous meningitis. The use of steroids continues to be the recommendation of the WHO. In most situations, the...
What is your approach to work up and management of a patient with advanced HIV and poor adherence to therapy presenting with dysphagia and fever?
I would first do an HPI (is the dysphagia for both liquids and solids?), then a quick physical exam, with a full set of vital signs. In terms of basic blood work, I would get a CBC and BMP, liver function tests, a set of blood cultures, a chest x-ray, along with a viral load and CD4 T cell count, wh...
Do you still use itraconazole for Aspergillus prophylaxis in heart transplant recipients, or have you transitioned exclusively to posaconazole?
We haven't used itraconazole for Aspergillus prophylaxis in heart transplant at my institution since I have been an attending (2021).
Do you recommend doxycycline over azithromycin as first-line treatment for outpatient community-acquired pneumonia in otherwise healthy adults, given rising macrolide resistance rates?
Yes - our county antibiogram shows >50% resistance of Streptococcus pneumoniae to azithromycin, and thus if there is a true concern for bacterial infection, I recommend doxycycline.
For hospitalized patients with confirmed viral respiratory infections who clinically improve but remain PCR-positive, how long do you maintain isolation precautions?
This is a great question and one that routinely comes up for patients, their families, and staff. Precautions should be continued until symptoms improve and for a minimum of 14 days after the onset of signs and symptoms. This is especially important for patients who can spread virus to individuals t...
Have you used Karius to work up fevers in the hospital when the source remains unknown?
This is a tricky question because Karius is an expensive test, which many experts believe should not be used for its negative predictive value (and I have anecdotally seen negative results where infection was still present, and infections/organisms detected of very unclear significance). I like to u...
Do you recommend treating Candida albicans on urine culture from an indwelling catheter in a patient with septic shock?
In a patient with septic shock, one is typically obligated to treat all things until further culture data is back, etc. If there are other clear causes of shock, I would not treat the candida (though I would try to change the catheter ASAP). If the patient is extremely ill and no other sources of in...
In what circumstances would you consider monotherapy for empiric treatment of unresectable nontuberculous mycobacterial lymphadenitis?
NTM lymphadenitis is rather uncommon, and I personally have little experience with it and did not see it much even at NJH. However, extrapolating from how I treat any NTM disease in general, I would shy away from monotherapy in any NTM disease, preferring at least two active agents. Perhaps one scen...
How long do you continue empiric anaerobic coverage for brain abscesses originating from sinus or tooth infection following surgical drainage?
Since anaerobes can be difficult to culture and are certainly associated with this type of infection, I would recommend continuing anaerobic coverage along with targeted therapy for any positive cultures. Anaerobic pathogens are often seen in conjunction with other pathogens. In a study looking at 3...
When do you consider adding steroids alongside intravenous antibiotics for patients with orbital cellulitis?
If the orbital cellulitis is infectious, I never add steroids. There is no literature or proof that they do anything, and decreasing immunity, in my opinion, is simply a bad idea. If it is inflammatory, then absolutely. Most infectious orbital cellulitis is from the sinuses and is more common in chi...