Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
What isolation policies are Rheumatology offices employing for both staff and patients diagnosed with COVID-19 given the new CDC guidelines?
Still the same: masking in all settings.
What is the risk of serious bacterial infection in a febrile solid tumor patient who has not yet started cancer-directed therapy and has normal cell counts with no central line?
This depends on the type of the tumor, the location, and the individual circumstances. It may not be wrong in this scenario to draw blood cultures and give a dose of ceftriaxone pending 24-hour results, but this practice may also vary based on these different variables e.g. RMS of paranasal-ear area...
For how long do you treat uncomplicated CRE bacteremia in an immunocompetent patient?
Assuming rapid resolution of the systemic inflammatory response, I generally recommend 7 days of antibiotic administration – and I am not aware of data that this should be prolonged when the pathogen is a CRE. One of the studies listed below [Soto et al] addresses CRE bacteremia and the duration of ...
In patients taking biologics who are planning joint replacement and are known MRSA carriers do you perform decolonization prior to surgery?
When should vaccines be given if not received prior to the start of high dose radiation (40-50 Gy) to the spleen?
Mortality due to infections is increased in asplenic individuals as well as those receiving radiation therapy to the spleen. The risk is low but measurable. For example, in a large Childhood Cancer Survivor Study, the cumulative incidence (35 years) after splenectomy of late infection-related mortal...
In patients with HTLV-1 associated acute T-cell leukemia, is there any clear benefit of adding antivirals?
There is no virologic rationale for using antivirals to treat HTLV-1-associated malignancies. HTLV-1 is a "transforming" retrovirus that directly causes cancer by oncogene expression. There is no significant "lytic" replication occurring once the cancer has manifested. Antiretrovirals only work with...
Do you consider anti-viral prophylaxis in patients taking JAK inhibitors who have recurrent uncomplicated Zoster infection, but would prefer not changing therapy?
This is a really good question without a clear answer. Patients on JAK inhibitors are not only at increased risk for VZV but also for recurrence. Data from Kevin Winthrop and colleagues examining the tofacitinib database revealed that patients with RA and PSA are at 10 to 20 times increased risk for...
How do you manage patients who are Hepatitis B core antibody positive/surface antigen negative and starting a biologic DMARD (other than rituximab)?
According to the 2015 American College of Rheumatology Guidelines, a patient with natural immunity to Hepatitis B (Core & Surface Antibody-positive; Antigen-negative, normal liver function tests) can be treated as any other patient. However, monitoring of viral load is recommended "regularly" at 6-1...
In what situations do you check for HIV status in your workup for inflammatory arthritis?
This brings up a great point - HIV screening is recommended for all patients at least once, and more frequently if the patient has risk factors for HIV. Seeing a patient in the clinic is a great opportunity to ensure they have been screened appropriately for HIV. In rheumatic disease situations, HIV...
Do you avoid any specific biologic therapies in HIV positive patients?
At present, the most safety data on the use of biologics in HIV is TNF inhibitors. CD4 count should be > 200 and VL undetectable. Etanercept is most preferable, give lower incidence of serious infections as well as its efficacy as monotherapy (without methotrexate). Wangsiricharoen et al., PMID 2733...