Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
How do you approach recommending ocular exams for asymptomatic candidemic patients considering the discordance between the IDSA and American Academy of Ophthalmology guidelines?
Endogenous endophthalmitis due to Candida sp. occurs in <1% of patients with candidemia. The IDSA 2016 guidelines for management of candidiasis outline evaluation and treatment of patients with endophthalmitis, with recommendations to perform a dilated ophthalmologic exam on all patients with candid...
How do you consider sending fungal studies in a patient with pneumonia?
This is a very good question. One that I’ve meant to look up for a while, so thank you for prompting me to do so. I agree with Dr. @Dr. First Last's answer (he is also my division chief!), but wanted to expand further. The articles I found most helpful are cited below.When to suspect a fungal pneumo...
Is there a role for dual antibiotic treatment with ethambutol and macrolide only, as opposed to three-drug antibiotic therapy, in the treatment of treatment-naive pulmonary MAC without cavitary disease?
That is a great question, as the role of rifampin (or rifabutin) regarding its relative contribution to the treatment of MAC is not overly clear. Historic data that is a few decades old raised the possibility of better activity when a rifamycin is combined with ethambutol (at least in vitro and furt...
What is the recommended fungal workup in an immunocompromised patient after 5 days of persistent fever?
For any patient with fevers, I focus significantly on any symptoms that a patient might have, like headache, diarrhea, and sinus symptoms, and work up a differential diagnosis based on possible pathogens in this area. If I am not finding anything, I would obtain a CT chest/abd/pelvis, as both invasi...
How do you choose VOWST versus REBYOTA after an antibiotic course for recurrent C. difficile?
Just keep the patient on PO vanco 125 mg BID. That's plenty. Your GI tract would have to contain over 50 liters of fluid to dilute the vancomycin to a concentration below that of the C. difficile. Also, initial treatment should be longer than 10 days. I never understood the studies with a 10-day DOT...
How do you approach patients who continue to experience pruritus and ongoing concern for persistent scabies despite having completed appropriate treatment?
Pruritus can not uncommonly continue in patients for 6 weeks or more after infestation is managed. High-dose antihistamines may be of some benefit. Consider if there is an ongoing untreated exposure that the patient has not thought of or cannot/will not share with you. Not all people infested with s...
Would you recommend anti-fungal treatment for aspergillus infection for a patient with an incidental finding of worsening ground glass opacities and enlarging nodules on CT chest with positive BAL galactomannan, elevated aspergillus IgE and IgG in an otherwise immunocompetent host with no respiratory symptoms?
No, I would not recommend antifungal treatment in this case. The patient, as described, does not seem to have invasive aspergillosis, chronic necrotizing aspergillosis, or allergic bronchopulmonary aspergillosis, so I don't believe antifungal treatment is indicated. There may be other details of the...
What is your threshold to offer trimethoprim-sulfamethoxazole for treatment of cyclosporiasis to an immunocompetent patient?
Most immunocompetent people with cyclosporiasis will clear the infection, and their symptoms will resolve within about a week. If diarrhea persists beyond a week and Cyclospora has been confirmed on testing, I'll treat with antibiotics. Diarrhea is a miserable symptom. If we can safely shorten the c...
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...
Under what circumstances do you consider valacyclovir for the management of VZV disease of the CNS?
If the patient has encephalitis would use IV acyclovir and only transition to high dose valcyclovir (2 g every 8 or every 6 hs depending on weight) after improvement. Although there is PK data to support these high doses, I would not use it initially. Immunosuppressed patients have a higher likeliho...