Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
In a patient with negative Hep B surface Ag, Hep B surface antibody+, and Hep B core antibody+ serologies, do you initiate antiviral prophylaxis (e.g. entecavir) prior to starting rituximab?
I would use entecavir for Hep B reactivation prophylaxis in this case - based on recommendations from AGA 2025 guidelines, which does classify b-cell depleting agents as higher risk for reactivation for both Hep B surface Ag-positive and Hep B surface Antigen neg/core positive patients. It should be...
What is your preferred oral regime with duration for treatment of onychomycosis?
My new favorite regimen is: terbinafine 500 mg once daily for one week, then take 3 weeks off. Repeat for 4, once weekly cycles. Sprenger et al., PMID 31487828
What is your approach to a situation where DILI is suspected secondary to an important medication (e.g., anticoagulation, antibiotics, etc.), but the diagnosis is uncertain and the liver injury is relatively mild?
If the drug suspected to induce liver injury causes symptoms and ALT is >3 times the upper limit of normal (ULN), I would stop the drug and find an alternative. Even if no symptoms are present, I would stop if ALT is >5 times ULN. Any level increase of ALT below the above parameters would still requ...
How do you dose daptomycin for treatment of discitis?
Daptomycin is indicated for skin and skin structure infections as well as right-sided infective endocarditis. With limited other options, it is used beyond that frequently, but the data is with those 2 infections, specifically. Vancomycin was approved during a day of vague approvals - "MRSA infectio...
How would you manage an elderly patient with a periprosthetic knee infection secondary to mycobacterium chelonae who is a poor surgical candidate for removal of hardware?
The answer has to be nuanced. How was the culture obtained? Just an aspiration, or was it from an open debridement procedure? How well was that procedure tolerated? Was this a DAIR procedure? Is there a sinus tract? Are there systemic symptoms? Any other pathogens in culture? You can try treating th...
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...
In what scenarios do you find trending beta-D-glucan helpful?
Like all biomarkers, β-D-glucan (BDG) has both strengths and limitations. It is best used as supportive evidence when an invasive fungal infection is suspected rather than as a standalone diagnostic test. While relatively nonspecific, BDG has a high negative predictive value for many invasive fungal...
How has your approach to managing asymptomatic bacteriuria in kidney transplant patients changed in light of a recent meta-analysis showing no significant differences in pyelonephritis, symptomatic UTI, or graft loss between patients treated with antibiotics and those who were not treated?
The referenced meta-analysis has not dramatically impacted my approach to asymptomatic bacteriuria (ASB) in kidney transplant recipients (KTRs). The included trials clearly show no benefit (and possible harm) in treating ASB at time periods >2 months post-transplant. So we do not screen and we do no...
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...
How do you approach use of Doxy PEP in a patient taking isotretinoin, as both drugs are (rarely) associated with pseudotumor cerebri, which is very uncommon in clinical practice?
Pseudotumor cerebri (IIH) is a devastating problem. I have seen a number of cases, usually neurosurgical shunt infections, over the years. These patients often have persistent headaches and may require VP shunting over and over again. Since doxy is sometime implicated in IIH (and has other side effe...