Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
How would you manage MRSA and Enterococcus faecalis bacteriuria in a patient presenting in severe heart failure without urinary symptoms, fever, or chills, two negative blood cultures, and whose transthoracic echocardiogram shows no new valvular abnormalities?
The core question here is: are you dealing with asymptomatic bacteriuria or a true infection? In the absence of urinary symptoms and in following the IDSA UTI guidelines, asymptomatic bacteria should not be treated except in specific clinical scenarios - pregnancy, urologic instrumentation, renal tr...
Do you substitute inhaled amikacin for intravenous amikacin in addition to the triple regimen of macrolide + ethambutol + rifampin for cavitary lung disease secondary to Mycobacterium malmoense?
This is a rare organism and I have not had to deal with anyone with this infection so I will approach this question as a general NTM question. Since there is no or very limited data on the use of liposomal amikacin inhalation form for people who are starting NTM treatment, my recommendation would be...
How do you suggest evaluating infection of a chronic wound in patients presenting with sepsis of unclear etiology?
A few lessons/tips I learned as a medical student have stuck with me through the years and would inform my initial evaluation. "How do you hide a $20 bill from an internist? Hide it under a bandage." Heard this the first time as a medical student, and it has stayed with me for 20+ years. A sharp re...
For a renal transplant patient on chronic immunosuppression with resolved esophageal symptoms (epigastric pain and intermittent dysphagia), does the presence of minimal CMV-positive cells on esophageal biopsy warrant preemptive antiviral therapy, or is clinical monitoring sufficient?
All things equal, in the average patient, if a patient has rare/minimal CMV-positive cells, it could occasionally represent a minimal infection or an incidental finding. However, in a transplant patient who is on immunosuppression, and especially one who has had recent symptoms (such as dysphagia in...
How often do you see bony erosions in patients with Lyme arthritis?
There are three ways that Lyme disease can result in joint involvement. The most common is diffuse arthralgias (not a true arthritis) associated with the acute infection. This is self-limited and does not harm the joint. The second is an inflammatory arthritis that is similar to other infected joint...
Do you use an antibiotic with antitoxin activity for the entire duration of therapy for patients with necrotizing MSSA or MRSA pneumonia or just until definitive clinical improvement?
I misread the question. I assumed a necrotizing S. aureus infection meant a necrotizing skin and soft-tissue infection. I’m not sure how “necrotizing pneumonia” is being defined here. Regarding MRSA pneumonia with toxin-mediated tissue injury, there are data suggesting that linezolid may yield bette...
How do you approach a patient who has anterior uveitis and is referred for evaluation of ocular TB with a positive Quantiferon gold (as part of their workup) in countries with low TB incidence?
It is a frustrating problem and is expected to increase without solid evidence. Until then, management should involve an interdisciplinary collaborative approach and a shared decision-making process.I see the following issues. I feel ophthalmologists follow the diagnostic criteria for TB uveitis us...
What do you think about chronic suppressive therapy for HSV-2 in a patient with positive antibodies but no prior clinical outbreak?
The first challenge is often the reliability of the test result. HSV-2 serologies and their interpretation can be challenging. A strongly positive result for HSV2, i.e., an EIA or similar index value well above the minimal cut-off, usually is reliable. Lesser values often are false positives, even t...
How do you approach management for patient's with HIV on ART with persistent low level viremia but no new resistance mutations identified?
The US Department of Health and Human Services describes the different levels of virologic response related to ART[1]: Virologic suppression: A confirmed HIV RNA level below the lower level of detection of available assays. Virologic failure: The inability to achieve or maintain suppression of viral...
Do you continue voriconazole beyond the minimum recommended duration in a patient with invasive pulmonary aspergillosis who is clinically improved but has persistent radiographic abnormalities on CT?
The "recommended" duration is based on expert opinion, rather than trials. The immune status of the patient counts. When I was taught how to treat invasive aspergillosis at the National Cancer Institute (this was before voriconazole was available), the recommendation was to continue treatment until ...