Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
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?
Not a lot of data to guide this, but for nontuberculous mycobacterial (NTM) prosthetic joint infections (PJIs), I would ensure the surgeons do a thorough incision and drainage (I&D) and washout, even if they cannot remove the hardware, followed by an intensive regimen of 3 to 4 active antimycobacter...
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...
How do you evaluate for an ascending UTI in a patient with a urostomy?
Evaluating for ascending UTI in a patient with a urostomy UA Generally low value; chronic pyuria/mucus makes results unreliable. Urine culture Essential; must be collected from a clean stoma catheterization or a fresh pouch, and not from the urostomy bag. Imaging (CT abdomen and pelvis wit...
How do you counsel patients and doctors on antibiotic avoidance in myasthenia gravis?
I generally recommend avoiding aminoglycosides and most macrolides in MG. The rationale is that there are alternative effective antibiotics for most of the infections covered by the above categories. With fluoroquinolones, however, it's not that simple, because there are some infections that are uni...
Do you offer antibiotic therapy for patients with a chronic joint infection, with no plans for surgery, and with an open draining sinus tract?
This is a complex question that requires a nuanced answer. I am assuming this is a periprosthetic joint infection. If so, why is there no plan for surgical intervention—is this because the patient’s care is comfort-focused? How old is the patient? What is the microbial etiology, and is it even amena...
What are your vaccine recommendations while patients are on biologics?
Live vaccines are best completed at least a month before initiation of biologics when these are appropriate (e.g., MMR, chickenpox, yellow fever). The data on non-live vaccines is limited. I personally think that some degree of protection is better than none. I will not interrupt biological therapy ...