Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
Do you use isavuconazole for treatment of moderate to severe histoplasmosis in patients with co-morbidities, acute or chronic renal failure, or other features that increase the risk of side effects of itraconazole or amphotericin?
No. I would not routinely use isavuconazole as initial therapy for moderate to severe histoplasmosis. For severe disease, liposomal amphotericin B remains the recommended first-line induction treatment, followed by step-down oral therapy, traditionally itraconazole. In patients with renal dysfunctio...
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 ...
What is the optimal therapy for laryngeal candidiasis in pregnancy?
Thirty years ago, I was consulted on a woman in her 30s with candidemia after fetal demise from Candida chorioamnionitis. During the pregnancy, she had been treated several times with clotrimazole for Candida vaginitis. Given that repeated exposure, I guessed that her Candida isolate would be azole-...
Have you used oral carbapenems to treat an outpatient with a complicated UTI caused by an ESBL-producing organism who would otherwise require hospitalization for IV carbapenem therapy, given concerns about community carbapenem stewardship?
To date, the only oral carbapenem that is licensed in the U.S. is tebipenem. I have no experience with this drug and would be very interested in using it when it becomes readily available.
Would you recommend switching from an integrase strand transfer inhibitor-based regimen to a different antiretroviral regimen, or would you instead add weight loss medications for a person with HIV experiencing weight gain that has not improved with lifestyle changes?
The data about weight gain attributable to integrase strand inhibitors is actually a bit controversial. Multiple studies have raised the concern for increased weight gain in patients treated with second-generation INSTIs (ADVANCE, NA-ACCORD), while others indicate more of an impact of tenofovir alaf...
What is your threshold to use nitazoxanide for treatment of cryptosporidium in an immunocompetent patient?
Nitazoxanide can be useful for the treatment of cryptosporidiosis in immunocompetent patients, although the reality is that most healthy people will eventually clear the infection and develop at least partially protective immunity. I would consider treatment if an individual patient were very sympto...
Do you use standard dose or "meningitis dosing" of antibiotics when treating epidural abscesses, in the absence of CNS symptoms?
Not always. While I will use meningitis dosing for initial therapy, I have no qualms about using cefazolin for MSSA (and several recent publications support this), nor using ceftriaxone 2g/d for streptococcal infection. And frequently after the initial 3-4 weeks on IV, I transition to oral doxycycli...
Is arbovirus testing available in your state outside the traditional summer season?
Within our health system, the majority of arbovirus testing is sent to commercial labs instead of to the state lab. This testing is available year round. Notably, there is a high risk for cross-reaction for ELISA serologic testing between viruses within the same genus such as the Orthoflaviviruses. ...
In drawing blood cultures from a central line to evaluate for CLABSI, do you advise drawing separate blood cultures from each port in case of dual or triple lumen line?
You don't need to use the central line to draw those cultures. Using the line to draw blood can in it by itself pose risk of introducing a microorganisms. NHSN CLABSi definition does not call for blood culture to be done from a line.
Are you more likely to use cefazolin over antistaphylococcal penicillins for MSSA bacteremia in light of the recent publication of the SNAP trial?
I had already mostly transitioned to using cefazolin; while I occasionally use oxacillin for CRRT patients, I have found that oxacillin is a very difficult drug for patients to tolerate (in my experience), with AIN happening with relatively alarming frequency considering how infrequently I use it. A...