Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
Do you consider holding PPIs in patients hospitalized with infections like pneumonia or C. diff colitis?
My practice is to try to get patients off PPIs if at all possible, and the hospital can be a good time to have that conversation with them. This is assuming no active indication for them (recent ulcer/upper GI bleed, H.pylori therapy, etc.) Use of PPIs has been associated with a higher incidence of ...
How do you decide whether to empirically cover Pseudomonas for pneumonia in hospitalized patients?
The decision to empirically cover Pseudomonas aeruginosa in pneumonia among hospitalized patients depends on the pneumonia type (community-acquired pneumonia, CAP vs. hospital-acquired pneumonia, HAP), disease severity, etiology, and specific risk factors. For Community-Acquired Pneumonia (CAP) Pa...
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?
I do not use doxycycline in almost all circumstances if a patient is on isotretinoin. That would certainly include using it as post-exposure prophylaxis (PEP). An exception to this combination would be treating a life-threatening disease such as Rocky Mountain spotted fever. Of course, a health care...
Do you routinely discontinue atypical coverage in community-acquired pneumonia when PCR testing (i.e., respiratory pathogen panel) is negative for atypical organisms?
In community-acquired pneumonia (CAP), here is how I approach the decision to discontinue atypical coverage (e.g., azithromycin or doxycycline) when respiratory pathogen panel PCR testing is negative for atypical organisms (most commonly, Mycoplasma pneumoniae, Chlamydia pneumoniae, Legionella pneum...
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...
Do you recommend prescribing Pneumocystis jiroveci pneumonia (PJP) prophylaxis for a patient with membranous glomerulonephritis on rituximab?
In general, I don't use Pneumocystis jirovecii pneumonia prophylaxis (PJP PPx) for patients with membranous nephropathy (MN) who have only received rituximab (RTX), unless they have also received high-dose glucocorticoids (GC) or cyclophosphamide (CYC). I usually give PJP PPx when patients receive h...
Would you start treatment for MAC in a patient with nodular bronchiectatic disease who has demonstrated radiographic progression but remains asymptomatic and smear-negative?
My default answer would be yes; this is a sign of progressive disease that will get worse without treatment. Having said that many things could be considered while making the decision, including patient preferences. First is there another cause? Does the patient have an exacerbation of bronchiectasi...
Do you recommend to exchange nephrostomy tubes when a patient is diagnosed with a urinary tract infection in the absence of any overt signs of infection at the exit site?
This patient has asymptomatic bacteriuria by definition - apparently with occasional symptomatic UTI. I would not change the tube because of the ASB like I would not change a urethral catheter in the setting of ASB. And as noted the patient has already demonstrated continued ASB after changing the t...
What approaches can we take to initiate therapy and improve survival rates in patients with HLH?
At our institution, we have comprised a multidisciplinary team to help treat these patients. The team or "HLH task force" as we like to call ourselves is comprised of a clinical immunologist, rheumatologist, dermatologist, critical care physician, hepatologist, BMT attending/hematologist, infectious...
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...