Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
Do you routinely recommend D-mannose or probiotics for patients with recurrent urinary tract infections?
I would like to add that estrogen is very helpful for postmenopausal women with recurrent UTIs-- and is underprescribed for this use. Data seems to be strongest for vaginal estrogen, but see for example, Tan-Kim et al., PMID 37178856 and Rosenblum, PMID 33927578.
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...
How do you approach a patient on anti-TNF with positive Quantiferon (previously negative) with negative chest x-ray and no symptoms?
Prior to routine screening for latent TB for patients receiving or about to receive TNF inhibitor therapy, there were reports of miliary TB developing after initiation of TNF inhibitors. Therefore, one cannot say that a negative chest x-ray and no symptoms means the patient is not at risk for develo...
When would you consider checking JC virus prior to initiating biologic therapy?
JC is a ubiquitous virus with sero-prevalence in the adult population of 60-70% in most studies. The concern is that in those who harbor latent JC are vulnerable to reactivation and ultimately the development of Progressive Multifocal Leukoencephalopathy (PML). The drug natalizumab used to treat MS ...
What is your preferred third antimicrobial agent for a patient with treatment-naive pulmonary MAC without cavitary disease and strict contraindications to utilization of rifampin or rifabutin?
There’s no clear winner yet. Inhaled liposomal amikacin solution has good potential and the data is trending this way with earlier clearance shown but the long-term outcomes, I believe are still pending. I’m relatively unconvinced or underwhelmed by moxi but as a third drug in the seemingly rare occ...
What is your approach to empiric treatment of achromobacter infections?
Achromobacter is a Gram-negative bacterium in the Burkholderia order. This pathogen is significant in immunocompromised patients, such as those with cancer or Cystic fibrosis, and is seen with bacteremia or causing pneumonia. They can also be associated with foreign device infections. Typically, the...
How many total days of antibiotics do you prescribe for uncomplicated non-purulent cellulitis in hospitalized patients who show clear clinical improvement within 48–72 hours?
Thanks for the question. Five days total, with transition to oral antibiotics upon clinical improvement to complete this course. Notably, my health system (via our EMR-based clinical decision support tool) recommends penicillin (IV) or amoxicillin (PO) as first-line treatment for nonpurulent celluli...
Do you routinely obtain a TEE or vascular imaging in a patient with non-typhoid salmonella bacteremia without persistent bacteremia?
No. Salmonella bacteremia is quite common, and endocarditis due to gram-negative bacillary bacteremia is extremely rare. If the patient has continuous bacteremia following treatment, both echocardiogram and vascular imaging would be appropriate.
How would you manage and determine the duration of antibiotics for a patient with suspected chronic postoperative spinal implant infection, status post lumbar fusion, now presenting with loosened hardware on imaging, normal inflammatory markers, and no systemic infection symptoms?
Loosening can be identified as lucency around pedicle screws on standard radiography, commonly at the upper or lower ends of the surgical construct. It was graded on a scale of 0-3. High-grade loosening (grade 2 or 3) is associated with increased odds of requiring revision surgery. It can be mechani...
Do you routinely recommend a lumbar puncture for patients with suspected ocular or otic syphilis in the absence of additional CNS symptoms?
No, this isn’t necessary, assuming no other evidence of non-ocular/otic neurosyphilis. I recommend management as advised by CDC in the 2021 treatment guidelines (https://www.cdc.gov/std/treatment-guidelines/STI-Guidelines-2021.pdf, p. 40). An especially careful neurological exam is advised, includin...