Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
Do you routinely test for toxoplasmosis during workup of fever of unknown origin in an immunocompetent patient with significant cat exposure?
Not with evidence of scratches and/or lypmpadnopathy, which can be very impressive.Tangentially, what definition of FUO is being used?SMS
When do you consider PET/CT to evaluate for an occult source of infection in patients with persistent bacteremia if TTE/TEE does not show evidence of endocarditis?
Great question. Generally, I consider PET/CT to evaluate for an occult source of infection in patients with persistent bacteremia if TTE/TEE does not show evidence of endocarditis, in the following scenarios: Persistent bacteremia ≥72 hours. TEE was negative or nondiagnostic. No source identified o...
Would you recommend antifungal treatment or observation without therapy in an immunocompetent patient with a pulmonary nodule who underwent malignancy workup and was found to have yeast forms consistent with histoplasma on GMS stain?
We have seen a number of patients who have had a lung biopsy for a solitary pulmonary nodule to exclude the diagnosis of cancer. When histoplasmosis is identified by pathology, we obtain a urine histoplasma antigen as well as a careful history and exam, and some lab tests for immunosuppression. If n...
Do you recommend routine neurosyphilis testing in patients being evaluated for dementia?
Syphilis is a rare cause of dementia without other evidence of neurological disease, at least in the US and most other industrialized countries. Of course, a careful neurological examination is required for all dementia patients, but the absence of other manifestations of neurosyphilis makes testing...
Would you use low-dose infliximab as adjunctive therapy in a patient with severe central nervous system tuberculosis?
I would not routinely use low-dose infliximab as adjunctive therapy in patients with severe central nervous system tuberculosis at this time. The biological rationale is understandable. Tumor necrosis factor–α plays a central role in the inflammatory cascade that drives tissue damage in tuberculous ...
Do you routinely transition to PO antibiotics for patients with native joint septic arthritis whom have undergone washout and the organism is not S. aureus?
Yes. Even if the organism is Staph aureus, I would feel comfortable with an appropriate, highly bioavailable oral antibiotics after appropriate source control (linezolid in the case of Staph aureus).
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...
When do you consider adding steroids alongside intravenous antibiotics for patients with orbital cellulitis?
If the orbital cellulitis is infectious, I never add steroids. There is no literature or proof that they do anything, and decreasing immunity, in my opinion, is simply a bad idea. If it is inflammatory, then absolutely. Most infectious orbital cellulitis is from the sinuses and is more common in chi...
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...
Do you still use fever as a minor criterion when applying the Duke–ISCVID criteria for infective endocarditis given data suggesting diagnostic accuracy may improve when it is omitted?
Actually, I still use fever as a minor criterium. I have not really thought much about it and have no instances where culture-negative endocarditis has come up since the publication. In fact, no one in my division has even brought this up for discussion. Anyhow, I think this is a minor modification....