Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
How do you approach PJP prophylaxis in patients with rheumatic disease on corticosteroids?
Here is a graphic I made covering PJP Prophylaxis with Dr. @Dr. First Last if anyone is interested! As noted, one can check absolute lymphocyte count (ALC) or CD4 count as factors to further risk stratify as well.
Do you routinely treat pregnant patients for latent tuberculosis or delay treatment until 2-3 months post-partum?
Guidelines from CDC, WHO, ATS/IDSA recommend delaying the treatment of latent TB in pregnancy until 2-3 months postpartum unless there is a high risk of progression to TB disease e.g. HIV co-infection. This is because the risk of hepatotoxicity from isoniazid is higher during pregnancy and in the ea...
Do you favor a certain NRTI to pair with dolutegravir and lamivudine in persons with HIV to minimize the risk of resistance to dolutegravir?
The data are strong to support DTG/lamivudine as a stand-alone regimen with low risk of resistance development as long as patients remain adherent, so there isn't necessarily a reason to add another NRTI. That said, the Beck et al., PMID 40898778 study would suggest that tenofovir is associated with...
What oral treatment options would you offer a patient with severe onychomycosis who is also on methotrexate for another condition?
I prefer pulsed terbinafine at 250 mg daily x1 week every other month. Dr. Zaias showed in a comparative study that pulsed terbinafine works as well as giving it daily for 3 months, and since the patient is only taking this for 1 week every other month, risks for hepatotoxicity are minimal.
What further evaluation do you pursue for patients who present with vague symptoms such as subjective fevers or intermittent night sweats, who have no pulmonary symptoms but have a positive IGRA?
Great question. Another scenario that is not uncommon is some degree of cough, sometimes for long periods of time, but no other symptoms. If their risk is higher for progression to active disease (e.g., immunocompromised; recent contact with an active case) I may do more than if the risk is low. My ...
Do you treat non-albicans strains of Candida on sputum culture or BAL in patients who are immunosuppressed?
I agree with these answers and do not treat either without biopsy.
Do you recommend, based on current evidence, avoiding antimotility agents in patients with non-fulminant C. difficile infection who have no evidence of ileus?
I generally avoid their use based on the notions that diarrhea may contribute to the elimination of non-invasive GI pathogens and that impairment of intestinal motility could increase the risk of complications, such as toxic megacolon.The data and recommendations have not progressed beyond the follo...
Do you ever favor cefazolin over ceftriaxone for bacteremia with susceptible E. coli?
We do cefazolin often unless h/o ESBL or complicated infection or procedural history. It is our preferred abx for pyelo or intra-abdominal infection (we add Flagyl for intra-abdominal) and is driven by our local susceptibility data.
How would you manage an early postoperative spinal implant infection when intraoperative cultures while on antibiotics are negative, no frank purulence or other evidence of infection is observed during washout, but there were fascial defects and fluid tracking down to the hardware?
This is quite an interesting spread of responses. I avoid using the term “broad,” as it is not a meaningful concept in infectious diseases. Unfortunately, there are no randomized trials to guide our practice in PSI. The closest comparable evidence is likely from the DATIPO trial, where 12 weeks of t...
What is the interpretation of an IGRA with positive TB wells and negative nil and negative mitogen wells?
We don't see positive controls in most clinical assays. They are run, of course, but hidden from view. The mitogen well is the positive control in the IGRAs. The mitogen used QuantiFERON-TB Gold is, I believe, PHA or phytohemagglutinin. PHA turns on T-cells to indiscriminately. If I remember my mito...