Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
How do you think about biologic use in patients with underlying HIV infection?
This is always a difficult problem, and a tough clinical call. However, over the years of seeing these people, I have come to realize that following their viral load and CD4 counts while looking for immunologic recovery allows us as Rheumatologists a lot of opportunities to treat. While I have class...
How do you approach management for patient's with HIV on ART with persistent low level viremia but no new resistance mutations identified?
The US Department of Health and Human Services describes the different levels of virologic response related to ART[1]: Virologic suppression: A confirmed HIV RNA level below the lower level of detection of available assays. Virologic failure: The inability to achieve or maintain suppression of viral...
How do you make decisions about decolonization for a chronic asymptomatic MRSA carrier?
Carriage of Staph aureus (either MSSA or MRSA, depending on environmental exposure) is the “baseline” state for 25 -35% of individuals, likely dependent on genetic factors, most of which have yet to be fully identified. It cannot be readily reversed over the long term, but can be transiently halted ...
In clinical practice, are you using single-dose liposomal amphotericin B for treatment of cryptococcal meningitis for patients living with HIV?
I have practiced in Dallas, Texas, at Parkland Hospital for nearly 20 years; unfortunately, we see at least 50 patients a year with cryptococcal meningitis and HIV. We have been using the standardized approach from the US DHHS guidelines that recommend at least a 14-day course of therapy of Ambisome...
Is there a role for routine LP in HIV patients with disseminated histoplasmosis even in the absence of CNS signs/symptoms?
I would not recommend routine LP in the absence of CNS symptoms as it is unlikely to change the management of the infection in someone who has disseminated disease. Prolonged therapy will still be used and as opposed to Cryptococcal meningitis where intracranial pressure management is critical, ther...
Have you used Karius to aid in the diagnosis of a non-resolving pneumonia, with negative bronchoscopy, biopsy, and other infectious work up in an immunocompetent patient?
Culture-negative hospital-acquired pneumonia is approximately 50%. Positive cultures are complicated by having to correlate results clinically as organisms may contaminate specimens (even if from a protected brush) and include an organism that doesn't even cause pneumonia, such as Enterococcus spp. ...
How do you approach treatment of RA with methotrexate in a patient with treated Hepatitis C and normal liver function?
Active hepatitis C infection can be present in the setting of normal liver function tests. So, I always check for the viral load, especially if the hep C treatment was done more than a few years ago. Here, the old alpha interferon-based treatments achieved a cure rate no better than 30%. The newer a...
For which pediatric oncology patients do you start bacterial prophylaxis, inpatient or outpatient, and what is your antibiotic of choice?
Bacterial prophylaxis in pediatric oncology patients should be guided by the intensity of treatment, depth and duration of neutropenia, and individualized risk for invasive infection. Current evidence and expert consensus support targeted prophylaxis in children with the highest risk of life-threate...
How do you approach DMARD therapy in patients with rheumatoid arthritis and chronic hepatitis B?
Patients with hepatitis B core positivity, surface antigen positivity, and positive PCR for viral DNA, should be treated with entecavir prior to starting any DMARD. Given the DNA PCR is positive too, that indicates active viral replication and they may need treatment for a while before starting anyt...
When do you consider repeating CSF studies in a patient with suspected viral encephalitis but overall initially unrevealing CSF?
Definitely not an expert on this topic, but this situation does come up, particularly for HSV encephalitis! One question worth asking your lab is what kind of assay are they using to run this test. If it's a dedicated HSV PCR assay (e.g., Simplexa), then the sensitivity is going to be quite robust, ...