Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
Can non-16/18 HPV types cause ASCUS and squamous cervical metaplasia on biopsy within 3 months of acquisition, or would it take longer?
It isn't clear that HPV causes ASCUS. I'm not sure how to interpret "squamous metaplasia" as opposed to dysplasia, but certainly many HPV types other than 16 and 18 cause cervical dysplasia, and probably can do so within 3 months of acquisition. However, I would be cautious in telling a patient that...
Would you consider antifungal prophylaxis for immunocompromised patients with COVID-19 requiring mechanical ventilation, considering the high risk of invasive pulmonary aspergillosis in patients with severe COVID-19?
I don't universally add anti-mold prophylaxis in all immunocompromised patients with severe COVID-19 requiring intubation, but I am always considering it. Factors that might push me to add would be: positive fungal markers (Beta-D-Glucan or galactomannan) on BAL or blood at time of intubation, use o...
Do you treat Stenotrophomonas maltophilia bacteremia with combination therapy and if so, what is your preferred combination of antibacterials?
Yes, I would use two agents, at least up front, as recommended in the 2024 IDSA guidelines (Tamma et al, PMID 39108079). The guidelines suggest two of the following agents should be used, unless the combination of ceftazidime-avibactam plus aztreonam is used instead: cefiderocol, TMP/SMX, levofloxac...
In light of recent measles outbreaks, have you adjusted your vaccination counseling or preventive strategies for adult immunocompromised patients?
Check measles antibody (once) in individuals working in public places, especially when working with kids.
How long do you continue antibiotics after cholecystostomy tube placement for acute cholecystitis?
The solution to questions regarding treatment duration invariably falls under the category of "it depends." For individuals with severe illnesses, particularly those with bacteremia, an extended treatment period ranging from 7-14 days might be needed. Conversely, for patients who show significant im...
Is there any role for prophylactic bronchial artery embolization in immunocompromised patients with invasive pulmonary aspergillosis?
Bronchial artery embolization is NOT without complications. Although the bleeding risk is very high in invasive pulmonary aspergillosis, empirical embolization is not well supported either by data or clinical practice. It probably should be a case-by-case decision.
Is there a risk of hepatitis C activation with rituximab in a patient who has a history of HCV treated with antivirals and who is in sustained viral response?
In general, the risk of HCV flare with immunosuppression in general including rituximab must be viewed as minimal for those who have achieved a sustained virologic response (Undetectable HCV RNA ≥12 weeks after treatment completion) and does not influence my therapeutic decision-making if the patien...
Do you routinely offer fungal prophylaxis for patients on BTK inhibitors?
We do not use antifungal prophylaxis for patients on BTK inhibitors. The risk of invasive fungal infection in patients treated with BTK inhibitors in recent large single institutional series have been 2 to 3%, without routine antifungal prophylaxis. The risk of fungal infection increases in patients...
How long do you continue surveillance with imaging and sputum cultures in a patient with NTM with no indications for treatment?
Since NTM lung disease typically develops over years, it is reasonable to monitor the patient with periodic HRCTs, even if the patient is relatively asymptomatic. I typically do this every 12 months in an otherwise stable patient. The reason for this is because we know that in up to 2/3 of patients,...
Would you recommend imaging of the brain and lungs to investigate potential disseminated disease in a recent heart transplant patient with a skin nodule that grew Rhizopus?
Yes. For any immune-compromised individual with Mucor on the skin or another organ, I look at the brain and the lungs.