Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
How do you balance diagnostic stewardship and high value cost-conscious care when working up a patient with newly diagnosed HIV/AIDS admitted to the ICU with shortness of breath who most likely has PJP pneumonia or cryptococcal infection but is at risk of multiple other pathogens?
Multiple concurrent OIs are common in individuals with advanced HIV and contribute significantly to morbidity. Because several infections can emerge simultaneously in the setting of profound immunosuppression, recognizing the likelihood of multiple coexisting pathogens is critical. Early identificat...
Do you regularly recommend an immunological workup for patients with suspected immunodeficiency or defer to immunology?
I defer after a very preliminary work-up based on the type of immunodeficiency expected. I try to direct the consult to a provider most likely to have expertise in the problem I suspect. Often, I suggest consulting with a provider at NIH.
What is your preferred first-line treatment for chronic fatigue in patients with long COVID-19?
Assuming that a thorough workup for other causes of fatigue (anemia, thyroid dysfunction, sleep apnea, etc.) has been performed and is negative, no single medication has been proven by a randomized placebo-controlled trial to help chronic fatigue in PASC. Anecdotally, my colleagues who treat PASC ha...
How should the timing of RSV vaccination be managed for patients who undergo stem cell transplant during periods of high community transmission?
As you can see from the reference article by Lotscher et al., PMID 41037295, those who were vaccinated early (<6 months) post-HSCT tended to have relatively poor responses. Therefore, I generally recommend waiting until at least 6 months based on currently available data. During periods of high comm...
What factors prompt you to treat enterococcus when isolated in polymicrobial culture from patients with urinary tract infection?
Enterococcus is an organism that I would treat when isolated in a clinically significant positive urine culture, even when polymicrobial. Since Enterococcus produces a biofilm, it can essentially trap other organisms in and be seen in the setting of a polymicrobial infection. In this setting, I woul...
Do you routinely give prophylactic antibiotics prior to ERCP for biliary obstruction in light of recent studies suggesting a reduction of periprocedural infection?
I did not use to give antibiotics routinely prior to ERCP, and it seemed post-ERCP antibiotics were given at the discretion of the advanced endoscopist, but the results of this meta-analysis will likely change my practice so that I'll give all patients a dose of Ceftriaxone prior to the procedure to...
Do you routinely give combination antifungal therapy for invasive mold infections?
The data on triazole single agent versus triazole plus echinocandin for the treatment of invasive aspergillosis are limited. I do not have a standard approach. I generally use a triazole alone, but will use the combination for initial treatment in patients with severe and/or rapidly progressive dise...
Do you recommend multisite testing for gonorrhea and chlamydia as a default screening strategy in sexually active women, regardless of reported sexual exposures?
First, the answers arguably may be different for gonorrhea and chlamydial infection. True pharyngeal chlamydia is relatively uncommon; a positive nucleic acid amplification test (NAAT) sometimes does not mean viable C. trachomatis; positive test results have not been associated with symptoms or sign...
How long do you treat uncomplicated streptococcal bacteremia?
Generally, recent data support 7 days of treatment for non-Staphylococcus aureus bloodstream infection (BSI), if the source is controlled. Overall, I consider in each case what the source of the bacteremia is, and how long I would treat for whatever the source or other resulting entity is first. (Fo...
Do you use MRSA nares PCR to influence antibiotic selection for non-respiratory infections?
BLUF: Yes, I use a MRSA nares PCR for early de-escalation in the stable patient with a non-purulent, non-respiratory infection. Mergenhagen et al., PMID 31573026 retrospectively examined nearly half a million clinical cultures and compared them to MRSA nares results. Among all infections, the NPVs w...