Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
How would you approach chronic isolated severe non-cyclic neutropenia with negative bone marrow and rheumatologic work-up?
My preference would be to use G-CSF at the lowest effective dose, i.e., the dose that maintains the ANC >1000. The risk of inducing leukemia is low in individuals with idiopathic, chronic neutropenia, but it is positively correlated with the G-CSF dose. There are also other side effects like bone pa...
How do you approach the timing of COVID-19 vaccination for patients with multiple sclerosis on B-cell depleting therapies?
B-cell depleting agents can interfere with a patient's ability to develop an adequate humoral response. With regards to the infusions such as rituximab and ocrelizumab, I recommend holding off on getting SARS-CoV2 vaccinations until at least 3 months and up to, at minimum, 2 weeks prior to the next ...
Is there a role for antibody testing to confirm vaccine response for patients on rituximab after COVID-19 vaccination?
It's a great question, but I do not feel that routinely performing COVID antibody testing would help in the management of these patients: We don't know how well most commercial antibody testing correlates with neutralizing antibody/immune-status (esp. if qualitative testing is performed), and I have...
How long would you treat with antimycobacterials before starting biologic DMARD in a patient with latent TB and active rheumatoid arthritis?
This is a common question rheumatologists ask their ID colleagues. Given the diversity of patient presentations, though, there isn't a blanket answer. One reason there's no blanket answer is because it is so hard to study LTBI risks, due to infrequent conversion to active TB, which is a fortunate th...
In which patients with oncologic or hematologic disorders are you recommending a 3rd dose of mRNA COVID vaccine?
In the ideal world, we would tailor the need for booster shots based on whether or not a patient achieves an appropriate immunologic response and maintains that response for long periods of time. This would include both seroconversion and T-cell-mediated immunity. However, we have neither routine no...
How are you timing the third dose of the COVID-19 mRNA vaccine in patients on rituximab?
At this point, I am advising the patients to do the 3rd vaccine at least 5 months after the previous Rituximab dose. Whenever feasible, I test them for B cell reconstitution prior to vaccination, and may delay the vaccination if B cells are undetectable.
Do you hold tocilizumab for patients who are diagnosed with Covid and are with mild to moderate symptoms or non-hospitalized?
I generally hold all immune suppressive medications, once a patient is diagnosed with COVID19 to allow for faster clearance of the infection. Inhibition of IL-6 and other immune modulating interventions should be reserved only for hospitalized severely ill patients where the immune system hyper-acti...
Which medications have the lowest risk of tuberculosis reactivation in patients with uncertain tuberculosis history and active rheumatologic disease?
Conventional synthetic DMARDs used in RA are at lower risk for reactivation of latent TB. Steroids do confer some risk of reactivation. The highest risk is the class of biologic DMARDs used to treat RA and many rheumatic diseases with the exception of rituximab.
What is your approach to the treatment of PML-IRIS in patients with HIV who have progressed to AIDS?
The first question I have is whether the diagnosis is truly PML-IRIS if someone is having a progressive HIV infection. By definition, IRIS suggests there is ongoing immune reconstitution, so the immune status of a patient with HIV infection should be improving, not progressing. If someone has HIV t...
Do you hold IV iron in the setting of active infection?
While there is no evidence of harm, there is enough conjecture about the danger to make it prudent to wait until infection is controlled. So yes, I do. Further because of the iron restricted erythropoiesis during infection, the efficacy is likely to be blunted.