Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
What is your approach to antiviral treatment of HSV acute retinal necrosis?
Acute Retinal Necrosis (ARN) is a rapidly progressive syndrome usually caused by varicella-zoster virus (VZV)and herpes simplex virus 1 or 2 (HSV). The syndrome is rapidly progressive in the absence of antiviral treatment. PCR performed on aqueous or vitreous sampling is highly sensitive and strongl...
How would you manage MRSA and Enterococcus faecalis bacteriuria in a patient presenting in severe heart failure without urinary symptoms, fever, or chills, two negative blood cultures, and whose transthoracic echocardiogram shows no new valvular abnormalities?
The core question here is: are you dealing with asymptomatic bacteriuria or a true infection? In the absence of urinary symptoms and in following the IDSA UTI guidelines, asymptomatic bacteria should not be treated except in specific clinical scenarios - pregnancy, urologic instrumentation, renal tr...
What do you prescribe for HIV post-exposure prophylaxis in patients who cannot swallow tablets and have no enteral tube?
We would prescribe cabotegravir and rilpivirine 600mg/900mg intramuscular x 1 injection to give 28 days of protection. IF there is a question of any resistance in the source patient, we would add lenacapavir 600mg po on days 0 and 1 as an oral loading dose plus lenacapavir 927 mg sq on day 0.
Would you consider transition to a cabotegravir/rilpivirine injectable regimen in a patient living with HIV who is well-suppressed on BIC/FTC/TAF since initial diagnosis in Colombia in 2022 at which time her viral load was in the 400s precluding genotypic resistance testing?
The clinical scenario as presented is somewhat ambiguous. If the patient is described as “well suppressed” on bictegravir/emtricitabine/tenofovir alafenamide, this typically implies consistent HIV RNA <200 copies/mL. A persistent viral load in the 400s, however, would suggest low-level virologic fai...
For how long would you treat a patient with latent TB before allowing them to proceed with a liver transplant?
There are a few ways to look at the answer to this question. If the individual is stable enough to complete the Latent TB Infection (LTBI) therapy without need for a liver transplant, then treat the LTBI to completion. If the individual may need the transplant during the treatment course, then start...
How do you approach the use of fidaxomicin versus vancomycin for initial Clostridioides difficile infection in immunocompromised patients, considering the lower recurrence rates but higher cost of fidaxomicin?
Whether immunocompromised or not, fidaxomicin has been demonstrated to be superior to vancomycin – not in resolution of the acute infection but in reducing the risk or recurrence by approximately one-half. In one study of hospitalized patients published in 2015, it was reported that, when taking int...
What is your approach to the management of asymptomatic bacteriuria in an elderly patient without clear urinary symptoms but with cognitive changes and falls?
Asymptomatic bacteruria does not cause altered mental status. Data suggests that when we attribute acute changes to it, we will be wrong about 85% of the time, thereby missing the true etiology. It is a difficult thing to educate staff of senior living facilities and families who have been told it w...
Does your hospital or institution have an Antimicrobial Stewardship Program (ASP), which oversees ID physicians, and if so, does the ASP have the authority to refuse an antibiotic prescribed by an ID consultant?
We have ASP and the ID docs have a very collegial relation with our PharmD who are both ID pharmacists. They are very helpful and they do not block the ID consultants. When ID consultant recommends something that should not be done due to drug interaction for instance The pharmacist will call explai...
Do you routinely recommend IV systemic antibiotic therapy in additional to intravitreal antibiotic therapy for exogenous bacterial endophthalmitis?
Post-surgical (exogenous) endophthalmitis is an uncommon complication with the incidence ranging from 0.04%-0.3%, 0.019%- 0.54%, and 0.11% - 0.03% following cataract surgery, intravitreal injection, and vitrectomy, respectively (Soliman et al., PMID 32467482). Initial management of exogenous endopht...
Do you recommend a prolonged duration of antibiotics and/or suppression for patients without pre-existing hardware who have placement of new hardware after decompression/washout of a Staphylococcus aureus epidural abscess?
This can be a difficult clinical scenario and the answer depends in part on whether there was any concern for osteomyelitis at the time the epidural abscess was drained. If so, I would suggest giving a prolonged duration of abx with 6 weeks of targeted IV abx therapy and oral Rifampin followed by 3 ...