Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
Do you recommend treating Candida albicans on urine culture from an indwelling catheter in a patient with septic shock?
In a patient with septic shock, one is typically obligated to treat all things until further culture data is back, etc. If there are other clear causes of shock, I would not treat the candida (though I would try to change the catheter ASAP). If the patient is extremely ill and no other sources of in...
In what circumstances would you consider monotherapy for empiric treatment of unresectable nontuberculous mycobacterial lymphadenitis?
NTM lymphadenitis is rather uncommon, and I personally have little experience with it and did not see it much even at NJH. However, extrapolating from how I treat any NTM disease in general, I would shy away from monotherapy in any NTM disease, preferring at least two active agents. Perhaps one scen...
How long do you continue empiric anaerobic coverage for brain abscesses originating from sinus or tooth infection following surgical drainage?
Since anaerobes can be difficult to culture and are certainly associated with this type of infection, I would recommend continuing anaerobic coverage along with targeted therapy for any positive cultures. Anaerobic pathogens are often seen in conjunction with other pathogens. In a study looking at 3...
When do you consider adding steroids alongside intravenous antibiotics for patients with orbital cellulitis?
If the orbital cellulitis is infectious, I never add steroids. There is no literature or proof that they do anything, and decreasing immunity, in my opinion, is simply a bad idea. If it is inflammatory, then absolutely. Most infectious orbital cellulitis is from the sinuses and is more common in chi...
Would you use the pneumococcal conjugate-21 vaccine (Capvaxive) instead of the conjugate-20 (Prevnar-20) for routine vaccinations in immunosuppressed patients?
PCV-21 was recently approved by the FDA and supported by ACIP. At this early stage (August 2024), CDC has not finalized guidance on PCV-21, so we do not know how the vaccine schedule will be changed. An important distinction is that PCV-21 covers different serotypes of pneumococcus, as outlined in t...
Would you recommend early empirical anti-mold therapy for patients with severe influenza pneumonia admitted to the ICU to reduce the incidence of influenza-associated pulmonary aspergillosis?
Although this is a known complication, I would not place someone on mold prophylaxis given the lack of supporting data, the rarity of the complication, and the fact that—when considered early—it can usually be identified based on signs and symptoms suggestive of invasive mold infection. Prophylaxis ...
What are your vaccine recommendations while patients are on biologics?
Live vaccines are best completed at least a month before initiation of biologics when these are appropriate (e.g., MMR, chickenpox, yellow fever). The data on non-live vaccines is limited. I personally think that some degree of protection is better than none. I will not interrupt biological therapy ...
Would you offer live vaccines (e.g., MMRV/measles) to patients on bispecific antibodies for multiple myeloma?
I agree with the answer here by Dr. @Dr. First Last. There are a lot of nuances, though. In regard to giving the vaccine safely and effectively, the best strategy is not to wait until patients have multiple relapses and are on bispecific therapy to vaccinate. Given the recent outbreaks of measles, i...
What is your approach to a patient with undetectable MMR titers checked prior to or during immunosuppression and a history of MMR vaccination in childhood?
MMR titers are good correlates of protection. If any titer is undetectable it could be one of these situations: Primary failure. The components of the MMR have different efficacy. Two doses of appropriately given MMR will have 96+% against measles, but only 88% for mumps. Thus 1 in 10 appropriately...
Would you consider levofloxacin graded challenge, extended IV aztreonam, or an alternative treatment in a patient with reported anaphylaxis to penicillin, fluoroquinolones, and cefuroxime with cavitary pneumonia secondary to Klebsiella and Pseudomonas?
The first and most important thing would be to establish whether the patient had a true penicillin (as well as other antibiotic) allergy since >90% of patients who think they are sensitive to PNC really are not. If it is established that the patient does have a PCN allergy, consultation with ID is a...