Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
Do you still use fever as a minor criterion when applying the Duke–ISCVID criteria for infective endocarditis given data suggesting diagnostic accuracy may improve when it is omitted?
Actually, I still use fever as a minor criterium. I have not really thought much about it and have no instances where culture negative endocarditis has come up since the publication. In fact, no one in my division has even brought this up for discussion. Anyhow, dI think this is a minor modification...
How do you decide whether to empirically cover Pseudomonas for pneumonia in hospitalized patients?
The decision to empirically cover Pseudomonas aeruginosa in pneumonia among hospitalized patients depends on the pneumonia type (community-acquired pneumonia, CAP vs. hospital-acquired pneumonia, HAP), disease severity, etiology, and specific risk factors. For Community-Acquired Pneumonia (CAP) Pa...
What is your preferred first-line regimen to treat a severe or fulminant C difficile infection?
IV vancomycin and PO Flagyl are the easiest combination to get for a hospitalized patient. I’ve had much experience with this, and it works very well. IV vancomycin and PO Flagyl as initial treatments in the hospital is my preference. This is before I go onto stronger drugs, with those requiring al...
What is your preferred laboratory test to assess treatment response or infection resolution in patients with bacterial pneumonia?
I don't generally check a laboratory test to assess resolution. I go more by their improved clinical status and seeing them get back to baseline oxygen status. If I am trending a WBC or procal, I do like to see it trend down, but it's not the only lab I hang my hat on to decide if someone has resolv...
What approaches can we take to initiate therapy and improve survival rates in patients with HLH?
At our institution, we have comprised a multidisciplinary team to help treat these patients. The team or "HLH task force" as we like to call ourselves is comprised of a clinical immunologist, rheumatologist, dermatologist, critical care physician, hepatologist, BMT attending/hematologist, infectious...
What is your approach to antibiotic selection for bacterial species that demonstrate susceptibility to penicillins or cephalosporins on testing, but are known to harbor inducible AmpC resistance?
I will assess how long I am treating the person/infection, and go from there in terms of how likely I am to induce the AmpC based on the duration of treatment. For example, if it's a 7-day course for UTI or GN bacteremia, I may risk the penicillin/cephalosporin (based on susceptibilities, of course)...
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...
How would you manage a patient with viremia up to 400 copies/mL on CAB/RIL injections who was previously undetectable on BIC/FTC/TAF and with prior genotypic testing without drug resistance mutations?
CAB/RPV seems to have a higher failure rate (around 1%) than BIC or DTG plus NRTIs. This may be a result of the lower potency of CAB. In addition, CAB has a lower barrier to resistance than BIC and DTG. That said, CAB/RPV is an excellent option for a wide range of patients. I review all injection ap...
What is your approach to monitoring blood parasite smears in an immunocompetent patient with babesiosis?
In an immunocompetent person the response rate to the treatment of acute babesiosis is extremely high and if a person is clinically improving follow-up smears are probably unnecessary. However, I generally check one at 48 hours to confirm a decrease in parasite burden. If that is favorable and the p...
What minimum inpatient monitoring and discharge criteria should be required after single high-dose liposomal amphotericin B induction for HIV-associated cryptococcal meningitis when the patient has persistent intracranial hypertension requiring serial lumbar punctures?
There are Cryptococcal meningitis guidelines by IDSA with a section devoted to what Dr. @Dr. First Last mentioned (IDsociety.org). I realize that we are getting pressure to think about discharge as soon as every patient is admitted, but this particular patient will need at least two weeks of Amphote...