Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
How do you incorporate positive respiratory viral testing and/or low procalcitonin into antibiotic de-escalation when chest imaging still suggests pneumonia in a hospitalized patient?
De-escalation of antibiotic use is a key part of antimicrobial stewardship. Respiratory illnesses are one of the most common reasons for hospitalization, and bacterial pneumonia is frequently the major concern in these patients. However, there is evidence that we overdiagnose and treat bacterial pne...
What is your approach to monitoring of inflammatory markers during treatment of native vertebral osteomyelitis?
As long as the patient is clinically stable and CRP is coming down, there is generally no need for follow up imaging. Key reference: Kowalski et al., PMID 16779743.Also, good to remember that ESR is a very expensive test which basically measures fibrinogen (may cost $500 or more since it has to be r...
In patients with SLE do you have concerns about using trimethoprim-sulfamethoxazole (Bactrim) because of a potential risk of lupus flare?
I agree with Dr. @Dr. First Last . I have had too many SLE patients over the years show up in my office with a severe flare from TMP/SMX. We have too many alternative antibiotics these days, including for PJP prophylaxis, so sulfonamide antibiotics should be avoided in SLE patients. The typical scen...
Do you recommend prescribing Pneumocystis jiroveci pneumonia (PJP) prophylaxis for a patient with membranous glomerulonephritis on rituximab?
In general, I don't use Pneumocystis jirovecii pneumonia prophylaxis (PJP PPx) for patients with membranous nephropathy (MN) who have only received rituximab (RTX), unless they have also received high-dose glucocorticoids (GC) or cyclophosphamide (CYC). I usually give PJP PPx when patients receive h...
Would you recommend against use of dupilumab for severe atopic dermatitis in a patient with a history of neonatal HSV meningitis but no history with recurrent outbreaks?
No, dupilumab may be used if the patient's atopic dermatitis remains moderate to severe with standard topical treatments. I am assuming this child has history of HSV meningitis, likely in the context of eczema herpeticum. Dupilumab lowers the risk of recurrent skin infections, including HSV.
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...
Are you routinely using PO antibiotics to treat patients with left-sided endocarditis?
Recent literature has demonstrated successful treatment of patients with endocarditis who have been transitioned to oral treatment. The POET trial was a randomized, controlled trial that enrolled 400 patients who fulfilled modified Duke criteria for definite endocarditis. The trial compared full cou...
Is it ever safe to use a biologic DMARD in a patient with RA who is on suppressive antibiotics due to a history of septic prosthetic arthritis?
I have used Orencia and HCQ as more immunomodulating with suppressive M/W/F antibiotics in a patient with UTI/Bactrim.
What recommendations do you provide patients regarding immunization or boosters prior to initiating rituximab?
To my knowledge, there is no unified recommendation, although the majority of us recommend all age-appropriate immunizations plus strong consideration of younger-than-standard-age immunization for diseases such as pneumococcus and VZV prior to initiation of rituximab when medically feasible. Timing ...
What is your approach to treatment of macrolide-sensitive localized bone/joint MAC disease?
Agree with the above answers. Obviously, no strong clinical studies on duration and outcomes. At NJH, we typically recommend: Aggressive debridement/resection, Treat with appropriate antimicrobial therapy (in macrolide-S MAC, then AZM/EMB/Rifamycin +/- IV AMK) for a minimum of 6 months total, but a...