Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
Do you favor remdesivir over nirmatrelvir/ritonavir when interaction management is complex but feasible in a high-risk outpatient with early COVID-19?
Yes. If nirmatrelvir/ritonavir interactions are complex and carry meaningful risk despite being manageable, I would favor remdesivir when IV treatment is feasible.
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...
How do you decide when to use streptococcal urine antigen as part of your workup for pneumonia?
Guidelines recommend only using it for severe CAP as defined by the ATS/IDSA guidelines.
Do you use MRSA nares PCR to influence antibiotic selection for non-respiratory infections?
BLUF: Yes, I use a MRSA nares PCR for early de-escalation in the stable patient with a non-purulent, non-respiratory infection. Mergenhagen et al., PMID 31573026 retrospectively examined nearly half a million clinical cultures and compared them to MRSA nares results. Among all infections, the NPVs w...
Do you provide empiric doxycycline for Lyme Disease to asymptomatic patients after a tick bite who haven't developed Erythema migrans or are not sure it was an Ixodes tick?
I would base post-exposure prophylaxis upon local prevalence (unless the patient has a recent notable travel history). For example, Lyme disease is very rare in California due to the Ixodes tick's intermediate host being the Western Fence Lizard (long story short, something in their blood kills the ...
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?
Pneumonia is not a radiographic diagnosis, and an infiltrate does not tell us the pathogen. Chest radiographic abnormalities overlap substantially between viral and bacterial pneumonia; in the EPIC pediatric cohort, for example, consolidation was present in 74% of typical bacterial infections but al...
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...
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...
Is a history of Zoster ophthalmicus a contraindication to starting upadacitinib?
A history of HZO (herpes zoster ophthalmicus) or herpes zoster in any dermatome is a relative contraindication to the use of upadacitinib or any JAK inhibitor. HZO is often a very unpleasant disease with pain, ocular discomfort, and vision loss, so the chance of reactivation should be minimized. The...
Are there instances when you use letermovir without the addition of acyclovir when managing a kidney transplant recipient for CMV prophylaxis?
I am assuming this question is about initial viral prophylaxis after transplant and exposure to induction immunosuppression. We have not used often letermovir as first line CMV prophylaxis outside of a research study, or during valcyte shortages. Cases where one might consider Letermovir as prophyla...