Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
What is your approach to management of patients with recurrent orolabial herpes?
Recurrent orolabial herpes is fundamentally a disease of viral latency with episodic reactivation, so my approach focuses less on “treating infection” and more on reducing recurrence burden, shortening symptom duration, and improving quality of life. First, I make sure we are actually dealing with H...
How would you manage an elderly patient with a periprosthetic knee infection secondary to mycobacterium chelonae who is a poor surgical candidate for removal of hardware?
Not a lot of data to guide this, but for nontuberculous mycobacterial (NTM) prosthetic joint infections (PJIs), I would ensure the surgeons do a thorough incision and drainage (I&D) and washout, even if they cannot remove the hardware, followed by an intensive regimen of 3 to 4 active antimycobacter...
Have you used Karius to work up fevers in the hospital when the source remains unknown?
This is a tricky question because Karius is an expensive test, which many experts believe should not be used for its negative predictive value (and I have anecdotally seen negative results where infection was still present, and infections/organisms detected of very unclear significance). I like to u...
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...
How long do you treat uncomplicated streptococcal bacteremia?
Generally, recent data support 7 days of treatment for non-Staphylococcus aureus bloodstream infection (BSI), if the source is controlled. Overall, I consider in each case what the source of the bacteremia is, and how long I would treat for whatever the source or other resulting entity is first. (Fo...
In what scenarios do you find trending beta-D-glucan helpful?
Like all biomarkers, β-D-glucan (BDG) has both strengths and limitations. It is best used as supportive evidence when an invasive fungal infection is suspected rather than as a standalone diagnostic test. While relatively nonspecific, BDG has a high negative predictive value for many invasive fungal...
How has your approach to managing asymptomatic bacteriuria in kidney transplant patients changed in light of a recent meta-analysis showing no significant differences in pyelonephritis, symptomatic UTI, or graft loss between patients treated with antibiotics and those who were not treated?
The referenced meta-analysis has not dramatically impacted my approach to asymptomatic bacteriuria (ASB) in kidney transplant recipients (KTRs). The included trials clearly show no benefit (and possible harm) in treating ASB at time periods >2 months post-transplant. So we do not screen and we do no...
How would you manage a patient with mild respiratory symptoms, imaging showing bronchiectasis, one AFB culture growing only mycobacterium avium complex, and a separate AFB culture growing only nocardia species?
I would recommend repeating at least two more acid-fast bacilli (AFB) sputa to see if Mycobacterium avium complex (MAC) repeatedly grows; ideally, they should be identified to the species or subspecies level, but I understand that can be hard to request. Admittedly, bronchiectasis alone (without nod...
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...
How do you consider sending fungal studies in a patient with pneumonia?
This is a very good question. One that I’ve meant to look up for a while, so thank you for prompting me to do so. I agree with Dr. @Dr. First Last's answer (he is also my division chief!), but wanted to expand further. The articles I found most helpful are cited below.When to suspect a fungal pneumo...