Washington Manual Infectious Disease Subspecialty Consult,
3rd Edition
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Contents
Cover
Title
Copyright
Contributors
Chairman’s Note
Preface
Approach to the Infectious Disease Consultation 1
Stephen Y. Liang, Michael J. Durkin, and Nigar Kirmani
The Acute Febrile Patient and Sepsis 9
Yasir Hamad and Stephen Y. Liang
Fever of Unknown Origin 31
Mohammad J. Saeed and Michael J. Durkin
Bacteremia and Infections of the Cardiovascular System 41
Merilda Blanco and Michael J. Durkin
Respiratory Infections 75
Carlos Mejia-Chew and Michael A. Lane
Infections of the Gastrointestinal and Hepatobiliary Tract 105
Lemuel B. Non and Jennie H. Kw on
Urinary Tract Infections 135
Juan J. Calix and Jeffrey P. Henderson
Infections of the Bone and Joint 153
Shadi Parsaei and Stephen Y. Liang
Skin and Soft Tissue Infections 177
Darrell McBride and Stephen Y. Liang
Central Nervous System Infections 201
Abdullah Aljorayid and Robyn S. Klein
Sexually Transmitted Infections 223
Matifadza Hlatshw ayo and Hilary Reno
Human Immunodeficiency Virus Infection 243
Jane O’Halloran and Rachel Presti
Opportunistic Infections Associated With HIV 265
Jane O’Halloran and Gerome Escota
Infection in Non-HIV Immunocompromised Hosts 285
Anupam Pande and Ige George
Dimorphic Mycoses 321
Krunal Raval and Andrej Spec
Zoonotic Infections and Ectoparasites 333
Abigail L. Carlson and Steven J. Law rence
Protozoal Infections 355
Derek Yee and F. Matthew Kuhlmann
Helminthic Infections 371
Carlos Mejia-Chew and Philip Budge
Infection Prevention 383
Caline S. Mattar and Michael J. Durkin
Antimicrobial Agents 391
David J. Ritchie, Maren Cow ley, and Nigar Kirmani
Antimicrobial Stewardship 433
Kevin Hsueh and Michael J. Durkin
What was Old is New Again: Arboviruses and Hemorrhagic Fevers 439
Michael Tang and Steven J. Law rence
Index
Copyright
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Third edition
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Copyright © 2013 by Department of Medicine, Washington University School of Medicine.
Copyright © 2006 by Department of Medicine, Washington University School of Medicine.
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Library of Congress Cataloging-in-Publication Data
Names: Kirmani, Nigar, editor. | Durkin, Michael J. (Michael Joseph), 1981- editor. | Liang, Stephen Y.,
editor. | Washington University (Saint Louis, Mo.). School of Medicine, sponsoring body.
Title: The Washington manual infectious diseases subspecialty consult / editors, Nigar Kirmani, Michael
J. Durkin, Stephen Y. Liang.
Other titles: Infectious diseases subspecialty consult | Washington manual subspecialty consult series.
Description: Third edition. | Philadelphia : Wolters Kluwer, [2020] | Series: Washington manual
subspecialty consult series | Includes bibliographical references and index.
Identifiers: LCCN 2019011923 | ISBN 9781975113421
Subjects: | MESH: Communicable Diseases | Diagnosis, Differential | Patient Care Planning |
Handbook
Classification: LCC RC111 | NLM WC 39 | DDC 616.9–dc23 LC record available at
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This work is provided “as is,” and the publisher disclaims any and all warranties, express or implied,
including any warranties as to accuracy, comprehensiveness, or currency of the content of this work.
This work is no substitute for individual patient assessment based upon healthcare professionals’
examination of each patient and consideration of, among other things, age, weight, gender, current or
prior medical conditions, medication history, laboratory data and other factors unique to the patient. The
publisher does not provide medical advice or guidance and this work is merely a reference tool.
Healthcare professionals, and not the publisher, are solely responsible for the use of this work including
all medical judgments and for any resulting diagnosis and treatments.
Given continuous, rapid advances in medical science and health information, independent professional
verification of medical diagnoses, indications, appropriate pharmaceutical selections and dosages, and
treatment options should be made and healthcare professionals should consult a variety of sources.
When prescribing medication, healthcare professionals are advised to consult the product information
sheet (the manufacturer’s package insert) accompanying each drug to verify, among other things,
conditions of use, warnings and side effects and identify any changes in dosage schedule or
contraindications, particularly if the medication to be administered is new, infrequently used or has a
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Dedication
For our families, without whose patience, encouragement, and many sacrifices this work would not be
possible.
—Nigar Kirmani, Michael J. Durkin, Stephen Y. Liang
In memoriam
We are eternally grateful to Gerald Medoff, MD, the former chief of the Infectious Diseases Division at
Washington University School of Medicine, who passed away shortly before publication of this book. He was
an extraordinary clinician, scientist, and teacher who trained generations of Infectious Disease fellows to push
the boundaries of current knowledge. He taught us all to take care of patients with compassion and respect.
Contributors
Abdullah Aljorayid MD Clinical Fellow,Division of Infectious Diseases,Department of Internal
Medicine, Washington University School of Medicine,St. Louis, Missouri
Merilda Blanco MD Assistant Professor of Medicine,Division of Infectious Diseases,Department of
Internal Medicine, Washington University School of Medicine,St. Louis, Missouri
Philip Budge MD Assistant Professor of Medicine,Division of Infectious Diseases,Department of Internal
Medicine, Washington University School of Medicine,St. Louis, Missouri
Juan J. Calix MD Clinical Fellow,Division of Infectious Diseases,Department of Internal Medicine,
Washington University School of Medicine,St. Louis, Missouri
Abigail L. Carlson MD Instructor in Medicine,Division of Infectious Diseases,Department of Internal
Medicine, Washington University School of Medicine,St. Louis, Missouri
Maren Cow ley MD Pharmacy Resident, Infectious Diseases,Barnes-Jewish Hospital,St. Louis, Missouri,
Michael J. Durkin MD Assistant Professor of Medicine,Division of Infectious Diseases,Department of
Internal Medicine, Washington University School of Medicine,St. Louis, Missouri
Gerome Escota MD Assistant Professor of Medicine,Division of Infectious Diseases,Department of
Internal Medicine, Washington University School of Medicine,St. Louis, Missouri
Ige George MD Assistant Professor of Medicine,Division of Infectious Diseases,Department of Internal
Medicine, Washington University School of Medicine,St. Louis, Missouri
Yasir Hamad MD Assistant Professor of Medicine,Division of Infectious Diseases,Department of Internal
Medicine, Washington University School of Medicine,St. Louis, Missouri
Jeffrey P. Henderson MD Associate Professor of Medicine,Division of Infectious Diseases,Department of
Internal Medicine, Washington University School of Medicine,St. Louis, Missouri
Matifadza Hlatshw ayo MD Clinical Fellow,Division of Infectious Diseases,Department of Internal
Medicine, Washington University School of Medicine,St. Louis, Missouri
Kevin Hsueh MD Assistant Professor of Medicine,Division of Infectious Diseases,Department of
Internal Medicine, Washington University School of Medicine,St. Louis, Missouri
Nigar Kirmani MD Professor of Medicine,Division of Infectious Diseases,Department of Internal
Medicine, Washington University School of Medicine,St. Louis, Missouri
Robyn S. Klein MD Professor of Medicine,Division of Infectious Diseases,Department of Internal
Medicine, Washington University School of Medicine,St. Louis, Missouri
F. Matthew Kuhlmann MD Assistant Professor of Medicine,Division of Infectious Diseases,Department of
Internal Medicine, Washington University School of Medicine,St. Louis, Missouri
Jennie H. Kw on MD Assistant Professor of Medicine,Division of Infectious Diseases,Department of
Internal Medicine, Washington University School of Medicine,St. Louis, Missouri
Michael A. Lane MD Assistant Professor of Medicine,Division of Infectious Diseases,Department of
Internal Medicine, Washington University School of Medicine,St. Louis, Missouri
Steven J. Law rence MD Associate Professor of Medicine,Division of Infectious Diseases,Department of
Internal Medicine, Washington University School of Medicine,St. Louis, Missouri
Stephen Y. Liang MD Assistant Professor of MedicineDivision of Infectious Diseases,Divisions of
Infectious Diseases and Emergency Medicine, Washington University School of Medicine,St. Louis,
Missouri
Darrell McBride MD Clinical Fellow,Division of Infectious Diseases,Department of Internal Medicine,
Washington University School of Medicine,St. Louis, Missouri
Carlos Mejia-Chew MD Clinical Fellow,Division of Infectious Diseases,Department of Internal
Medicine, Washington University School of Medicine,St. Louis, Missouri
Caline S. Mattar MD Assistant Professor of Medicine,Division of Infectious Diseases,Department of
Internal Medicine, Washington University School of Medicine,St. Louis, Missouri
Lemuel B. Non MD Assistant Professor of Medicine,Division of Infectious Diseases,Department of
Internal Medicine, Washington University School of Medicine,St. Louis, Missouri
Jane O’Halloran MD Clinical Fellow,Division of Infectious Diseases,Department of Internal Medicine,
Washington University School of Medicine,St. Louis, Missouri
Anupam Pande MD Assistant Professor of Medicine,Division of Infectious Diseases,Department of
Internal Medicine, Washington University School of Medicine,St. Louis, Missouri
Shadi Parsaei DO Clinician, Infectious Diseases,Norton Hospital,Louisville, Kentucky,
Rachel Presti MD Assistant Professor of Medicine,Division of Infectious Diseases,Department of Internal
Medicine, Washington University School of Medicine,St. Louis, Missouri
Krunal Raval MD Clinical Fellow,Division of Infectious Diseases, Washington University School of
Medicine,St. Louis, Missouri
Hilary Reno MD Assistant Professor of Medicine,Division of Infectious Diseases,Department of Internal
Medicine, Washington University School of Medicine,St. Louis, Missouri
David J. Ritchie PharMD Clinical Pharmacist, Infectious Diseases,Barnes-Jewish Hospital,Professor of
Pharmacy Practice, St. Louis College of Pharmacy,St. Louis, Missouri
Mohammad J. Saeed MD Instructor in Medicine,Division of Infectious Diseases, Department of Internal
Medicine,Washington University
Andrej Spec MD Assistant Professor of Medicine,Division of Infectious Diseases,Department of Internal
Medicine, Washington University School of Medicine,St. Louis, Missouri
Michael Tang MD Instructor in Medicine,Division of Hospital Medicine, Washington University School
of Medicine,St. Louis, Missouri
Derek Yee MD Instructor in Medicine,Division of Hospital Diseases,Department of Internal Medicine,
Washington University School of Medicine,St. Louis, Missouri
Chairman’s Note
It is a pleasure to present the new edition of The Washington Manual ® Infectious Diseases Subspecialty
Consult. This pocket-size book remains a primary reference for medical students, interns, residents, and
other practitioners who need ready access to practical clinical information to diagnose and treat patients
with a wide variety of infectious diseases. Infectious diseases continue to be major causes of morbidity
and mortality around the world. New and emerging pathogens and increasing antimicrobial drug
resistance have created major challenges in many healthcare settings. Medical knowledge surrounding
microbial pathogenesis, host pathogen interactions, and mechanisms of drug resistance has grown
dramatically. There have also been significant advances in rapid molecular diagnostics for infectious
diseases as well as new therapeutic and preventive strategies. The astounding rate of scientific discoveries
in the area of infectious diseases creates a challenge for physicians to keep up with the biomedical
discoveries and novel therapeutics that can positively impact patient outcomes. This manual addresses
this challenge by concisely and practically providing current scientific information for clinicians to aid
them in the diagnosis, investigation, and treatment of infectious diseases.
I want to personally thank the authors, who include the residents, fellows, and attendings at Washington
University School of Medicine and Barnes-Jewish Hospital. Their commitment to patient care and
education is unsurpassed, and their efforts and skill in compiling this manual are evident in the quality of
the final product. In particular, I would like to acknowledge our editors, Drs. Nigar Kirmani, Michael J.
Durkin, and Stephen Y. Liang, and the series editors, Drs. Tom De Fer and Thomas Ciesielski, who have
worked tirelessly to produce another outstanding edition of this manual. I would also like to thank Dr.
Melvin Blanchard, Chief of the Division of Medical Education in the Department of Medicine at
Washington University School of Medicine, for his advice and guidance. I believe this subspecialty
manual will meet its desired goal of providing practical knowledge that can be directly applied at the
bedside and in outpatient settings to improve patient care.
Victoria J. Fraser, MD
Adolphus Busch Professor
Chair of the Department of Medicine
Washington University School of Medicine
Preface
We are delighted to introduce the third edition of The Washington Manual ® Infectious Diseases
Subspecialty Consult. The chapters have been contributed primarily by faculty and fellows from the
Infectious Diseases Division in the Department of Internal Medicine at the Washington University School
of Medicine in St. Louis. In this edition, we have added chapters on antimicrobial stewardship,
arboviruses, and hemorrhagic fevers, and we updated content in all other chapters.
Infectious disease is an exciting field in constant evolution. Even since the release of the last edition of this
manual, there have been new diseases, new diagnostic methods, and new treatment challenges with the
development of multiple-drug–resistant organisms. There continues to be a need for specialists in this
field. Infectious disease specialists treat patients of all ages, deal with all organ systems, and collaborate
with nearly all other medical specialties and subspecialties. In infectious disease, no case is exactly the
same, so there is no “cookbook” approach to these problems. This makes each case intriguing, and even
the most mundane cases have appeal. It is our hope that this manual stimulates interest in infectious
disease among its readers and inspires them to pursue a career in this specialty.
This manual complements the Washington Manual of Medical Therapeutics by providing more in-depth
coverage of infectious diseases. We have focused on providing easy-to-follow guidance for the diagnosis
and treatment of infectious diseases likely to be seen by trainees and practicing physicians. Diseases are
organized primarily by organ system to facilitate generating a useful differential diagnosis based on a
patient’s presentation. By providing practical guidance for common problems, the manual serves not as a
comprehensive textbook, but rather as a go-to reference that can be kept handy on the wards.
It should be noted that the dosing information in the text assumes normal renal function unless
otherwise indicated. Dosing information for impaired renal function is available in a chapter dedicated to
antimicrobial agents.
We would like to offer special thanks to Katie Sharp for her extensive assistance in keeping the project
organized and moving forward. This book wouldn’t have been possible without her. We would also like
to thank Dr. Tom De Fer in the Department of Medicine for his editorial guidance, and Dr. Thomas
Ciesielski for reviewing each and every chapter. Finally, we would like to recognize Dr. William G.
Powderly, the J. William Campbell Professor in the Department of Medicine and Co-Chief of the
Infectious Diseases Division, and Dr. Victoria Fraser, the Adolphus Busch Professor and Chair of the
Department of Medicine, for their leadership, mentorship, and unwavering support.
N.K.
M.J.D.
S.Y.L.
CHAPTER 1
Approach to the Infectious Disease
Consultation
Stephen Y. Liang
Michael J. Durkin
Nigar Kirmani
The Value of the Infectious Disease Consultation
Infectious disease consultation is associated with high quality care. The value
of an infectious disease consultation has been borne out in studies
demonstrating reduced mortality for a number of conditions including
Staphylococcus aureus bacteremia, 1 solid organ transplant infections, 2
infections due to multidrug-resistant pathogens, 3 cryptococcal infections, 4
and candidemia. 5 It is likely that these benefits stem from improved
adherence to evidence-based clinical practice guidelines. 4,5 Infectious disease
physicians are also more likely to prescribe the most appropriate antibiotics
and decrease overall antibiotic utilization in hospitals. 6 By following the
approaches described in this chapter, we believe that you can provide
outstanding and high-quality patient care while effectively communicating
with your colleagues.
General Principles
The greatest challenge of the infectious disease consultation is the
breadth of the subspecialty. Disease manifestations can involve multiple
organ systems, expanding across a broad range of medical and surgical
disciplines. Infectious disease consultation requires thorough
evaluation, organized thought processes, and an ability to appropriately
consider rare but significant diagnoses.
Infectious disease consultations can be divided into four general
categories:
Diagnostic dilemmas are by far the most challenging consultation;
these are consults in which a diagnosis remains elusive (e.g., fever of
unknown origin). A thorough history detailing potential exposures
and systematic physical examination is critical.
Therapeutic management involves treatment of a specific infection
as it relates to the overall care of the patient, such as an infected
prosthetic joint.
Antibiotic management ensures appropriate selection, dosing, and
duration of antibiotics for a given infection.
Occupational health and infection prevention address the health of
employees, patients, and visitors within health care facilities.
Ten commandments for effective consultation. Introduced in 1983 and
modified in 2007, these rules provide a framework for effective patient
care and communication with requesting physicians. 7,8 Understanding
the specific expectations of the requesting physician allows one to
address the underlying concerns prompting an infectious disease
consultation. Always remember that a physician requests a service from
the consultant much like a consumer buys products from a vendor.
Determine your customer. Are you providing management for a
surgeon or guidance for an internist? What specific question(s) need
to be answered?
Establish urgency. How quickly should the patient be seen? Several
infectious diseases (e.g., necrotizing fasciitis, cerebral malaria)
require emergent consultation to initiate proper therapy.
Look for yourself. Although one does not need to repeat every
excruciating detail in written consultation, each important detail
should be reconfirmed.
Be as brief as appropriate. Write concise assessments that
adequately explain your rationale.
Be specific and humble. Write clear plans. Provide help in executing
the plans when requested. Such help may include writing orders or
obtaining additional information from other hospitals or health
departments.
Provide contingency plans. Determine likely problems and provide
guidance for their remediation. Provide around-the-clock contact
information to assist in addressing such problems when they arise.
Determine the appropriate level of management. How much should
you intervene regarding writing orders and dictating patient care?
This should be agreed on with the requesting physician during
initial discussions.
Teach with tact and pragmatism. Provide educational materials or
discussions appropriate to the given situation.
Talk is essential. Always call the requesting physician with your
recommendations.
Follow up daily. Daily written/electronic notes should be provided
until problems are no longer active as determined by yourself and
the requesting physician. Provide appropriate long-term follow-up
care.
The “curbside” consultation. Requesting physicians frequently seek
opinions based on limited conversations. Such “curbside consultations”
are considered a courtesy and promote collegiality. When providing
curbside consultation, one should always speak in general terms and
avoid providing absolute recommendations. Frequently, important
historical details are unintentionally omitted, limiting the ability to
provide accurate advice. Generalized guidelines for providing curbside
consultation are as follows:
Appropriate for curbside consultation
Dose or duration of antibiotics for simple infections
Choice of antibiotics for simple infections
Inappropriate for curbside consultation
Complex patient problems
Uncertainty regarding the question being asked by the
requesting physician
Infections due to highly resistant organisms, rare organisms, or
bloodstream infections
Addressing patient concerns. Many patients may feel that additional
questioning by a consultant is redundant or insulting. Frequently, a
thorough review of the medical record followed by empathetic
consultations strengthens rapport with the patient. The following
suggestions can aid in alleviating patient fear:
Advise patients that you are visiting them on the request of their
primary physician and that you will work closely with that physician
to provide the best possible care.
Consider telling the patient that you have reviewed his/her history
and have additional specific questions that you would like to ask
before providing an opinion on his/her care.
Ask the patient to confirm your brief understanding of his/her
history and to supplement information with important details. After
the initial conversation, specific or open-ended questions regarding
the history of the patient’s illness can be asked.
Do not provide information that directly contradicts the clinical care
of the primary provider. Reasons for following a specific care plan
may not be readily apparent at the time of the patient encounter and
should be clarified with the requesting physician before instituting
changes.
Structure of Consult Notes
Consult notes should be written in a fashion similar to that of an
admission history and physical, supplemented with details unique to the
epidemiology and clinical presentation of infectious diseases.
History of present illness (HPI). Provide a thorough review of the
patient’s current illness (i.e., onset, severity, duration, location, etc.) and
hospital course. Specific details of positive findings or pertinent negative
findings from the review of systems, past medical/surgical history,
family history, and social history should be included.
Review of systems. Be thorough and comprehensive in characterizing
the presence or absence of signs and symptoms of disease. Patients may
neglect significant details of the history in their initial encounters that
