Vanderbilt Internal Medicine Residency Podcast · Jared Freitas and Terra Swanson

S6: E3 Infectious disease: Pages and Pearls with Casey Smiley

January 6, 2023·37 min·3 clips

Casey Smiley reveals why treating asymptomatic bacteria in urine is often unnecessary and potentially harmful.

Dr. Casey Smiley, a second-year infectious diseases fellow and former co-host, returns to the podcast to share practical advice on managing common infectious disease pages and consults. The episode focuses on building resident confidence in triaging issues before consulting specialists. Dr. Smiley addresses several frequent clinical scenarios, starting with asymptomatic bacteriuria, emphasizing that urine is not sterile and treatment should be guided by symptoms, not just a positive culture. She notes exceptions include pregnancy, recent kidney transplants, and pre-urologic procedures, while altered mental status alone is not a UTI symptom. The discussion covers the limited utility of sputum cultures, which often reflect colonization rather than true infection, particularly with organisms like *Stenotrophomonas*. Dr. Smiley critiques the vague "infectious workup" for fever, advising against automatic urinalysis and chest X-rays without corresponding symptoms. A significant portion examines interpreting *Staphylococcus epidermidis* in blood cultures, which is often a contaminant but requires evaluation for indwelling lines, prosthetic joints, or heart valves. She recommends obtaining three sets of peripheral blood cultures for fever of unknown origin and always treating *Staphylococcus aureus* or *Candida* in the blood as true pathogens. Dr. Smiley stresses that fungal pneumonias like histoplasmosis are not imaging diagnoses and require a compatible history, physical, and specific risk factors like immunosuppression. She highlights that diagnostic tests like 1,3-beta-D-glucan are non-specific and treatment often involves lengthy, toxic regimens. A key insight is that many ID consults revolve around core medical skills, and a thoughtful initial assessment improves consult quality. The hosts emphasize examining the patient and formulating a specific question before calling for help. The tone is educational and conversational, with hosts and guest sharing clinical anecdotes and personal frustrations. This episode is ideal for internal medicine residents seeking to refine their approach to common infections and reduce unnecessary consults. Listeners looking for highly specialized ID content or narrative storytelling might find it too foundational.

As heard by us

A useful reset on when an infectious workup helps and when it just adds noise.

Casey Smiley leads an infectious-disease teaching session about a familiar cross-cover problem: what to do when sign-out says to do an infectious workup and treat to source. The guidance is practical and keeps coming back to clinical context.

Read the full review in PlayNext →

Why you'd press play

If you keep hearing 'infectious workup,' this is the cleaner version for cross-cover judgment.

Read the full recommendation in PlayNext →

Listen to the show on

Apple Podcasts Spotify

Play clips from this episode More from Vanderbilt Internal Medicine Residency Podcast