Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
Have the growing reports about doxycycline resistance in gonorrhea isolates from patients prescribed doxy PEP for prevention of bacterial STIs influenced your use of doxycycline for this indication?
No, they have not. For 2-3 decades, the prevalence of tetracycline resistance in N. gonorrhoeae worldwide, including the US and Western Europe, has been too high to rely on doxycycline or other tetracyclines in treating gonorrhea. The rise in prevalence of tetracycline resistance in MSM, the main po...
How do you weigh the risk of urinary catheter or fecal management system placement with that of soiling sacral wounds?
This question is an important question that arises for many of our bed-bound and poorly mobile patients, as sacral wounds commonly develop due to pressure injury. They become very challenging to treat due to fecal and urinary contamination, which can lead to further infection. Fecal and urinary dive...
What, if any, oral or IV antibiotic suppression options would you consider for a patient with a history of recurrent fluoroquinolone- and TMP-SMX-resistant ESBL E. coli bacteremia with relapsed ESBL E. coli lumbar spinal hardware infection who previously underwent lumbar I&D with hardware retention and is not a candidate for further surgery?
I would base this decision on the full susceptibility profile of the isolate, as well as the specifics of the clinical scenario. The full susceptibility profile is not available to me, but if the isolate is susceptible to any oral beta-lactams, these tend to be associated with the fewest side effect...
How many total days of antibiotics do you prescribe for uncomplicated non-purulent cellulitis in hospitalized patients who show clear clinical improvement within 48–72 hours?
Thanks for the question. Five days total, with transition to oral antibiotics upon clinical improvement to complete this course. Notably, my health system (via our EMR-based clinical decision support tool) recommends penicillin (IV) or amoxicillin (PO) as first-line treatment for nonpurulent celluli...
Would you consider single dose benzathine penicillin G for treatment of latent syphilis of unknown duration based on recent observational data suggesting non-inferiority of one vs three doses for management of all stages of syphilis, as well as to mitigate issues with adherence, poor follow up, and drug shortage?
Yes. I would now consider a single dose of benzathine penicillin G the treatment of choice for all asymptomatic late syphilis in addition to primary, secondary, and latent syphilis under a year in duration. The 3-dose BPG recommendation always was pretty much data-free, an echo of the early days of ...
Do you routinely use oral antibiotics for treatment of vertebral osteomyelitis?
Speaking specifically to my clinical practice, it is very dependent on the individual patient--more or less if they can do the IV/OPAT situation, and what happened with surgery, and what organism; also, are they coming to you outpatient vs inpatient? IDSA guidelines (from 2015) still endorse IV. It ...
How do you approach perioperative antimicrobial prophylaxis in patients undergoing reconstructive surgery with myocutaneous flaps whom have recently been treated for active infection?
Generally speaking, if the patient has been fully treated, I do not give antimicrobial prophylaxis other than the guideline-based 1 dose of therapy prior to surgery. If a flap is planned, generally, I would like the patients to complete their course of therapy for active infection prior to flap plac...
How do you balance the risk of unnecessary treatment with acyclovir against the risk of delaying treatment in encephalitis cases where CSF pleocytosis is absent?
Treatment with IV acyclovir should start as soon as the diagnosis of Herpes simplex encephalitis is considered. Since the question states that CSF pleocytosis is absent, then CSF has been obtained. PCR for HSV should be obtained on that CSF. Early in my career, when acyclovir was investigational and...
When do you recommend limited or targeted respiratory pathogen testing versus a full respiratory pathogen panel in a patient presenting with URI symptoms?
I think we’re asking the wrong group of people. How infectious disease physicians use respiratory pathogen panels is not the same as how emergency medicine or urgent care clinicians use them. For stewards of diagnostics, especially ID providers, the test often doesn’t change management. In many sett...
Do you routinely recommend adjunctive rifampin therapy for the management of Staphylococcus aureus native vertebral osteomyelitis?
The short answer is 'no.' Rifampin was first studied to use with orthopedic hardware infections due to MRSA as a way to penetrate the biofilm layers on the hardware. That concept is true with prosthetic heart valves (but not universally). Can a heart valve develop a Staph aureus biofilm? Yes, but th...