Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
Do you routinely give prophylactic antibiotics prior to ERCP for biliary obstruction in light of recent studies suggesting a reduction of periprocedural infection?
I did not use to give antibiotics routinely prior to ERCP, and it seemed post-ERCP antibiotics were given at the discretion of the advanced endoscopist, but the results of this meta-analysis will likely change my practice so that I'll give all patients a dose of Ceftriaxone prior to the procedure to...
Do you routinely give combination antifungal therapy for invasive mold infections?
The data on triazole single agent versus triazole plus echinocandin for the treatment of invasive aspergillosis are limited. I do not have a standard approach. I generally use a triazole alone, but will use the combination for initial treatment in patients with severe and/or rapidly progressive dise...
Do you recommend multisite testing for gonorrhea and chlamydia as a default screening strategy in sexually active women, regardless of reported sexual exposures?
First, the answers arguably may be different for gonorrhea and chlamydial infection. True pharyngeal chlamydia is relatively uncommon; a positive nucleic acid amplification test (NAAT) sometimes does not mean viable C. trachomatis; positive test results have not been associated with symptoms or sign...
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 routinely order karius in evaluation of culture negative prosthetic valve endocarditis?
Don’t “routinely” order Karius test. Rarely, in culture-negative suspected endocarditis, especially if a prosthetic valve is present. Once for suspected culture-negative aortic graft infection. 3x for culture-negative meningitis. Likely to become more frequent but adoption very dependent on cost an...
What is you approach to C. difficile treatment in patients admitted for acute severe ulcerative colitis (ASUC) with a positive GDH and PCR with a negative EIA for toxins?
GDH is an excellent screening test, but not specific for C. diff. The PCR is for the toxin gene, but does not necessarily indicate that there is toxin production or clinical C. diff. So this combination does not likely represent active C. diff. However, the toxin assay has about a 15% false negative...
Would you treated with a prolonged antibiotic course of 6 weeks for sacral osteomyelitis in a patient with underwent surgical debridement and negative pressure wound therapy device placement but for whom there is no plan for flap coverage?
I would consider shortening the duration of intravenous (IV) antibiotic treatment with earlier transition to oral antibiotics if there was a bone biopsy that was negative for residual osteomyelitis, or if, in discussion with the surgeon, they felt very confident in having removed the area of infecti...
Do you recommend chronic oral suppressive antibiotics after initial intensive treatment of 6-8 weeks in patients with culture-negative prosthetic joint or bone infections with retained hardware?
Another one of those questions without a clear-cut answer. Several retrospective, uncontrolled papers (I should know. I’ve co-authored one myself) suggest this practice is “helpful”. BUT, virtually all these observations are retrospective with relatively short-term follow-up (often 1 or 2 years), an...
Do you switch to an alternative agent for C difficile colitis for a patient with suspected infection and positive testing who continues to have >3 watery bowel movements daily despite multiple days of oral vancomycin treatment?
The question about switching to another agent for Clostridioides difficile (Cdif) colitis in a patient who tests positive for Cdif but continues to have diarrhea despite multiple days of oral vancomycin treatment does not include any information regarding the clinical status of the patient, the pres...
Do you typically narrow to penicillin or first-generation cephalosporin or continue broader anaerobic coverage for patients with cervical lymphadenitis requiring surgical drainage whose cultures grow only group A strep and gram stains only gram positive cocci?
I think the question is getting at whether to continue covering for anaerobes that may come from the oropharynx, even in scenarios where you have proven Group A Strep. In such scenarios, I would typically attribute Group A Strep as the main pathogen and thus focus my treatment on this organism and w...