Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
Would you still treat with course for osteomyelitis if proximal bone cultures after amputation are still positive but pathology does not demonstrate osteomyelitis?
Like many questions in Infectious Diseases, the answer is “it depends.” This includes the type of amputation (I have a lower threshold to treat after a ray amputation, whereas I am more comfortable stopping therapy after a below-knee amputation), the organism isolated (particularly when Staphylococc...
How would you approach treatment in a patient with refractory Coccidioidal meningitis who has previously been treated with IV amphotericin B?
The previous receipt of amphotericin B is irrelevant. Shortly after its introduction in the mid-1950s, it was recognized that it was ineffective in the treatment of coccidioidal meningitis when given intravenously and that intrathecal administration was necessary (Winn, PMID 14065439). The introduct...
How many doses of IM penicillin would you recommend for a patient with biopsy confirmed syphilis proctitis?
Syphilis is not a common cause of proctitis but apparently the biopsy confirms it. Almost certainly, the patient has primary or secondary syphilis, and standard treatment for early syphilis, a single 2.4 MU dose of benzathine penicillin G, is sufficient. If other evidence is more consistent with syp...
What is your approach to relapsing babesiosis in immunosuppressed patients?
The first thing to do is to try to confirm that this is a relapse rather than a reinfection. If it is a true relapse, there is no proven established approach, but these are the options. If possible, try to decrease the level of immunosuppression The IDSA guidelines from 2020 recommend 6 weeks of st...
How do you manage increasing EBV viremia of 15,000 copies in a seropositive heart transplant recipient with transplant performed 15 years ago in a patient who is otherwise asymptomatic?
This begs the question as to why it was checked. Without knowing that, the answer is difficult. If the patient is truly asymptomatic, then perhaps this can be ignored. Current immunosuppression would also be relevant; for example, if there was recent rejection or a change in immunosuppressant medica...
Under what circumstance would you order dalbavancin instead of vancomycin or daptomycin for MRSA endocarditis?
IVDU or any barriers to get daily IV abx.
Do you routinely use two empiric antibiotics to cover for Pseudomonas aeruginosa in the management of CF exacerbations?
Historically, two antibiotics have been used to cover Pseudomonas pulmonary exacerbations. The last guidelines were published in 2009 (Flume et al., PMID 19729669 ). At that time, the expert guidelines stated, "The CF Foundation concludes that there is insufficient evidence to recommend the use of a...
Has your approach to direct-from-blood bacterial testing changed after a pragmatic RCT showed no reduction in antibiotic duration compared to blood cultures alone?
No. As an ID practitioner and steward, I am using the data provided by the rapid diagnostics to target therapy as quickly as possible and minimize unnecessary broad abx as possible. As summarized by Banerjee et al., PMID 26197846, and as cited in this paper, active stewardship with audit/feedback is...
What drug and specific dosing would you use for secondary pneumocystis prophylaxis in a patient with renal transplant, documented TMP-SMX allergy, and normal G6PD testing, who was diagnosed with moderate PJP and improved on clindamycin/primaquine and steroids?
I think the options are dapsone (which is tolerated by most patients allergic to TMP/SMX), atovaqone, and inhaled pentamidine. During my career, those choices have depended to some extent on the local practice. I have preferred inhaled pentamidine because I have worked in places with low volume and ...
What is your approach to a situation where DILI is suspected secondary to an important medication (e.g., anticoagulation, antibiotics, etc.), but the diagnosis is uncertain and the liver injury is relatively mild?
If the drug suspected to induce liver injury causes symptoms and ALT is >3 times the upper limit of normal (ULN), I would stop the drug and find an alternative. Even if no symptoms are present, I would stop if ALT is >5 times ULN. Any level increase of ALT below the above parameters would still requ...