Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
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 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...
Do you recommend, based on current evidence, avoiding antimotility agents in patients with non-fulminant C. difficile infection who have no evidence of ileus?
I generally avoid their use based on the notions that diarrhea may contribute to the elimination of non-invasive GI pathogens and that impairment of intestinal motility could increase the risk of complications, such as toxic megacolon.The data and recommendations have not progressed beyond the follo...
How long would you hold antibiotics before performing a vertebral biopsy to optimize culture yield in a patient who has been on empiric antibiotics for a week for suspected vertebral osteomyelitis?
I would devote my efforts to obtaining a sample for WGS or other molecular technology and (briefly) delay sampling until an administrative route has been identified. If absolutely not available, antibiotics delay would depend on a) clinical status of the patient and b) tissue T1/2 of antibiotics adm...
Can you safely use a cephalosporin in a patient who previously developed acute interstitial nephritis to amoxicillin?
Amoxicillin-associated interstitial nephritis is most often a type IV hypersensitivity reaction. Cross-reactivity with other beta-lactams is possible but poorly studied. I would try hard to find an alternative.
What is your preferred first-line regimen to treat a severe or fulminant C difficile infection?
IV vancomycin and PO Flagyl are the easiest combination to get for a hospitalized patient. I’ve had much experience with this, and it works very well. IV vancomycin and PO Flagyl as initial treatments in the hospital is my preference. This is before I go onto stronger drugs, with those requiring al...
How would you manage a patient with strongly suspected Lyme arthritis and negative bacterial synovial fluid cultures who was started on empiric antibiotics against typical bacterial pathogens arthritis before arthrocentesis and collection of cultures?
In a patient with a high clinical suspicion for Lyme arthritis who has negative synovial fluid bacterial cultures after receiving empiric antibiotics for presumed septic arthritis, management should be guided by clinical probability rather than the culture results. Antibiotics given before arthrocen...
Do you treat diabetic foot osteomyelitis without surgical resection with a fixed 6-week antibiotic course, or do you shorten duration based on clinical and inflammatory marker response?
The real key factor in successfully treating diabetic foot infections is adequate debridement (and sometimes amputation, like TMA) in the setting of infected bone. We have excellent Podiatrists at our County Hospital and VA, and foot/ankle and vascular surgeons at our University Hospital. You can't ...
How long do you treat Staphylococcus aureus pyomyositis with antibiotics?
I agree, and certainly evaluating for bacteremia that can be associated with these types of infections, which would alter the duration of therapy.
Do you add an adjunctive echinocandin in patients with Pneumocystis?
Though there is emerging literature suggesting that echinocandins may have a role in treating PJP, the dose has not been defined, and TMP-SMX remains the first-line agent.