Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
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...
Do you routinely recommend transition to dual PO antibiotic coverage for strep species and MRSA, for patients with purulent cellulitis and in the absence of culture data?
I use mostly Linezolid because: It’s now much cheaper. Even if on serotonin drugs, I can half the serotonin dose while they are on it. Covers pretty much all Strep and Staph, including MRSA. Protein synthesis inhibition may reduce toxins (like clinda in Strep fasciitis). There is no renal dose adju...
Do you recommend multisite testing for gonorrhea and chlamydia as a default screening strategy in sexually active women, regardless of reported sexual exposures?
Yes
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...
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...
Do you recommend to exchange nephrostomy tubes when a patient is diagnosed with a urinary tract infection in the absence of any overt signs of infection at the exit site?
This patient has asymptomatic bacteriuria by definition - apparently with occasional symptomatic UTI. I would not change the tube because of the ASB like I would not change a urethral catheter in the setting of ASB. And as noted the patient has already demonstrated continued ASB after changing the t...
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...
What approaches can we take to initiate therapy and improve survival rates in patients with HLH?
At our institution, we have comprised a multidisciplinary team to help treat these patients. The team or "HLH task force" as we like to call ourselves is comprised of a clinical immunologist, rheumatologist, dermatologist, critical care physician, hepatologist, BMT attending/hematologist, infectious...
Should asymptomatic esophageal candidiasis identified incidentally on endoscopy be treated?
Yes, in our practice, we do treat asymptomatic esophageal candidiasis when found incidentally on endoscopy. A few things to consider: 1) While patients may be asymptomatic at the time of the endoscopy, untreated disease can lead to the future development of complications/symptoms, such as odynophagi...