Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
How do you use gut microbiome or gut microbiota analysis in your clinical practice, if at all?
While I am presented with microbiome analyses on a regular basis by patients, I do not believe that these are useful, as we are still not there when it comes to defining the "normal" microbiome. This indeed may vary tremendously between individuals depending on age, gender, diet, geographic location...
Would you recommend antifungal treatment or observation without therapy in an immunocompetent patient with a pulmonary nodule who underwent malignancy workup and was found to have yeast forms consistent with histoplasma on GMS stain?
We have seen a number of patients who have had a lung biopsy for a solitary pulmonary nodule to exclude the diagnosis of cancer. When histoplasmosis is identified by pathology, we obtain a urine histoplasma antigen as well as a careful history and exam, and some lab tests for immunosuppression. If n...
Do you treat prosthetic joint infections after a two-stage revision arthroplasty with oral antibiotics for the full duration of therapy, assuming a susceptible oral option is available?
This is a hard one-I definitely think the data is there for PO, but until the IDSA recommendations change and the culture of practice changes it is hard to make the switch to doing a full regimen PO! I also think the accountability of IV antibiotics is useful -with the visiting nurse, weekly labs, i...
What is the recommended duration of therapy for Enterococcal bacteremia from a urinary source in patients with prosthetic valves assuming negative TEE and clearance of bacteremia?
I guess a few questions. How quickly did the blood cultures clear? How good was the quality of the TEE? What is meant by treatment of enterococcal bacteremia, a single agent or endocarditis regimen? How long was the patient sick before they came in? ESR? Hgb? I guess, peripheral stigmata can be look...
How exhaustive (especially considering cost) should an immunological workup be for patients with extensive, recurrent, or deep seated Staph aureus infections without obvious immunocompromise (e.g. cancer, diabetes, steroids) or recurrent breaks in skin integrity?
Obviously, children with recurrent Staph aureus infections should be evaluated for both CGD (chronic granulomatous disease) and IgM deficiency. However, the majority of adults with recurrent SA infections do not have a known systemic immunodeficiency. We should keep in mind that Staph aureus is an a...
What is your approach to duration of fidaxomicin in a patient receiving treatment for first C difficile infection while also receiving concurrent antibiotics for an infection?
Yes, I would extend the duration of Fidaxomicin for at least 7 days past the completion of antibiotics. Additionally, I would consider resuming Fidaxomicin if a patient needs additional antibiotics within 2 weeks of having completed C diff treatment.
How would you manage a frail but functioning elderly patient with extensive thoracolumbar spinal fusions 4-5 years ago now presenting with copious purulent drainage from L2-L4 whose MRI shows no osteomyelitis or abscess, and who has mild pain but no systemic signs or symptoms of illness?
I would see if there is any way to get a culture (not a swab of the purulence, but maybe a bedside procedure where a deeper sample can be taken without requiring anesthesia). Once I have the culture, I would target the bacteria isolated and give chronic lifelong suppressive oral antibiotic therapy t...
Do you recommend immunomodulating treatments such as steroids or IVIG for West Nile Virus neuroinvasive disease?
In review of the literature and CDC recommendations, the outcomes when using IVIG in this setting are variable. It has been utilized in immunocompromised patients such as solid organ transplant recipients. I have not found enough evidence to support using it in a non-immunocompromised patient. The s...
Do you ever switch to vancomycin after clinical improvement and blood culture clearance in a patient with high grade vancomycin-susceptible MRSA bacteremia in whom a salvage regimen was initiated?
1. Salvage regimen (usually higher dose daptomycin + beta-lactam agent, often, ceftaroline) is used in various scenarios. Persistent bacteremia with: High vancomycin MIC No obvious source The source is obvious, but the source control is not imminently possible or too risky to justify any surgical i...
Are there situations where you would consider treating E faecalis or E faecium that grows from a respiratory culture?
Pretty much almost never! Enterococcus is not recognized as a pneumonia pathogen. In the setting of a lung abscess, I suppose you could consider treating it as part of a polymicrobial infection. In a heavily immunocompromised patient, it is possible that enterococcus might cause pneumonia—and it has...