Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
How do you suggest incorporating POCUS into the evaluation of SSTIs, and do you use this as a means to guide initial antibiotic selection?
I routinely incorporate POCUS into my SSTI evaluation because it reliably distinguishes simple cellulitis from purulent infection, which directly guides my initial management. A quick bedside scan allows me to rule out a drainable abscess. If the scan shows only cobblestoning without a fluid collect...
How do you treat a patient with a gram-negative infection with resistance to imipenem but sensitivity to meropenem and negative for Carbapenem resistant organism by xpert Carba-R-assay?
The finding of meropenem susceptible, imipenem resistant GNR can be explained in Pseudomonas aeruginosa by efflux pump overexpression and porin (particularly OprD) loss. The opposite pattern in P. aeruginosa - imipenem susceptible, meropenem resistant – has often been attributed to overexpression of...
When do you consider using a paramedian approach for a lumbar puncture?
I consider the paramedian approach for lumbar puncture in several clinical scenarios: When patients are unable to adequately flex their spine. When midline interspaces are narrow (<1 cm). When ultrasound reveals densely calcified spinal ligaments—a common finding in elderly patients that can obscure...
What is your approach to distinguishing a Jarisch-Herxheimer reaction from a delayed anaphylactoid reaction?
As with most things in medicine, this is context-dependent. The Jarisch-Herxheimer reaction is a systemic inflammatory response to the death of bacteria (most commonly associated with spirochetes and in particular, syphilis), typically in the hours following antibiotic administration. This response ...
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...
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...
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...