Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
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...
How do you approach perioperative antimicrobial prophylaxis in patients undergoing reconstructive surgery with myocutaneous flaps whom have recently been treated for active infection?
Generally speaking, if the patient has been fully treated, I do not give antimicrobial prophylaxis other than the guideline-based 1 dose of therapy prior to surgery. If a flap is planned, generally, I would like the patients to complete their course of therapy for active infection prior to flap plac...
What is the best approach to determine whether antiviral post-exposure prophylaxis for influenza is appropriate in an elderly immunocompromised patient who has been vaccinated?
This is purely a matter of clinical judgement. The studies showing the benefits of post-exposure prophylaxis did not use any laboratory data, but it is believed that starting prophylaxis within 48h of exposure is important. The risk of severe complications or death in the hypothetical is unknown, bu...
In addition to ampicillin, is there any benefit to the addition of either gentamicin or Bactrim when treating a patient with listeria meningitis?
There has been a lot of misinformation in the literature for decades about the treatment of Listeria bacteremia and meningitis/encephalitis. Some of this arose based on publications of in vitro studies that claimed that "PCN and ampicillin are bacteriostatic against Listeria." This was based on dete...
Would you consider using long-acting injectable cabotegravir/rilpivirine for pregnant women with HIV?
At this time, long-acting injectable cabotegravir/rilpivirine (CAB/RPV) is not generally recommended during pregnancy due to limited safety data and unknown effects on the developing fetus. So far, there have not been any reported safety concerns regarding harm to the fetus for either long-acting in...