Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
How do you decide between ceftolozane/tazobactam and ceftazidime/avibactam for empiric treatment of an infection due to difficult-to-treat Pseudomonas aeruginosa while awaiting additional susceptibilities?
Either is generally acceptable. The choice of empiric therapy in this circumstance may be dependent on additional information, if available. As an example, a patient with cystic fibrosis may have recent microbiological data that could guide the decision. Such information, however, is not often avail...
What is the role of anticoagulation in patients with septic thrombophlebitis?
The role of heparin anticoagulation in septic thrombophlebitis is controversial. There are limited to no randomized trials to document outcomes. A systematic review (Falagas et al., PMID 17222406) supported this practice, and the Infectious Disease Society also supports this practice. The role of or...
Do you use standard dose or "meningitis dosing" of antibiotics when treating epidural abscesses, in the absence of CNS symptoms?
Not always. While I will use meningitis dosing for initial therapy, I have no qualms about using cefazolin for MSSA (and several recent publications support this), nor using ceftriaxone 2g/d for streptococcal infection. And frequently after the initial 3-4 weeks on IV, I transition to oral doxycycli...
Have you used oral vancomycin as prophylaxis for C difficile infection in patients admitted for allogeneic hematopoietic cell transplant?
Yes, but only in patients with a history of C difficile in the previous year and starting at the time of initiation of broad-spectrum antibiotics (e.g., for fever and neutropenia). We use 125 mg daily.We are aware this practice may be controversial. To my knowledge, there is only one randomized tria...
Would you treat a brain abscess due to S. anginosus longer than one caused by another organism?
Depending on the Clinical Picture, usually standard duration, but I once had a case with Strep anginosis abscess which started as a liver abscess, went on to be a pneumonia, then a brain abscess and also Thoracic Spine intramedullary abscess. I did 12 weeks of therapy. Repeat scans showed a mild dec...
Do you routinely perform echocardiography in patients with Staphylococcus aureus bacteremia deemed low risk for metastatic infection, or do you selectively omit it based on specific clinical criteria?
A limitation of the applicability of this study is that no isolates of MRSA were detected. Thus, there would be no strains, such as USA300-like strains, with both virulence and resistance mechanisms. In this situation, the goal is to avoid morbidity and mortality from a uniformly deadly disease: S. ...
Do you recommend low or intermediate dosing of TMP-SMX over high dosing for the initial treatment of non-disseminated pulmonary nocardiosis?
I would use low or intermediate dosing for non-disseminated pulmonary nocardiosis. I am not familiar with evidence supporting high-dose in this setting, and a retrospective review from investigators from the Mayo clinic sites last year showed similar outcomes (Yetmar et al., PMID 38922564). High-dos...
Do you use first generation cephalosporins to treat non-endovascular streptococcus mitis infections?
If the organism is susceptible, I would recommend to use Ceftriaxone as the recommended cephalosporin. There has been an overall increase in resistance to Beta Lactams with Strep Mitis, so a review of susceptibility would be important.
Do you choose an antibiotic with CSF penetration, such as nafcillin over cefazolin, in the setting of MSSA endocarditis with septic emboli to the brain (assuming no concomitant meningitis or brain abscess)?
The prevailing theory that cefazolin has poor CNS penetration is really based on 3-4 studies performed in the 1980s (Nolan & Ulmer, PMID 7365282) where they were extrapolating data from studies looking at cephalothin concentration in CSF. Another study looking specifically at cefazolin concentration...
What factors influence your decision to initiate antifungal treatment in asymptomatic lung transplant recipients colonized with Aspergillus?
My main driver for using Aspergillus treatment/prophylaxis for asymptomatic colonized patients is their level of immunosuppression; if they have received augmentation for rejection or because of a treatment for cancer, I would strongly consider treatment; another reason would be if they are listed f...