Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
Do you typically narrow to penicillin or first-generation cephalosporin or continue broader anaerobic coverage for patients with cervical lymphadenitis requiring surgical drainage whose cultures grow only group A strep and gram stains only gram positive cocci?
I think the question is getting at whether to continue covering for anaerobes that may come from the oropharynx, even in scenarios where you have proven Group A Strep. In such scenarios, I would typically attribute Group A Strep as the main pathogen and thus focus my treatment on this organism and w...
Do you obtain routine blood cultures in a non-immunocompromised patient with community-acquired pneumonia who does not meet criteria for severe CAP?
Fabre et al., PMID 31942949, categorizes "non-severe community-acquired pneumonia" as low yield for bacteremia and therefore less critical and potentially wasteful/poor stewardship to obtain blood cultures, however do note that severe community-acquired pneumonia (CAP) falls into a moderate pre-test...
How do you decide when to initiate antibiotics for superimposed bacterial pneumonia in patients with influenza?
Antibiotic therapy should not be routinely prescribed for patients with influenza and should instead be reserved for those with a specific clinical concern for secondary bacterial pneumonia. This diagnosis is best identified by clinical trajectory. Key triggers include initial improvement followed b...
What is the recommended fungal workup in an immunocompromised patient after 5 days of persistent fever?
For any patient with fevers, I focus significantly on any symptoms that a patient might have, like headache, diarrhea, and sinus symptoms, and work up a differential diagnosis based on possible pathogens in this area. If I am not finding anything, I would obtain a CT chest/abd/pelvis, as both invasi...
Do you recommend, based on current evidence, avoiding antimotility agents in patients with non-fulminant C. difficile infection who have no evidence of ileus?
I generally avoid their use based on the notions that diarrhea may contribute to the elimination of non-invasive GI pathogens and that impairment of intestinal motility could increase the risk of complications, such as toxic megacolon.The data and recommendations have not progressed beyond the follo...
How would you manage a patient with necrotizing pneumonia due to a susceptible Pseudomonas aeruginosa strain who continues to have significant purulent secretions and worsening imaging while receiving cefepime?
I agree, not enough information here to make a firm recommendation, but often times these necrotic pneumonias will undergo significant liquefactive necrosis, and all of that dead lung and purulence has to come out through the mouth. I tell patients that they may have a worse cough for a while, and t...
What is your preferred oral regime with duration for treatment of onychomycosis?
My new favorite regimen is: terbinafine 500 mg once daily for one week, then take 3 weeks off. Repeat for 4, once weekly cycles. Sprenger et al., PMID 31487828
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...
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.