Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
What is your approach to the management of asymptomatic bacteriuria in an elderly patient without clear urinary symptoms but with cognitive changes and falls?
Asymptomatic bacteruria does not cause altered mental status. Data suggests that when we attribute acute changes to it, we will be wrong about 85% of the time, thereby missing the true etiology. It is a difficult thing to educate staff of senior living facilities and families who have been told it w...
Does your hospital or institution have an Antimicrobial Stewardship Program (ASP), which oversees ID physicians, and if so, does the ASP have the authority to refuse an antibiotic prescribed by an ID consultant?
We have ASP and the ID docs have a very collegial relation with our PharmD who are both ID pharmacists. They are very helpful and they do not block the ID consultants. When ID consultant recommends something that should not be done due to drug interaction for instance The pharmacist will call explai...
Do you routinely recommend IV systemic antibiotic therapy in additional to intravitreal antibiotic therapy for exogenous bacterial endophthalmitis?
Post-surgical (exogenous) endophthalmitis is an uncommon complication with the incidence ranging from 0.04%-0.3%, 0.019%- 0.54%, and 0.11% - 0.03% following cataract surgery, intravitreal injection, and vitrectomy, respectively (Soliman et al., PMID 32467482). Initial management of exogenous endopht...
What is your approach to work up and management of a patient with advanced HIV and poor adherence to therapy presenting with dysphagia and fever?
I would first do an HPI (is the dysphagia for both liquids and solids?), then a quick physical exam, with a full set of vital signs. In terms of basic blood work, I would get a CBC and BMP, liver function tests, a set of blood cultures, a chest x-ray, along with a viral load and CD4 T cell count, wh...
Do you recommend a prolonged duration of antibiotics and/or suppression for patients without pre-existing hardware who have placement of new hardware after decompression/washout of a Staphylococcus aureus epidural abscess?
This can be a difficult clinical scenario and the answer depends in part on whether there was any concern for osteomyelitis at the time the epidural abscess was drained. If so, I would suggest giving a prolonged duration of abx with 6 weeks of targeted IV abx therapy and oral Rifampin followed by 3 ...
For patients with MSSA bacteremia and planned oxacillin at home via OPAT due to start the day after discharge, would you consider discharging after a one-time dose of ceftriaxone or daptomycin?
In a patient with MSSA bacteremia, I would not be comfortable sending a patient home after one dose of ceftriaxone or daptomycin to continue outpatient anti-staph IV antibiotics. Staphylococcus aureus bacteremia causes distant seeding in more than 1/3 of cases and has a mortality rate ranging betwee...
In light of recent measles outbreaks in the US, would you recommend an MMR booster for immunocompetent patients born before 1957?
I would not recommend a measles vaccine for a person born before 1957. This year has been chosen because people before born before 1957 have a very very high likelihood of having had measles because virtually all children got this highly contagious disease. On the other hand, there is no harm to get...
Do you use MRSA nares PCR to influence antibiotic selection for non-respiratory infections?
BLUF: Yes, I use a MRSA nares PCR for early de-escalation in the stable patient with a non-purulent, non-respiratory infection. Mergenhagen et al., PMID 31573026 retrospectively examined nearly half a million clinical cultures and compared them to MRSA nares results. Among all infections, the NPVs w...
Should asymptomatic esophageal candidiasis identified incidentally on endoscopy be treated?
Yes, in our practice, we do treat asymptomatic esophageal candidiasis when found incidentally on endoscopy. A few things to consider: 1) While patients may be asymptomatic at the time of the endoscopy, untreated disease can lead to the future development of complications/symptoms, such as odynophagi...
Would you recommend anti-fungal treatment for aspergillus infection for a patient with an incidental finding of worsening ground glass opacities and enlarging nodules on CT chest with positive BAL galactomannan, elevated aspergillus IgE and IgG in an otherwise immunocompetent host with no respiratory symptoms?
No, I would not recommend antifungal treatment in this case. The patient, as described, does not seem to have invasive aspergillosis, chronic necrotizing aspergillosis, or allergic bronchopulmonary aspergillosis, so I don't believe antifungal treatment is indicated. There may be other details of the...