Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
Do you routinely recommend adjunctive rifampin therapy for the management of Staphylococcus aureus native vertebral osteomyelitis?
The short answer is 'no.' Rifampin was first studied to use with orthopedic hardware infections due to MRSA as a way to penetrate the biofilm layers on the hardware. That concept is true with prosthetic heart valves (but not universally). Can a heart valve develop a Staph aureus biofilm? Yes, but th...
What is your approach to secondary prophylaxis for C difficile infection during concomitant antibiotic use in a patient with a history of C difficile infection?
We have been restricting secondary prophylaxis to those patients with severe protein malnutrition, receiving immunosuppressive chemotherapy, generally at the extremes of age who require unavoidable systemic antibiotics that cannot be withdrawn. Based on the 2024 paper by Ronza Najjar-Debbiny et al.,...
What is your approach to therapy in patients with progressive Scedosporium pulmonary infection who are not candidates for surgical debridement?
Scedosporium species are increasingly common clinical isolates in patients with bronchiectasis (both CF and NCFBE). There are precious few publications describing these infections in immune-competent hosts, but it seems that these infections tend to be symptomatic (rather than asymptomatic colonizat...
For which patients or under which circumstances do you recommend a 9-month over a 6-month course of isoniazid for treatment of LTBI?
The preferred regimens now for the treatment of latent TB infection are shorter rifamycin-based regimens. We have options of 3 months of isoniazid and rifapentine given once weekly, or 4 months of rifampin given daily, or 3 months of isoniazid and rifampin given daily. Isoniazid-only regimens are no...
Do you transition to oral antibiotics to treat uncomplicated Staphylococcus aureus bacteremia after patients have improved with intravenous antibiotic therapy?
I don't understand the design of these "PO vs IV" abx trials. RCTs, of course, are done to minimize the differences between the experimental and control groups. Hopefully, through randomization, the only significant difference will be the "experiment" or treatment. However, in this and most "PO" stu...
What is the preferred treatment regimen for cardiovascular syphilis, specifically syphilitic ostial coronary artery disease?
The standard treatment with benzathine pen G 2.4 MU IM, 1-3 doses at weekly intervals, depending on likely duration of syphilis, should be sufficient. Most likely there is no need for especially high dose penicillin therapy. I can understand a theoretical rationale for it, for urgent or potentially ...
Do you preferentially avoid use of piperacillin-tazobactam for empiric anti-pseudomonal coverage in hospitalized patients due to risk of nephrotoxicity?
The bulk of published data indicates that the onset of nephrotoxicity in patients receiving piperacillin-tazobactam plus vancomycin seldom occurs before 3 days of the combination. Thus, I do not object to initiation of this combination empiric therapy, but, as in all cases, therapy must be reevaluat...
Would you ever consider oral doxycycline for treatment of either gram-negative or gram-positive uncomplicated bacteremia?
I would not consider this a first or even second-line option due to the poor serum levels that are achieved. I supposed that this could be used for "mop up" therapy, but in such cases, it's almost as if you are using the doxy to treat yourself rather than the patient.
Is arbovirus testing available in your state outside the traditional summer season?
Within our health system, the majority of arbovirus testing is sent to commercial labs instead of to the state lab. This testing is available year round. Notably, there is a high risk for cross-reaction for ELISA serologic testing between viruses within the same genus such as the Orthoflaviviruses. ...
Do add a macrolide for immunomodulatory effect in patients with macrolide-resistant M. abscessus?
I think using azithromycin is something that definitely can be considered, but on an individual basis; if there is significant bronchiectasis with exacerbations, then it makes sense to consider azithromycin; more likely to consider also if there are other microorganisms, especially Pseudomonas drivi...