Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
Is there a role for dual antibiotic treatment with ethambutol and macrolide only, as opposed to three-drug antibiotic therapy, in the treatment of treatment-naive pulmonary MAC without cavitary disease?
That is a great question, as the role of rifampin (or rifabutin) regarding its relative contribution to the treatment of MAC is not overly clear. Historic data that is a few decades old raised the possibility of better activity when a rifamycin is combined with ethambutol (at least in vitro and furt...
What workup is sufficient to determine if an aortic aneurysm is "mycotic/infectious" or not, in that you would not prescribe empiric antibiotic therapy?
It depends on your index of suspicion. If the clinical picture looks consistent with mycotic aneurysm, this is the one time where I have found karius testing to be helpful, particularly with nutritionally-variant strep species which can be tough to culture.
Do you routinely recommend treatment for patients with chronic osteomyelitis of long bones based on radiographic findings alone in the absence of superficial infection or recommend bone biopsy to evaluate for therapy?
I don't routinely treat an unconfirmed diagnosis. The plan should always be to ascertain the diagnosis.
What additional workup would you recommend for a patient with a liver abscess caused by Fusobacterium and Aggregatibacter, who has had unrevealing endoscopies and no other abdominal masses on a CT scan?
When I trained, we called it actinobacillus, now apparently aggregatibacter. Part of the HACEK group - causes of periodontitis and endocarditis. Fusobacterium I also with dental disease, oral infections and bacteremia. So my main interest would be the teeth, head/neck and endocarditis. In my populat...
Is there a role for beta-lactams as step-down oral therapy for uncomplicated gram-negative bacteremia?
For carefully selected patients - yes. Patients who might be good candidates for transition to oral beta-lactams for uncomplicated gram-negative bacteremia would-be patients: clinically stable, improving on IV abx with functioning GI tracts (no issues with absorption of antibiotics) not immunocompro...
When would you initiate exchange transfusion in babesiosis and significant hemolysis?
There are no studies that answer this question. Some people have extrapolated from the use of exchange transfusions for severe malaria to consider using this treatment with babesiosis, another intraerythrocytic protozoan infection. Unfortunately, though there are some studies on malaria, the results...
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...