Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
Do you prefer vancomycin or daptomycin for gram-positive coverage in culture-negative prosthetic valve endocarditis considering both Corynebacterium and Enterococcus are notable possible pathogens?
In recent years, we have transitioned from using Vancomycin to Daptomycin for the treatment of endocarditis, whether it involves a native or prosthetic valve or culture negative. This shift is primarily due to concerns about intolerance rather than Vancomycin resistance. Additionally, recent literat...
How long would you treat an upper urinary tract infection in a patient with acute obstructive pyelonephritis due to a kidney stone status-post urinary stenting without yet removal of the stone?
After treatment of an ascending urinary tract infection for 7 days, the infection will be treated. However, if the stone is large enough it may be colonized and cause recurrent infection. I would make my best efforts to get the stone removed as soon as possible and I would likely give the patient a ...
Do you recommend starting anti-fungal prophylaxis for patients on systemic antibiotics who have a peritoneal dialysis catheter that is only currently being accessed for once weekly flushes?
This is a unique situation which is for me a strictly hypothetical one, as I've not encountered this situation in my 38-year PD career. Nor am I aware of data to guide a response. On reflection, however, I would answer in the affirmative. Fungal peritonitis is a very serious infection which invariab...
Do you consider the use of tocilizumab in patients with COVID pneumonia who have had an improvement in supplemental O2 requirements but have significantly elevated inflammatory markers after day two of remdesivir and dexamethasone?
I don’t use tocilizumab if the clinical condition is improving.
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...
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.