Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
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...
For how long would you treat Klebsiella aerogenes folliculitis of the face manifesting as a cystic lesion?
My recommendation would be to treat for 7-10 days. It is more typical to see gram-positive organisms causing facial folliculitis so I would choose an antimicrobial that has gram-positive coverage as well if possible, based on sensitivity. Additionally, I would ask the patient (if male, to change to ...
Have you incorporated the use of steroids for patients with severe community-acquired pneumonia?
Yes, the evidence is pointing toward starting steroids (hydrocortisone at 200mg total daily dose) early (in the first 24 hours) in patients with severe CAP who do NOT have influenza. In septic shock caused by CAP, steroid recs follow the septic shock guidelines. Dequin et al., PMID 36942789 showed t...
Do you consider late latent syphilis adequately treated if a patient receives a 10-14 day course of IV ceftriaxone for another indication?
This is a great question and not uncommon scenario. First, I would emphasize the importance of accurately staging the patient as 'late latent' and be sure there are no current signs or symptoms concerning for neurosyphilis, ocular, or otic (even before the IV CTX was given). Having said that, the bo...
What infectious prophylaxis do you use for patients with newly diagnosed multiple myeloma?
Excellent question for sure. In order of controversial nature/lack of evidence/lack of consensus around evidence: 1) Antiviral prophylaxis - I don't think there's any controversy around this, particularly in patients on PIs and/or a CD38 mAb. We do use acyclovir even in patients who have received th...