Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
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.
Do you choose an antibiotic with CSF penetration, such as nafcillin over cefazolin, in the setting of MSSA endocarditis with septic emboli to the brain (assuming no concomitant meningitis or brain abscess)?
The prevailing theory that cefazolin has poor CNS penetration is really based on 3-4 studies performed in the 1980s (Nolan & Ulmer, PMID 7365282) where they were extrapolating data from studies looking at cephalothin concentration in CSF. Another study looking specifically at cefazolin concentration...
What factors influence your decision to initiate antifungal treatment in asymptomatic lung transplant recipients colonized with Aspergillus?
My main driver for using Aspergillus treatment/prophylaxis for asymptomatic colonized patients is their level of immunosuppression; if they have received augmentation for rejection or because of a treatment for cancer, I would strongly consider treatment; another reason would be if they are listed f...
How would you approach treatment duration for patients with persistent Candida species fungemia with a history of a prosthetic heart valve but negative TEE/CT PET and no other identifiable source of infection?
Persistent fungemia in the presence of a prosthetic valve with no other identifiable source despite appropriate treatment is challenging. Few studies report high mortality in the nonalbicans candida group, and the risk increases if the patient is immunocompromised. A multidisciplinary management app...
How would you manage a patient with progressive/refractory molluscum contagiosum who is well controlled on methotrexate for seropositive rheumatoid arthritis?
Molluscum can be more challenging to treat when a pt is taking any immunosuppressive. In treating that patient, I would attempt to use cimetidine 400 mg TID along with a topical retinoid such as Retin A 0.1% bid to each individual molluscum. If there are only a few remaining, recalcitrant lesions, I...
When would you consider long-term suppressive antibiotic therapy in patients with chronic or recurrent bacterial prostatitis who continue to experience symptoms despite multiple courses of antibiotics?
I think this would depend on the organism to be honest. First, I would make sure the patient is seen by urology and evaluated for possible structural reasons for recurrent or chronic prostatitis. If there are no structural issues that can be rectified, I would consider a prolonged course of therapy ...