Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
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.
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...
What is your approach to antimicrobial prophylaxis in adult patients undergoing treatment for HLH?
We often use bactrim for pneumocystis prophylaxis if high dose steroids are used and discuss the use of possible fluconazole for antifungal prophylaxis on a case by case basis. However, we do not have a specific protocol for these patients.
How would you manage a patient with Crohn's disease on a biologic and presents with non-bloody diarrhea, normal-appearing mucosa on sigmoidoscopy but severe colitis on biopsy with a positive CMV stain?
A few key pieces of information help distinguish CMV colitis from other competing diagnoses in this frequently encountered conundrum. An experienced pathologist will usually be able to tell you: If the CMV immunohistochemistry stain has good controls and whether it is floridly positive or scant. Al...
How do you factor cerebrospinal fluid (CSF) antibody results when deciding on the diagnosis and treatment of racemose neurocysticercosis, given the uncertainties associated with CSF antibody testing?
Antibody testing using an enzyme-linked immunoelectrotransfer blot (EITB) is an excellent test. It actually performs better when done on serum than CSF. Therefore, I do not do it on the CSF. The sensitivity of serum is close to 100%. This is available through the CDC and some commercial laboratories...