Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
For how long would you treat a patient with dematiaceous fungi growing on a native heart valve discovered at the time of valve replacement?
The first step is to determine whether the positive culture may be a contaminant, as it very well could be. Every valve sent for culture should have also been sent for histopathological examination. In a patient with fungal endocarditis, one should expect to find evidence of acute inflammation and t...
Which biomarkers or diagnostic tools do you prioritize to support the decision to start antifungal treatment in septic patients with no clear source of infection but at high risk for fungal infections?
In general terms we do not use biomarkers to decide to start antifungals in a septic patient. We use them to confirm or rule out the infection once the antifungals were started based on clinical suspicion/presentation. BDG in particular has very good negative predictive value for candidemia, but due...
How have the results of the BALANCE trial, which demonstrated the noninferiority of 7 days of antibiotics compared to 14 days for non-S. aureus bloodstream infections, influenced your practice?
Although one trial does not make a standard of care, we have been aware of this publication and have “kicked around” the possibility of instituting such a short course. Not ready to adopt this (yet), but we have chosen to transition from IV to oral therapy earlier and earlier. Not quite the same iss...
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...
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...