Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
Do you recommend a prolonged duration of antibiotics and/or suppression for patients without pre-existing hardware who have placement of new hardware after decompression/washout of a Staphylococcus aureus epidural abscess?
If the hardware is placed in the setting of active infection, then I usually chronically suppress the patient indefinitely after treating for the acute infection.
How do you approach the use of fidaxomicin versus vancomycin for initial Clostridioides difficile infection in immunocompromised patients, considering the lower recurrence rates but higher cost of fidaxomicin?
Whether immunocompromised or not, fidaxomicin has been demonstrated to be superior to vancomycin – not in resolution of the acute infection but in reducing the risk or recurrence by approximately one-half. In one study of hospitalized patients published in 2015, it was reported that, when taking int...
When do you use a carbapenem empirically to treat a patient with Acinetobacter infection?
Significant rates of Acinetobacter resistance to multiple classes of antimicrobial agents are a global concern. Mechanisms of resistance include bacterial production of beta-lactamases (i.e., carbapenemases), changes in porin channels, and alterations of target or cellular function due to mutations ...
How do you counsel a patient diagnosed with HTLV after an abnormal blood donor screening, especially in light of new data that dolutegravir may reduce uncommon but severe neurological outcomes associated with infection?
We actually do not see many individuals with HTLV disease at present in the US. Having said that, HTLV is a retrovirus, so it is biologically plausible that integrase inhibitors (like dolutegravir) could reduce viral spread in the body. However, the key counseling message is: evidence is still emerg...
What is your approach to empiric treatment of achromobacter infections?
Achromobacter is a Gram-negative bacterium in the Burkholderia order. This pathogen is significant in immunocompromised patients, such as those with cancer or Cystic fibrosis, and is seen with bacteremia or causing pneumonia. They can also be associated with foreign device infections. Typically, the...
How would you manage MRSA and Enterococcus faecalis bacteriuria in a patient presenting in severe heart failure without urinary symptoms, fever, or chills, two negative blood cultures, and whose transthoracic echocardiogram shows no new valvular abnormalities?
The core question here is: are you dealing with asymptomatic bacteriuria or a true infection? In the absence of urinary symptoms and in following the IDSA UTI guidelines, asymptomatic bacteria should not be treated except in specific clinical scenarios - pregnancy, urologic instrumentation, renal tr...
Do you perform routine screening for latent tuberculosis in a patient who resides in the United States, has frequent, 1-2 week trips to see family in a highly endemic country, but who otherwise has no significant risk factors or high risk exposure activities?
If an individual has qualifying risk factors for latent TB, including frequent travel with relatively prolonged stays to TB endemic regions, I do offer and perform testing for latent TB. This is an opportunity to identify individuals with latent TB and offer treatment. Failing to screen is a missed ...
Would you consider leaving fever untreated in patients with sepsis to potentially enhance immune responses and antimicrobial efficacy?
In light of the review article attached (Tilanus et al., PMID 41113323), there is some data reviewed supporting that fever is actually therapeutic. Four articles are of special interest in the review. Two are from the 70s, before sepsis was defined as it is today. Two are in the last 15 years, but o...
Do you generally recommend device exchange/removal in patients with gram positive bacteremia in the setting of intra-aortic balloon bump or other mechanical circulatory devices?
I am assuming in this case that the patient has a mechanical circulatory support device such as an LVAD, IABP, or another implantable device, and has developed gram-positive bacteremia. No further details about the device type or clinical scenario are provided. In such cases, device removal is recom...
What is your approach to monitoring of inflammatory markers during treatment of native vertebral osteomyelitis?
As long as the patient is clinically stable and CRP is coming down, there is generally no need for follow up imaging. Key reference: Kowalski et al., PMID 16779743.Also, good to remember that ESR is a very expensive test which basically measures fibrinogen (may cost $500 or more since it has to be r...