Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
Do you usually recommend a modified diet for Clostridioides difficile infection (CDI)?
Post-infection IBS is common after C. diff infection, and some of these patients have dietary intolerances. Other than avoiding foods that exacerbate these symptoms, I do not recommend any particular diet. I also do not recommend probiotics, in keeping with society guidelines.
How do you manage resistant infections that persist after stopping antibiotic therapy in patients with non-CF bronchiectasis?
It depends on what is meant by resistant infections; if this means multi-drug resistant bacteria that remain present after treatment ends and when symptoms have returned to baseline, there are many things to consider. First, has the person had many exacerbations before? Or do they have minimal sympt...
How would you approach a patient without a history of chronic urticaria who presents with urticaria to multiple antibiotics of different classes (penicillin, cephalosporins, TMP/sulfa, azithromycin)?
While theoretically you could formally evaluate (and try to delabel) all 4 classes of antibiotics, generally it makes sense to focus on the ones that are clinically most useful - which are 1) the beta-lactams, 2) macrolides, and 3) sulfonamides. For a typical patient with a history of only urticaria...
How does trimethoprim-sulfamethoxazole's efficacy against S. pyogenes influence your empirical treatment of skin infections in regions with high resistance rates?
Recommendations against using trimethoprim-sulfamethoxazole (TMP/SMX) for group A strep (GAS) skin and soft tissue infections (SSTIs) likely stemmed from a misconception that GAS is inherently resistant to the drug. Older studies reporting resistance used media containing a high thymidine concentrat...
Do you obtain routine blood cultures in a non-immunocompromised patient with community-acquired pneumonia who does not meet criteria for severe CAP?
Fabre et al., PMID 31942949, categorizes "non-severe community-acquired pneumonia" as low yield for bacteremia and therefore less critical and potentially wasteful/poor stewardship to obtain blood cultures, however do note that severe community-acquired pneumonia (CAP) falls into a moderate pre-test...
Do you add empiric anti-MRSA coverage to the initial antibiotic regimen for a patient admitted with community-acquired pneumonia who has risk factors for MRSA but a negative MRSA nasal screen?
Thank you for this excellent and highly relevant clinical question. I approach this scenario by blending robust evidence-based medicine with fundamental principles of diagnostic reasoning. The short answer is generally no, you probably do not need to add empiric anti-MRSA coverage for a standard CAP...
What is your approach to the management of asymptomatic bacteriuria in an elderly patient without clear urinary symptoms but with cognitive changes and falls?
Asymptomatic bacteruria does not cause altered mental status. Data suggests that when we attribute acute changes to it, we will be wrong about 85% of the time, thereby missing the true etiology. It is a difficult thing to educate staff of senior living facilities and families who have been told it w...
Under what circumstances would you recommend early fecal microbiota transplantation over antibiotic treatment or bezlotoxumab in a patient with recurrent C. difficile infection?
Assuming donor stool is available, if the patient is not expected to need another course of antibiotics in the foreseeable future, I would recommend FMT.
What is your approach to antibiotic selection for bacterial species that demonstrate susceptibility to penicillins or cephalosporins on testing, but are known to harbor inducible AmpC resistance?
I follow the recommendations from the IDSA guidelines (Tamma et al., PMID 39108079). Duration of treatment does not influence my decision about whether to use a beta-lactam for organisms with inducible AmpC. For Enterobacter cloacae complex, Klebsiella aerogenes, and Citrobacter freundii, I do not u...
How do you use gut microbiome or gut microbiota analysis in your clinical practice, if at all?
While I am presented with microbiome analyses on a regular basis by patients, I do not believe that these are useful, as we are still not there when it comes to defining the "normal" microbiome. This indeed may vary tremendously between individuals depending on age, gender, diet, geographic location...