Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
Should patients starting cyclophosphamide be screened routinely for latent tuberculosis (TB)?
Yes, I think patients starting Cyclophosphamide should be screened routinely for latent TB since CYC is a strong immunosuppressant and increases the risk of TB reactivation. The issue is that CYC is often being considered for life or organ-threatening situations, for which it may not be ideal to wai...
How many doses of IM penicillin would you recommend for a patient with biopsy confirmed syphilis proctitis?
Syphilis is not a common cause of proctitis but apparently the biopsy confirms it. Almost certainly, the patient has primary or secondary syphilis, and standard treatment for early syphilis, a single 2.4 MU dose of benzathine penicillin G, is sufficient. If other evidence is more consistent with syp...
Should tuberculosis screening be performed before beginning methotrexate for treatment of rheumatoid arthritis?
While it is not recommended or required to screen for latent TB (LTBI) prior to starting methotrexate, for many patients this may serve as a good opportunity to screen for LTBI, as many patients will go on to require biologic therapy due to incomplete response to methotrexate. There are many limitat...
What is your preferred third antimicrobial agent for a patient with treatment-naive pulmonary MAC without cavitary disease and strict contraindications to utilization of rifampin or rifabutin?
There’s no clear winner yet. Inhaled liposomal amikacin solution has good potential and the data is trending this way with earlier clearance shown but the long-term outcomes, I believe are still pending. I’m relatively unconvinced or underwhelmed by moxi but as a third drug in the seemingly rare occ...
What factors do you consider when deciding between monotherapy with an antipseudomonal cephalosporin and combination therapy in ICU patients with Pseudomonas aeruginosa bloodstream infection who are not in septic shock?
In a patient who is critically ill, combination therapy can be used if there is concern that there may be a drug-resistant organism. In that case, a combination regimen can be used while awaiting the susceptibility test results. The combination choice should be based on the resistance patterns of th...
Do you continue PJP prophylaxis indefinitely in patients on rituximab maintenance therapy?
Risk for PJP infection is usually in the context of moderate-high dose corticosteroid therapy or low T cell counts.
Have the growing reports about doxycycline resistance in gonorrhea isolates from patients prescribed doxy PEP for prevention of bacterial STIs influenced your use of doxycycline for this indication?
No, they have not. For 2-3 decades, the prevalence of tetracycline resistance in N. gonorrhoeae worldwide, including the US and Western Europe, has been too high to rely on doxycycline or other tetracyclines in treating gonorrhea. The rise in prevalence of tetracycline resistance in MSM, the main po...
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...
How do you weigh the risk of urinary catheter or fecal management system placement with that of soiling sacral wounds?
This question is an important question that arises for many of our bed-bound and poorly mobile patients, as sacral wounds commonly develop due to pressure injury. They become very challenging to treat due to fecal and urinary contamination, which can lead to further infection. Fecal and urinary dive...
What, if any, oral or IV antibiotic suppression options would you consider for a patient with a history of recurrent fluoroquinolone- and TMP-SMX-resistant ESBL E. coli bacteremia with relapsed ESBL E. coli lumbar spinal hardware infection who previously underwent lumbar I&D with hardware retention and is not a candidate for further surgery?
I would base this decision on the full susceptibility profile of the isolate, as well as the specifics of the clinical scenario. The full susceptibility profile is not available to me, but if the isolate is susceptible to any oral beta-lactams, these tend to be associated with the fewest side effect...