Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
Do you routinely use oral antibiotics for treatment of vertebral osteomyelitis?
Speaking specifically to my clinical practice, it is very dependent on the individual patient--more or less if they can do the IV/OPAT situation, and what happened with surgery, and what organism; also, are they coming to you outpatient vs inpatient? IDSA guidelines (from 2015) still endorse IV. It ...
How do you approach perioperative antimicrobial prophylaxis in patients undergoing reconstructive surgery with myocutaneous flaps whom have recently been treated for active infection?
Generally speaking, if the patient has been fully treated, I do not give antimicrobial prophylaxis other than the guideline-based 1 dose of therapy prior to surgery. If a flap is planned, generally, I would like the patients to complete their course of therapy for active infection prior to flap plac...
Would you start treatment for MAC in a patient with nodular bronchiectatic disease who has demonstrated radiographic progression but remains asymptomatic and smear-negative?
My default answer would be yes; this is a sign of progressive disease that will get worse without treatment. Having said that many things could be considered while making the decision, including patient preferences. First is there another cause? Does the patient have an exacerbation of bronchiectasi...
How do you balance the risk of unnecessary treatment with acyclovir against the risk of delaying treatment in encephalitis cases where CSF pleocytosis is absent?
Treatment with IV acyclovir should start as soon as the diagnosis of Herpes simplex encephalitis is considered. Since the question states that CSF pleocytosis is absent, then CSF has been obtained. PCR for HSV should be obtained on that CSF. Early in my career, when acyclovir was investigational and...
When do you recommend limited or targeted respiratory pathogen testing versus a full respiratory pathogen panel in a patient presenting with URI symptoms?
I think we’re asking the wrong group of people. How infectious disease physicians use respiratory pathogen panels is not the same as how emergency medicine or urgent care clinicians use them. For stewards of diagnostics, especially ID providers, the test often doesn’t change management. In many sett...
Do you routinely recommend adjunctive rifampin therapy for the management of Staphylococcus aureus native vertebral osteomyelitis?
The short answer is 'no.' Rifampin was first studied to use with orthopedic hardware infections due to MRSA as a way to penetrate the biofilm layers on the hardware. That concept is true with prosthetic heart valves (but not universally). Can a heart valve develop a Staph aureus biofilm? Yes, but th...
For a patient on appropriate treatment for invasive aspergillosis, how do you determine if and when it is acceptable to reintroduce a TNF inhibitor that likely contributed to their acquisition of the infection but is considered essential for control of their inflammatory condition?
There is no established answer to this question. The reintroduction of a TNF inhibitor must be individualized based on the clinical situation of the patient under consideration. There are two critical questions. First, how much does the patient need the inhibitor”? The more the patient is dependent ...
How do you approach PJP prophylaxis in patients with rheumatic disease on corticosteroids?
Here is a graphic I made covering PJP Prophylaxis with Dr. @Dr. First Last if anyone is interested! As noted, one can check absolute lymphocyte count (ALC) or CD4 count as factors to further risk stratify as well.
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...
What is your preferred first-line treatment for chronic fatigue in patients with long COVID-19?
Assuming that a thorough workup for other causes of fatigue (anemia, thyroid dysfunction, sleep apnea, etc.) has been performed and is negative, no single medication has been proven by a randomized placebo-controlled trial to help chronic fatigue in PASC. Anecdotally, my colleagues who treat PASC ha...