Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
Do you treat complicated pneumonia with a drained empyema longer if Streptococcus anginosus is cultured, either in isolation or with other organisms, compared to cases in which it is not?
Targeted antimicrobial therapy for any bacterial etiology of an empyema will be individualized for each patient but a general duration of 4-6 weeks. I would not consider strep anginosus differently in this regard. What I am looking for is adequacy of drainage with clinical improvement. Radiographic ...
When would you consider glucocorticoids as adjunctive therapy for for community-acquired pneumonia outside of the ICU setting?
Thank you for bringing this new study to my attention; I hadn't seen it yet. After reviewing the article, my practice regarding steroids remains unchanged. While the trial was well-executed, and it is laudable to see such research coming out of a limited-resource setting, that environment differs si...
What specific criteria or patient conditions would make you hesitant to use fluoroquinolones early in the treatment course for managing MSSA joint infections with oral antibiotics?
For MSSA joint infections, I have moved away from using FQ to using high-dose cephalosporins as a step-down therapy, particularly cefadroxil 1 g twice daily, given less frequent dosing/increased adherence. Considering the risk-benefit analysis, I prefer using FQ as an oral option in polymicrobial an...
Do you consider use of oral antibiotics for complicated polymicrobial intra-abdominal infections?
Depends on how you're defining "complicated" IAI. Source control is key (I like this review: Source Control and Antibiotics in Intra-Abdominal Infections), especially if there's a fistula or anastomotic leak; but once an abscess is <5cm, if I have oral options that the patient can tolerate/dosed app...
How would you approach treatment of latent TB for patients who cannot tolerate rifamycins or isoniazid due to allergy, intolerance, or drug-drug interactions?
Levofloxacin or moxifloxacin. Duration is 6-9 months.
Do you use an antibiotic with antitoxin activity for the entire duration of therapy for patients with necrotizing MSSA or MRSA pneumonia or just until definitive clinical improvement?
I use targeted therapy to the organism identified; if I do not have an organism yet and the patient has appropriate risk factors for MRSA necessitating empiric coverage, I do favor linezolid but specifically for its data in pneumonia and not its use in necrotizing fasciitis/toxin data. Once I have a...
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 minimum inpatient monitoring and discharge criteria should be required after single high-dose liposomal amphotericin B induction for HIV-associated cryptococcal meningitis when the patient has persistent intracranial hypertension requiring serial lumbar punctures?
If a patient has persistent ICH despite serial LPs, I would ask neurosurgery to place a lumbar drain. I would also continue the liposomal amphoB until the ICH came down. In addition, the CSF cell counts, glucose, and protein should be followed along with CSF CrAg/culture to confirm that all are impr...
How do people approach non-HIV patients with hepatitis B, a negative Hepatitis B E antigen, normal LFTs and relatively low HBV DNA between 2000-20000?
Treatment of chronic Hep B is recommended to prevent maternal-fetal transmission, reactivation during chemotherapy, recurrence after liver transplantation, and in patients with decompensated cirrhosis. Treatment has been shown to reverse fibrosis and cirrhosis. Specifically referring to the above sc...
What is your approach to iron supplementation in patients with an active infection?
In patients with active infections, I generally avoid intravenous iron due to the potential for promoting pathogen growth, a practice supported by cautions from nephrology and gastroenterology society guidelines. However, evidence for the risk of infection with IV iron is inconsistent, underpowered,...