Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
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...
When do you consider adding steroids alongside intravenous antibiotics for patients with orbital cellulitis?
If the orbital cellulitis is infectious, I never add steroids. There is no literature or proof that they do anything, and decreasing immunity, in my opinion, is simply a bad idea. If it is inflammatory, then absolutely. Most infectious orbital cellulitis is from the sinuses and is more common in chi...
How do you manage patients from endemic areas who have positive Lyme serology with ocular abnormalities that are rarely reported in Lyme disease (optic neuropathy, disc edema, etc)?
In patients from Lyme-endemic areas, I try very hard not to let a positive serology become the diagnosis. A positive two-tier Lyme test tells me the patient has been exposed to Borrelia at some point; it does not necessarily tell me that Borrelia is responsible for the ocular findings in front of me...
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...
Is there a role for nitazoxanide for treatment of norovirus gastroenteritis in immunocompromised patients?
There is no good-quality evidence supporting a role for nitazoxanide for treatment of norovirus gastroenteritis in immunocompromised patients. The efficacy of nitazoxanide in viral gastroenteritis is supported by a small manufacturer-sponsored randomized, double-blind trial in non-immunocompromised ...
In a patient with multiple organ abscesses, no known predisposing factors, negative genetic panel testing for CGD and normal oxidative burst, what other testing modalities should be considered?
I would work the patient up for CVID. Also, I would find all the culture and sensitivity results to ensure it’s not MRSA. Also, culture results may open the door to other etiologies.
How do you decide whether to empirically cover Pseudomonas for pneumonia in hospitalized patients?
The decision to empirically cover Pseudomonas aeruginosa in pneumonia among hospitalized patients depends on the pneumonia type (community-acquired pneumonia, CAP vs. hospital-acquired pneumonia, HAP), disease severity, etiology, and specific risk factors. For Community-Acquired Pneumonia (CAP) Pa...
Do you have any concerns about using long-acting cabotegravir/rilpivirine in obese patients with HIV?
There have been concerns raised about adequate drug levels being maintained in patients with high BMI. One concern is that injections may be deposited in subcutaneous rather than intramuscular tissue. A recent computer modeling study also indicated subtherapeutic drug levels in patients with BMI >40...
What do you think about chronic suppressive therapy for HSV-2 in a patient with positive antibodies but no prior clinical outbreak?
The first challenge is often the reliability of the test result. HSV-2 serologies and their interpretation can be challenging. A strongly positive result for HSV2, i.e., an EIA or similar index value well above the minimal cut-off, usually is reliable. Lesser values often are false positives, even t...