Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
Would you recommend empiric coverage for vancomycin-resistance enterococcus in an unstable patient with sepsis, multiple comorbidities, and a recent ICU stay in a high VRE prevalence unit, despite recent cultures without growth of VRE?
I would go back to the assessment of community onset vs hospital onset as to when the sepsis is "setting in." If patient is coming from the community, hasn't had antibiotics in the last 90 days, hospitalized in the last 90 days, has no positive microbiology for VRE in the last year, then no, I would...
Do you routinely prescribe linezolid to patients who are concomitantly on methadone?
There are a few ways to interpret this question: Potential for serotonin syndrome with possible interaction between methadone and linezolid. Potential for further QTc prolongation with the addition of linezolid to methadone. Whether empiric oral antibiotics (when IV antibiotics could be used) are ...
What is your preferred first-line regimen to treat a severe or fulminant C difficile infection?
IV vancomycin and PO Flagyl are the easiest combination to get for a hospitalized patient. I’ve had much experience with this, and it works very well. IV vancomycin and PO Flagyl as initial treatments in the hospital is my preference. This is before I go onto stronger drugs, with those requiring al...
How do you approach using fecal microbiota therapy for recurrent Clostridioides difficile infection in immunocompromised patients?
We generally do not do the single donor FMT via colonoscopy, that was popular 5-10 years ago. We do offer both the oral and enema-based products, with a slight preference for the oral-based product due to ease of use.
How has your approach to managing asymptomatic bacteriuria in kidney transplant patients changed in light of a recent meta-analysis showing no significant differences in pyelonephritis, symptomatic UTI, or graft loss between patients treated with antibiotics and those who were not treated?
The referenced meta-analysis has not dramatically impacted my approach to asymptomatic bacteriuria (ASB) in kidney transplant recipients (KTRs). The included trials clearly show no benefit (and possible harm) in treating ASB at time periods >2 months post-transplant. So we do not screen and we do no...
Do you routinely give combination antifungal therapy for invasive mold infections?
The data on triazole single agent versus triazole plus echinocandin for the treatment of invasive aspergillosis are limited. I do not have a standard approach. I generally use a triazole alone, but will use the combination for initial treatment in patients with severe and/or rapidly progressive dise...
How do you approach patients who continue to experience pruritus and ongoing concern for persistent scabies despite having completed appropriate treatment?
Pruritus can not uncommonly continue in patients for 6 weeks or more after infestation is managed. High-dose antihistamines may be of some benefit. Consider if there is an ongoing untreated exposure that the patient has not thought of or cannot/will not share with you. Not all people infested with s...
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 ...
Do you offer antibiotic therapy for patients with a chronic joint infection, with no plans for surgery, and with an open draining sinus tract?
I think this depends on (1) the organism, (2) the host - if he/she is immunocompromised or not, and (3) if the patient is symptomatic. Generally, if the patient has a draining sinus tract that is stable and is not causing any fevers, chills, leukocytosis, etc., then I would favor not treating, as tr...
How would you manage a patient with well-controlled HIV on Biktarvy, who is interested in switching to injectable HAART but also has a history of a prior Hepatitis B Infection?
HBV is a common co-infection in people with HIV (PWH), due to shared transmission routes. Two large meta-analyses of studies published found a global a pooled prevalence of HBV infection among PWH to be between 7.6 and 8.4%, with a higher prevalence in less developed countries (10.4%) compared to mo...