Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
How do you incorporate positive respiratory viral testing and/or low procalcitonin into antibiotic de-escalation when chest imaging still suggests pneumonia in a hospitalized patient?
De-escalation of antibiotic use is a key part of antimicrobial stewardship. Respiratory illnesses are one of the most common reasons for hospitalization, and bacterial pneumonia is frequently the major concern in these patients. However, there is evidence that we overdiagnose and treat bacterial pne...
What is the interpretation of two IGRAs with negative mitogen wells, in the absence of immunosuppression?
If I understand this case correctly, the patient is actively ill and the patient's doctors are considering tuberculosis as a possible etiology of the patient's illness. In that scenario, IGRAs and PPDs have a limited to no role. Epidemiology, family history, and other possible exposures do. In your ...
What toxicity threshold would make you stop bepirovirsen while pursuing functional cure in a noncirrhotic patient with chronic HBV on suppressive nucleos(t)ide analogue therapy?
From the paper: "On the basis of a phase 2a randomized controlled trial assessing safety, tolerability, and antiviral activity of bepirovirsen, in which ALT elevations associated with HBsAg reductions were reported for NA-naïve patients, ALT increases were considered AEs of special interest. Class e...
Do you use daptomycin interchangeably with staphylococcal beta-lactams for ease of dosing on discharge for patients with serious MSSA infections (endocarditis, bacteremias, etc)?
I don’t use daptomycin interchangeably with antistaphylococcal beta-lactams for serious MSSA infections, and I think doing so routinely is a mistake. For invasive diseases like endocarditis, prolonged or complicated bacteremia, and deep-seated foci of infection, the outcome data consistently favor b...
Do you favor skin testing over direct oral challenge when the penicillin reaction history is remote but poorly characterized in a hospitalized adult?
Both the fact that the reaction was remote and poorly characterized support direct amoxicillin challenge (rather than skin testing). According to the 2022 Drug Allergy Practice Parameter Update, direct oral amoxicillin challenge may be considered in adults with distant mild reactions, and since that...
In a patient with persistent symptoms of Lyme arthritis after initial treatment course with oral antibiotics, do you prefer a second course of oral antibiotics or do you frequently offer a course of IV ceftriaxone?
Patients diagnosed with Lyme arthritis should receive a 28-day course of oral antibiotics, preferably doxycycline. If patients achieve at least a partial response, a second course of oral antibiotics may be given. However, in patients with minimal to no response following the initial course of oral ...
Do you favor switching a virologically suppressed patient with HIV and significant weight gain to dolutegravir/lamivudine over bictegravir/emtricitabine/tenofovir alafenamide, given PASO-DOBLE trial data showing noninferior virologic efficacy with less weight gain?
I wouldn’t “favor” DTG/3TC over BIC/FTC/TAF purely on the basis of PASO-DOBLE’s average weight trajectory, because the weight effect size is modest, the trial is not designed to prove superiority on metabolic outcomes, and regimen choice in a suppressed patient hinges on a few high-impact individual...
How has your approach to de-escalating a conversation with a distressed or angry family member evolved over your career?
My approach to de-escalating conversations with distressed or angry family members has shifted from trying to solve the problem immediately to first understanding the emotion driving the conflict. Early in my career, I often responded by providing more medical information, assuming that greater clar...
For patients with candida species osteomyelitis who have undergone extensive surgical debridement, do you routinely still recommend 6-12 months of antifungal therapy or opt for a shorter duration?
After removal of hardware, if present, and debridement of infected bone, my practice is to treat Candida osteomyelitis with an intravenous echinocandin for two weeks followed an oral azole, to which the fungus is susceptible, for at least six months. If full debridement is not possible, such as vert...
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...