Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
Do you routinely obtain a TEE or vascular imaging in a patient with non-typhoid salmonella bacteremia without persistent bacteremia?
No. Salmonella bacteremia is quite common, and endocarditis due to gram-negative bacillary bacteremia is extremely rare. If the patient has continuous bacteremia following treatment, both echocardiogram and vascular imaging would be appropriate.
How would you manage and determine the duration of antibiotics for a patient with suspected chronic postoperative spinal implant infection, status post lumbar fusion, now presenting with loosened hardware on imaging, normal inflammatory markers, and no systemic infection symptoms?
Loosening can be identified as lucency around pedicle screws on standard radiography, commonly at the upper or lower ends of the surgical construct. It was graded on a scale of 0-3. High-grade loosening (grade 2 or 3) is associated with increased odds of requiring revision surgery. It can be mechani...
Do you routinely recommend a lumbar puncture for patients with suspected ocular or otic syphilis in the absence of additional CNS symptoms?
No, this isn’t necessary, assuming no other evidence of non-ocular/otic neurosyphilis. I recommend management as advised by CDC in the 2021 treatment guidelines (https://www.cdc.gov/std/treatment-guidelines/STI-Guidelines-2021.pdf, p. 40). An especially careful neurological exam is advised, includin...
Do you routinely observe inpatients for 24 hours after transitioning from IV empiric antibiotics to an oral regimen prior to discharge when the source of infection is unclear?
To be sure, this is a big question with much nuance and should be broken down into component parts. To begin with, the lack of a source is not, in and of itself, a clear justification for continued hospitalization. What should drive the decision for discharge is established clinical stability and an...
How do you suggest incorporating POCUS into the evaluation of SSTIs, and do you use this as a means to guide initial antibiotic selection?
I routinely incorporate POCUS into my SSTI evaluation because it reliably distinguishes simple cellulitis from purulent infection, which directly guides my initial management. A quick bedside scan allows me to rule out a drainable abscess. If the scan shows only cobblestoning without a fluid collect...
How do you treat a patient with a gram-negative infection with resistance to imipenem but sensitivity to meropenem and negative for Carbapenem resistant organism by xpert Carba-R-assay?
The finding of meropenem susceptible, imipenem resistant GNR can be explained in Pseudomonas aeruginosa by efflux pump overexpression and porin (particularly OprD) loss. The opposite pattern in P. aeruginosa - imipenem susceptible, meropenem resistant – has often been attributed to overexpression of...
Do you recommend treating Candida albicans on urine culture from an indwelling catheter in a patient with septic shock?
In a patient with septic shock, one is typically obligated to treat all things until further culture data is back, etc. If there are other clear causes of shock, I would not treat the candida (though I would try to change the catheter ASAP). If the patient is extremely ill and no other sources of in...
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...
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...
What is your preferred laboratory test to assess treatment response or infection resolution in patients with bacterial pneumonia?
I don't generally check a laboratory test to assess resolution. I go more by their improved clinical status and seeing them get back to baseline oxygen status. If I am trending a WBC or procal, I do like to see it trend down, but it's not the only lab I hang my hat on to decide if someone has resolv...