Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
When do you consider using a paramedian approach for a lumbar puncture?
I consider the paramedian approach for lumbar puncture in several clinical scenarios: When patients are unable to adequately flex their spine. When midline interspaces are narrow (<1 cm). When ultrasound reveals densely calcified spinal ligaments—a common finding in elderly patients that can obscure...
What is your approach to distinguishing a Jarisch-Herxheimer reaction from a delayed anaphylactoid reaction?
As with most things in medicine, this is context-dependent. The Jarisch-Herxheimer reaction is a systemic inflammatory response to the death of bacteria (most commonly associated with spirochetes and in particular, syphilis), typically in the hours following antibiotic administration. This response ...
Would you still treat with course for osteomyelitis if proximal bone cultures after amputation are still positive but pathology does not demonstrate osteomyelitis?
Like many questions in Infectious Diseases, the answer is “it depends.” This includes the type of amputation (I have a lower threshold to treat after a ray amputation, whereas I am more comfortable stopping therapy after a below-knee amputation), the organism isolated (particularly when Staphylococc...
How would you approach treatment in a patient with refractory Coccidioidal meningitis who has previously been treated with IV amphotericin B?
The previous receipt of amphotericin B is irrelevant. Shortly after its introduction in the mid-1950s, it was recognized that it was ineffective in the treatment of coccidioidal meningitis when given intravenously and that intrathecal administration was necessary (Winn, PMID 14065439). The introduct...
How many doses of IM penicillin would you recommend for a patient with biopsy confirmed syphilis proctitis?
Syphilis is not a common cause of proctitis but apparently the biopsy confirms it. Almost certainly, the patient has primary or secondary syphilis, and standard treatment for early syphilis, a single 2.4 MU dose of benzathine penicillin G, is sufficient. If other evidence is more consistent with syp...
What is your approach to relapsing babesiosis in immunosuppressed patients?
The first thing to do is to try to confirm that this is a relapse rather than a reinfection. If it is a true relapse, there is no proven established approach, but these are the options. If possible, try to decrease the level of immunosuppression The IDSA guidelines from 2020 recommend 6 weeks of st...
How do you manage increasing EBV viremia of 15,000 copies in a seropositive heart transplant recipient with transplant performed 15 years ago in a patient who is otherwise asymptomatic?
This begs the question as to why it was checked. Without knowing that, the answer is difficult. If the patient is truly asymptomatic, then perhaps this can be ignored. Current immunosuppression would also be relevant; for example, if there was recent rejection or a change in immunosuppressant medica...
Under what circumstance would you order dalbavancin instead of vancomycin or daptomycin for MRSA endocarditis?
The short answer is active/recent IV drug use. Personally, I don’t or didn’t agree with not using PICC and 6 weeks of daily IV abx. My understanding, although it may be outdated, is that there is evidence that most patients would not abuse the PICC. That had been my experience, I had only one patien...
Do you routinely use two empiric antibiotics to cover for Pseudomonas aeruginosa in the management of CF exacerbations?
Historically, two antibiotics have been used to cover Pseudomonas pulmonary exacerbations. The last guidelines were published in 2009 (Flume et al., PMID 19729669 ). At that time, the expert guidelines stated, "The CF Foundation concludes that there is insufficient evidence to recommend the use of a...
Do you routinely transition to PO antibiotics for patients with native joint septic arthritis whom have undergone washout and the organism is not S. aureus?
Yes. Even if the organism is Staph aureus, I would feel comfortable with an appropriate, highly bioavailable oral antibiotics after appropriate source control (linezolid in the case of Staph aureus).