Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
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...
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...