Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
Do you still use fever as a minor criterion when applying the Duke–ISCVID criteria for infective endocarditis given data suggesting diagnostic accuracy may improve when it is omitted?
Actually, I still use fever as a minor criterium. I have not really thought much about it and have no instances where culture-negative endocarditis has come up since the publication. In fact, no one in my division has even brought this up for discussion. Anyhow, I think this is a minor modification....
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 routinely recommend diagnostic endoscopy for patients with persistent enterococcus bacteremia despite receiving adequate antimicrobial therapy and no clear nidus?
It depends. Did you do an echocardiogram to rule out endocarditis? Urine cultures were negative? Gallbladder ultrasound was negative? CT of the abdomen and pelvis with contrast was negative?Any other symptomatology that accompanied the recurrent episodes of enterococcus bacteremia that could help us...
In what situations do you recommend secondary prophylaxis for Nocardia after completion of treatment?
I do not recommend routine secondary prophylaxis after completion of treatment for Nocardia infection. While recurrence can occur, particularly in immunocompromised individuals (organ transplant patients), outcomes with repeat treatment are generally favorable. More importantly, there is no strong e...
Do you continue PJP prophylaxis indefinitely in patients on rituximab maintenance therapy?
Risk for PJP infection is usually in the context of moderate-high dose corticosteroid therapy or low T cell counts.
How would you manage a patient with viremia up to 400 copies/mL on CAB/RIL injections who was previously undetectable on BIC/FTC/TAF and with prior genotypic testing without drug resistance mutations?
We have definitely seen treatment failure with CAB/RPV, which unfortunately made using both classes of medications impossible. Assuming usual issues of adherence and attending appointments are not issues, I would review the administration technique, particularly if the patient has an elevated BMI or...
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...
What is your approach to antibiotic selection for bacterial species that demonstrate susceptibility to penicillins or cephalosporins on testing, but are known to harbor inducible AmpC resistance?
I will assess how long I am treating the person/infection, and go from there in terms of how likely I am to induce the AmpC based on the duration of treatment. For example, if it's a 7-day course for UTI or GN bacteremia, I may risk the penicillin/cephalosporin (based on susceptibilities, of course)...
What is your approach to monitoring blood parasite smears in an immunocompetent patient with babesiosis?
In an immunocompetent person the response rate to the treatment of acute babesiosis is extremely high and if a person is clinically improving follow-up smears are probably unnecessary. However, I generally check one at 48 hours to confirm a decrease in parasite burden. If that is favorable and the p...
What minimum inpatient monitoring and discharge criteria should be required after single high-dose liposomal amphotericin B induction for HIV-associated cryptococcal meningitis when the patient has persistent intracranial hypertension requiring serial lumbar punctures?
There are Cryptococcal meningitis guidelines by IDSA with a section devoted to what Dr. @Dr. First Last mentioned (IDsociety.org). I realize that we are getting pressure to think about discharge as soon as every patient is admitted, but this particular patient will need at least two weeks of Amphote...