Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
Under what circumstance would you order dalbavancin instead of vancomycin or daptomycin for MRSA endocarditis?
In our practice, we consider dalbavancin as an alternative to vancomycin or daptomycin for treating MRSA endocarditis in clinically stable patients who are unable or unwilling to complete the standard 6-week course of intravenous therapy, especially among people who inject drugs.
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...
Has your approach to direct-from-blood bacterial testing changed after a pragmatic RCT showed no reduction in antibiotic duration compared to blood cultures alone?
No. As an ID practitioner and steward, I am using the data provided by the rapid diagnostics to target therapy as quickly as possible and minimize unnecessary broad abx as possible. As summarized by Banerjee et al., PMID 26197846, and as cited in this paper, active stewardship with audit/feedback is...
How long would you hold antibiotics before performing a vertebral biopsy to optimize culture yield in a patient who has been on empiric antibiotics for a week for suspected vertebral osteomyelitis?
I would devote my efforts to obtaining a sample for WGS or other molecular technology and (briefly) delay sampling until an administrative route has been identified. If absolutely not available, antibiotics delay would depend on a) clinical status of the patient and b) tissue T1/2 of antibiotics adm...
What drug and specific dosing would you use for secondary pneumocystis prophylaxis in a patient with renal transplant, documented TMP-SMX allergy, and normal G6PD testing, who was diagnosed with moderate PJP and improved on clindamycin/primaquine and steroids?
I think the options are dapsone (which is tolerated by most patients allergic to TMP/SMX), atovaqone, and inhaled pentamidine. During my career, those choices have depended to some extent on the local practice. I have preferred inhaled pentamidine because I have worked in places with low volume and ...
What is your approach to a situation where DILI is suspected secondary to an important medication (e.g., anticoagulation, antibiotics, etc.), but the diagnosis is uncertain and the liver injury is relatively mild?
If the drug suspected to induce liver injury causes symptoms and ALT is >3 times the upper limit of normal (ULN), I would stop the drug and find an alternative. Even if no symptoms are present, I would stop if ALT is >5 times ULN. Any level increase of ALT below the above parameters would still requ...
Under what circumstances would you consider treating uncomplicated gonorrhea with zoliflodacin instead of the standard treatment regimen with ceftriaxone and azithromycin?
The standard advice (CDC and its various counterpart agencies in other countries) no longer includes azithromycin; ceftriaxone 500 mg alone is advised as routine treatment for uncomplicated (genital, anorectal, pharyngeal) gonorrhea. If chlamydial infection is present or likely, doxycycline 100 mg P...
How do you advise using Mycoplasma antibody testing to guide antibiotic selection in patients with pneumonia?
I do not. It takes several days to result, and I would not change treatment duration or choice of antibiotic based on a result. I treat all patients with pneumonia with a cell wall inhibitor like amoxicillin and something for atypical coverage like azithromycin. In patients with community-acquired p...
Under what circumstances would you recommend early fecal microbiota transplantation over antibiotic treatment or bezlotoxumab in a patient with recurrent C. difficile infection?
Assuming donor stool is available, if the patient is not expected to need another course of antibiotics in the foreseeable future, I would recommend FMT.
Would you use oral cefixime as an alternative treatment for early syphilis in cases of benzathine penicillin G shortages?
Based on in vitro activity against T. pallidum and the study you cite, cefixime 400 mg BID for 14 days likely is effective for treatment of early syphilis (Klementová et al., PMID 40795115). However, I see no advantage over the recommended option of doxycycline (100 mg BID for 14 days) when BPG isn'...