Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
With OpenBiome no longer in operation, what is your current approach for obtaining FMT for inpatients with acute severe/fulminant C. difficile infection unresponsive to antibiotics?
Consider Rebyota by enema or flex sig, similar to what you had done with standard FMT.
Do you consider use of oral antibiotics for complicated polymicrobial intra-abdominal infections?
Depends on how you're defining "complicated" IAI. Source control is key (I like this review: Source Control and Antibiotics in Intra-Abdominal Infections), especially if there's a fistula or anastomotic leak; but once an abscess is <5cm, if I have oral options that the patient can tolerate/dosed app...
Do you provide empiric doxycycline for Lyme Disease to asymptomatic patients after a tick bite who haven't developed Erythema migrans or are not sure it was an Ixodes tick?
I would base post-exposure prophylaxis upon local prevalence (unless the patient has a recent notable travel history). For example, Lyme disease is very rare in California due to the Ixodes tick's intermediate host being the Western Fence Lizard (long story short, something in their blood kills the ...
How would you approach management of multidrug resistant Streptococcus mitis bacteremia in a patient with prolonged neutropenia and prior severe allergic reaction to vancomycin?
I think it depends on what it is sensitive to. Fluoroquinolones might be an option. Linezolid might be an option.
Would you consider single dose benzathine penicillin G for treatment of latent syphilis of unknown duration based on recent observational data suggesting non-inferiority of one vs three doses for management of all stages of syphilis, as well as to mitigate issues with adherence, poor follow up, and drug shortage?
Yes. I would now consider a single dose of benzathine penicillin G the treatment of choice for all asymptomatic late syphilis in addition to primary, secondary, and latent syphilis under a year in duration. The 3-dose BPG recommendation always was pretty much data-free, an echo of the early days of ...
Do you prescribe empiric antibiotics to patients with CAP who test positive for a respiratory virus?
I do not start antibiotics when there is a detected viral etiology. And I tend to stop them if they were started. Obviously, this changes if the symptoms worsen and/or I suspect a bacterial superinfection. Another caveat would be in a patient with underlying COPD where Azithromycin may play a role i...
How long do you treat an isolated bacterial liver abscess which has either undergone percutaneous drainage or for which an indwelling drain is placed?
Until it's gone... Percutaneous drainage of liver abscesses is, in my experience, less effective than drainage of intra-abdominal abscesses, which isn't very effective. Neither type of abscess isn't, as I explain to other doctors and pts, a water balloon. Liver abscesses are more complicated than ot...
What do you think about chronic suppressive therapy for HSV-2 in a patient with positive antibodies but no prior clinical outbreak?
The first challenge is often the reliability of the test result. HSV-2 serologies and their interpretation can be challenging. A strongly positive result for HSV2, i.e., an EIA or similar index value well above the minimal cut-off, usually is reliable. Lesser values often are false positives, even t...
Under what circumstances would you initiate antibiotics in adults hospitalized with RSV and a suspected bacterial co-infection?
Bacterial co-infection in patients hospitalized with RSV ranges between 8% and 29% (Karlsen et al., PMID 41488696). The American Thoracic Society 2025 guidelines recommend prescribing empiric antibiotics to all hospitalized patients with clinical and imaging evidence of community-acquired pneumonia ...
How do you evaluate for an ascending UTI in a patient with a urostomy?
Evaluating for ascending UTI in a patient with a urostomy UA Generally low value; chronic pyuria/mucus makes results unreliable. Urine culture Essential; must be collected from a clean stoma catheterization or a fresh pouch, and not from the urostomy bag. Imaging (CT abdomen and pelvis wit...