Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
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'...
What is the preferred four-drug regimen for initial treatment of pan-susceptible tuberculous meningitis, given the need to achieve optimal CNS penetration?
I will defer to the guidelines for the specific regimen. One general issue I would like to address is the idea of "CNS penetration." Since we don't routinely do brain biopsies in humans to truly assess levels of antimicrobials in the brain/spinal cord/meninges, many people think that "CSF levels = C...
Is there a role for suppressive antibiotic therapy when it comes to chronic femoral/tibial osteomyelitis?
Suppressive antibiotic therapy would be considered if there is felt to be a nidus that cannot be removed. For example, if a patient has hardware in place that is infected with associated osteomyelitis, but is not a candidate for surgery due to advanced age perhaps. This patient can be considered for...
In a patient with negative Hep B surface Ag, Hep B surface antibody+, and Hep B core antibody+ serologies, do you initiate antiviral prophylaxis (e.g. entecavir) prior to starting rituximab?
I would use entecavir for Hep B reactivation prophylaxis in this case - based on recommendations from AGA 2025 guidelines, which does classify b-cell depleting agents as higher risk for reactivation for both Hep B surface Ag-positive and Hep B surface Antigen neg/core positive patients. It should be...
What clinical criteria do you use to decide whether to continue intravenous gentamicin or fluoroquinolone for the full duration of treatment or to step down to oral therapy in hospitalized patients with tularemia?
There are no prospective, controlled trials for the treatment of tularemia. I am comfortable in treating mild-moderate infections with a PO quinolone. In severe infections (meningitis, endocarditis, extensive pneumonia, etc.), I would definitely start parenterally and step down to an oral regimen wh...
Do you use combination therapy for persistent MSSA bacteremia?
I don’t think I’ve ever come across a situation where the problem wasn’t source control…
Do you add adjunctive gentamicin and/or rifampin for treatment of prosthetic valve Staphylococcus aureus endocarditis?
No, we do not add adjunctive gentamicin for treatment of Staphylococcus aureus (SA) prosthetic valve endocarditis (PVE). The potential benefit of using an aminoglycoside in this setting is minimal, if any, and is outweighed by the risk of toxicity.With respect to using rifampin, it depends on whethe...
Should patients starting cyclophosphamide be screened routinely for latent tuberculosis (TB)?
Yes, I think patients starting Cyclophosphamide should be screened routinely for latent TB since CYC is a strong immunosuppressant and increases the risk of TB reactivation. The issue is that CYC is often being considered for life or organ-threatening situations, for which it may not be ideal to wai...
Do you routinely order karius in evaluation of culture negative prosthetic valve endocarditis?
Don’t “routinely” order Karius test. Rarely, in culture-negative suspected endocarditis, especially if a prosthetic valve is present. Once for suspected culture-negative aortic graft infection. 3x for culture-negative meningitis. Likely to become more frequent but adoption very dependent on cost an...