Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
How do you manage increasing EBV viremia of 15,000 copies in a seropositive heart transplant recipient with transplant performed 15 years ago in a patient who is otherwise asymptomatic?
This begs the question as to why it was checked. Without knowing that, the answer is difficult. If the patient is truly asymptomatic, then perhaps this can be ignored. Current immunosuppression would also be relevant; for example, if there was recent rejection or a change in immunosuppressant medica...
Under what circumstance would you order dalbavancin instead of vancomycin or daptomycin for MRSA endocarditis?
IVDU or any barriers to get daily IV abx.
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...
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 ...
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'...
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...