Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
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 treat patients with neurosyphilis with IM penicillin for 1-3 weeks after completing a full treatment course of IV penicillin?
The same question was asked almost exactly two years ago. Repeating the same reply with minor edits: This has been a topic of a debate among syphilis experts for decades. There are no data at all on whether there is benefit (e.g. in preventing later relapse) in adding low-dose but long-acting penici...
Which patients with NNRTI resistance mutations who wish to simplify their HIV antiretroviral regimens do you consider switching to cabotegravir/rilpivirine?
Personally, I would be cautious of using cab/rilpivirine in any patient with virologic failure and NNRTI resistance. However, the K103N mutation (signature resistance mutation in patients treated with efavirenz and nevirapine) is not associated with resistance to rilpivirine; these patients were inc...
How do you approach a patient who has anterior uveitis and is referred for evaluation of ocular TB with a positive Quantiferon gold (as part of their workup) in countries with low TB incidence?
It is a frustrating problem and is expected to increase without solid evidence. Until then, management should involve an interdisciplinary collaborative approach and a shared decision-making process.I see the following issues. I feel ophthalmologists follow the diagnostic criteria for TB uveitis us...
Would you give long term antistreptococcal antibiotic prophylaxis to a patient who presents with features of poststreptococcal reactive arthritis but who also meets criteria for Acute Rheumatic Fever?
Acute rheumatic fever should have prophylaxis. If no rheumatic heart disease, the recommendation is penicillin up to age 21 or for five years after the last episode. If heart disease is present, that recommendation is for life. In the setting of penicillin G benzathine shortage, the only option for ...