Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
What is the optimal therapy for laryngeal candidiasis in pregnancy?
Thirty years ago, I was consulted on a woman in her 30s with candidemia after fetal demise from Candida chorioamnionitis. During the pregnancy, she had been treated several times with clotrimazole for Candida vaginitis. Given that repeated exposure, I guessed that her Candida isolate would be azole-...
What additional antibiotic coverage, if any, would you give to a patient with penicillin-susceptible Strep viridans prosthetic valve endocarditis on ceftriaxone who needs to undergo a dental procedure?
I'm a little baffled by the phraseology of "therapeutic endocarditis" because this implies to me the patient is on therapy for endocarditis and therefore is therapeutic on the ceftriaxone therapy. Additionally, the patient could be switched to penicillin as either is recommended as therapy in the 20...
Would you avoid using cephalosporins in a patient with a history of cephalosporin neurotoxicity in the setting of CKD?
In elderly patients with underlying CNS disease, renal dysfunction and prior history of cephalosporin neurotoxicity, I would avoid the use of Cephalosporin therapy if possible. If there are not other alternatives, I would strive to give the lowest possible therapeutic dose of the antibiotic to dimin...
How do you rule out spontaneous bacterial peritonitis in a patient with minimal ascites that is not amenable to paracentesis?
You can’t, unfortunately. You either need to keep looking for a good pocket (move patient to each side, etc.) or use clinical judgement and decide whether or not to treat empirically.
How would you manage a patient with necrotizing pneumonia due to a susceptible Pseudomonas aeruginosa strain who continues to have significant purulent secretions and worsening imaging while receiving cefepime?
I agree, not enough information here to make a firm recommendation, but often times these necrotic pneumonias will undergo significant liquefactive necrosis, and all of that dead lung and purulence has to come out through the mouth. I tell patients that they may have a worse cough for a while, and t...
How do you explain the use of an AI scribe to patients the first time it is used in their care?
I use an AI scribe in my outpatient clinic, and around 90–95% of my patients agree to it. I obtain consent at the start of each visit and make it clear that it's completely optional—that they can say no at the start or change their mind at any point in the visit, with no impact on their care. I also...
Should asymptomatic esophageal candidiasis identified incidentally on endoscopy be treated?
Yes, in our practice, we do treat asymptomatic esophageal candidiasis when found incidentally on endoscopy. A few things to consider: 1) While patients may be asymptomatic at the time of the endoscopy, untreated disease can lead to the future development of complications/symptoms, such as odynophagi...
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...
How would you manage persistent Norovirus diarrheal infections in a kidney transplant patient that are not responding to a decrease in the patient’s maintenance immunosuppressive regimen?
This is a difficult situation and does not have a strong evidence based response. First, I would really make sure they are not on mycophenolate as this is really the main problem with chronic Norovirus for most patients. Next, I would see if there are any available clinical trials that the patient m...
Have you used oral vancomycin as prophylaxis for C difficile infection in patients admitted for allogeneic hematopoietic cell transplant?
We also use oral vancomycin as secondary prophylaxis for anyone who develops C difficile infection, at a dose of vancomycin 125 mg PO BID, for up to 7 days after concurrent antibiotics are discontinued. This recommendation is based on Morrisette et al., PMID 31255741, a retrospective cohort study of...