Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
What is your approach to antibiotic selection for bacterial species that demonstrate susceptibility to penicillins or cephalosporins on testing, but are known to harbor inducible AmpC resistance?
I will assess how long I am treating the person/infection, and go from there in terms of how likely I am to induce the AmpC based on the duration of treatment. For example, if it's a 7-day course for UTI or GN bacteremia, I may risk the penicillin/cephalosporin (based on susceptibilities, of course)...
Do you routinely give prophylactic antibiotics prior to ERCP for biliary obstruction in light of recent studies suggesting a reduction of periprocedural infection?
I did not use to give antibiotics routinely prior to ERCP, and it seemed post-ERCP antibiotics were given at the discretion of the advanced endoscopist, but the results of this meta-analysis will likely change my practice so that I'll give all patients a dose of Ceftriaxone prior to the procedure to...
What is your approach to monitoring blood parasite smears in an immunocompetent patient with babesiosis?
In an immunocompetent person the response rate to the treatment of acute babesiosis is extremely high and if a person is clinically improving follow-up smears are probably unnecessary. However, I generally check one at 48 hours to confirm a decrease in parasite burden. If that is favorable and the p...
What minimum inpatient monitoring and discharge criteria should be required after single high-dose liposomal amphotericin B induction for HIV-associated cryptococcal meningitis when the patient has persistent intracranial hypertension requiring serial lumbar punctures?
If a patient has persistent ICH despite serial LPs, I would ask neurosurgery to place a lumbar drain. I would also continue the liposomal amphoB until the ICH came down. In addition, the CSF cell counts, glucose, and protein should be followed along with CSF CrAg/culture to confirm that all are impr...
What is your approach to work up and management of a patient with advanced HIV and poor adherence to therapy presenting with dysphagia and fever?
I would first do an HPI (is the dysphagia for both liquids and solids?), then a quick physical exam, with a full set of vital signs. In terms of basic blood work, I would get a CBC and BMP, liver function tests, a set of blood cultures, a chest x-ray, along with a viral load and CD4 T cell count, wh...
How would you manage a patient with good adherence on darunavir/cobicistat/emtricitabine/tenofovir alafenamide with persistent viremia 300-400 copies/mL with genotypic resistance testing demonstrating isolated T97A INSTI mutation, L10L/V, I13V, E35D, M36I, and L89M protease inhibitor mutations and no RT resistance?
Complicated question and answer: Confirm and evaluate causes (do now) Repeat HIV RNA promptly (e.g., in ~2–4 weeks) to confirm persistence and trend. Medication reconciliation/interactions (common culprits even with “good adherence”): cation-containing supplements/antacids (relevant mainly to INST...
Do you switch patients living with HIV off of boosted protease inhibitor-based regimens if possible to avoid the increased cardiovascular risk associated with them?
Yes, I usually do, despite my deep respect for PIs, which turned the tide in the United States in the 1990s from a universally fatal condition into a chronic disease. Some studies, most prominently the D:A:D study, suggest that ritonavir-boosted darunavir may increase the risk of CVD; however, other...
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 routinely recommend transition to dual PO antibiotic coverage for strep species and MRSA, for patients with purulent cellulitis and in the absence of culture data?
I use mostly Linezolid because: It’s now much cheaper. Even if on serotonin drugs, I can half the serotonin dose while they are on it. Covers pretty much all Strep and Staph, including MRSA. Protein synthesis inhibition may reduce toxins (like clinda in Strep fasciitis). There is no renal dose adju...