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Reposted by Stanford Antimicrobial Safety & Sustainability Program

MAD-ID The Antimicrobial Stewardship Meeting @mad-id.bsky.social · 12/03/2026

From infants to elders, tackle CAP conundrums with Dr Holubar and Dr. Yu. Register today for the 2026 MAD-ID and SIDP Annual meeting, May 14-17 in Orlando. @pidsociety.bsky.social 🔗 buff.ly/KWgqZS6

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Stanford Antimicrobial Safety & Sustainability Program @stanfordasp.bsky.social · 11/03/2026

🔗 For more details, refer to these guidelines: IDSA Guidelines on Intra-Abdominal Infections Tokyo Guidelines 2018 - Acute Cholangitis Cholecystitis SIS Guidelines on IAI - 2024 (DOI: 10.1089/sur.2024.137) SHC Intra-Abdominal Infection Guideline (click link below)

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Stanford Antimicrobial Safety & Sustainability Program @stanfordasp.bsky.social · 11/03/2026

⚠️ In contrast, empiric anaerobic coverage is recommended for other intra-abdominal infections such as: ✅Appendicitis ✅Diverticulitis ✅Secondary & tertiary peritonitis ✅Infected necrotic pancreatitis

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Stanford Antimicrobial Safety & Sustainability Program @stanfordasp.bsky.social · 11/03/2026

📊 Why? Studies show very low recovery rates of anaerobic bacteria from biliary cultures and blood cultures in patients with acute cholecystitis or cholangitis.

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Stanford Antimicrobial Safety & Sustainability Program @stanfordasp.bsky.social · 11/03/2026

🔍 A: 🚫According to guidelines, empiric anaerobic coverage for community-acquired acute cholecystitis and cholangitis of mild/moderate severity is NOT recommended unless there's an entero-biliary anastomosis or emphysematous cholecystitis.

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Stanford Antimicrobial Safety & Sustainability Program @stanfordasp.bsky.social · 11/03/2026

🌟 ABX Pearl of the Day 💡 Q: My patient is admitted with an acute biliary infection. Is empiric metronidazole needed in this and other IAI? #IDsky #MedSky #PharmSky #SkyRX #AMSsky

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Stanford Antimicrobial Safety & Sustainability Program @stanfordasp.bsky.social · 26/02/2026

📚 References: Berbari et al., IDSA Osteomyelitis Guidelines (2015) — PMID: 26229122 IWGDF/IDSA 2023 Diabetes‑related Foot Infection Guidelines — PMID: 37779323

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Stanford Antimicrobial Safety & Sustainability Program @stanfordasp.bsky.social · 26/02/2026

⚠️ Start empiric antibiotics immediately if the patient is: -Hemodynamically unstable -Showing signs of impending sepsis -Having neurologic compromise -Or has a superimposed acute infection In these cases ➜ urgent surgical consultation should also be considered.

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Stanford Antimicrobial Safety & Sustainability Program @stanfordasp.bsky.social · 26/02/2026

✅ A: Consider holding antibiotics before a diagnostic procedure to improve culture yield IF: 🚫 No evidence of impending sepsis or hemodynamic instability 🚫 No neurologic compromise (for vertebral osteomyelitis) 🚫 No superimposed acute infection (e.g., overlying SSTI)

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Stanford Antimicrobial Safety & Sustainability Program @stanfordasp.bsky.social · 26/02/2026

🌟 ABX Pearl of the Day ❓ Q: In a patient with suspected osteomyelitis, should I start empiric antibiotics or withhold antibiotics to improve diagnostic yield? #IDsky #medsky #meded #pharmsky #skyRX

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Stanford Antimicrobial Safety & Sustainability Program @stanfordasp.bsky.social · 19/02/2026

💡 Take-home: If you see E. gallinarum, think: ➡️ Intrinsic vancomycin resistance (vanC) ➡️ Usually ampicillin susceptible ➡️ Pip/tazo likely active but broader than necessary

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Stanford Antimicrobial Safety & Sustainability Program @stanfordasp.bsky.social · 19/02/2026

🔎 These principles also apply to other less common enterococcal species: • Enterococcus casseliflavus • Enterococcus raffinosus

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Stanford Antimicrobial Safety & Sustainability Program @stanfordasp.bsky.social · 19/02/2026

🧪 Diagnostic pearl ❗ vanC is NOT detected by available rapid diagnostic tests (RDTs detect vanA and vanB genes only) Most microbiology labs will automatically report E. gallinarum as vancomycin resistant due to known intrinsic resistance.

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Stanford Antimicrobial Safety & Sustainability Program @stanfordasp.bsky.social · 19/02/2026

🧬 Why is it vancomycin resistant? Resistance is modulated by the vanC phenotype, which is chromosomally encoded. • Typically confers lower-level resistance (MIC 4–32 mg/L) • 🚫 vancomycin should be avoided for treatment

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Stanford Antimicrobial Safety & Sustainability Program @stanfordasp.bsky.social · 19/02/2026

A: ⚠️ E. gallinarum is intrinsically vancomycin resistant. 👉 However, these organisms are typically ampicillin susceptible, so they are likely covered empirically by pip/tazo. 💊 Linezolid is not indicated empirically unless the patient is intolerant to penicillins.

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Stanford Antimicrobial Safety & Sustainability Program @stanfordasp.bsky.social · 19/02/2026

🌟 ABX Pearl of the Day: Enterococcus gallinarum in Blood Cultures ❓ Q: My patient’s blood cultures are growing Enterococcus gallinarum with susceptibilities pending. They’re on empiric vancomycin + piperacillin/tazobactam. Is this appropriate coverage? #IDsky #medsky #meded #pharmsky #skyRX

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Stanford Antimicrobial Safety & Sustainability Program @stanfordasp.bsky.social · 12/02/2026

📚 References: Keller EC et al. Cleve Clin J Med. 2012. PMID: 22854433 Hirschmann JV et al. J Am Acad Dermatol. 2012. PMID: 22794815 Rzepecki AK, Blasiak R. Curr Geri Rep. 2018. DOI: 10.1007/s13670-018-0257-x

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Stanford Antimicrobial Safety & Sustainability Program @stanfordasp.bsky.social · 12/02/2026

🔍 Notable mimics of cellulitis include (but are not limited to): - Stasis dermatitis - Lymphedema - Contact dermatitis - Lipodermatosclerosis - Eosinophilic cellulitis - Deep vein thrombosis

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Stanford Antimicrobial Safety & Sustainability Program @stanfordasp.bsky.social · 12/02/2026

💡 A: Cellulitis can be tricky to diagnose due to other clinical syndromes that can present in a similar way. 👣In patients with bilateral lower extremity erythema, alternative etiologies should be explored, as cellulitis is unlikely to present this way. In fact, it's almost never due to infection.

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Stanford Antimicrobial Safety & Sustainability Program @stanfordasp.bsky.social · 12/02/2026

🌟 ABX Pearl of the Day: bilateral LE erythema = cellulitis? ❓ Q: What are common mimics of cellulitis? #IDsky #medsky #meded #pharmsky #skyRX

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Stanford Antimicrobial Safety & Sustainability Program @stanfordasp.bsky.social · 04/02/2026

References: 1. NCCN Guidelines Prevention and Treatment of Cancer Related Infections v3.2024 2. ECIL-10 Guidelines 3. Elting, et al. J. Clin Oncol. 2000; PMID: 11054443 4. SHC FN Guidelines med.stanford.edu/content/dam/...

med.stanford.edu

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Stanford Antimicrobial Safety & Sustainability Program @stanfordasp.bsky.social · 04/02/2026

TL;DR: 🔥 Persistent fever in stable FN ≠ automatic escalation to carbapenems 💡 Stick with cefepime, keep looking for the cause, escalate thoughtfully

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Stanford Antimicrobial Safety & Sustainability Program @stanfordasp.bsky.social · 04/02/2026

🔍 Instead of escalating antibiotics: -Continue diagnostic workup for an infectious source -Consider non‑bacterial causes (e.g., fungal infection, drug fever) -Consider ID consult if persistently febrile without a clear diagnosis or concern for non-bacterial/opportunistic infection.

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Stanford Antimicrobial Safety & Sustainability Program @stanfordasp.bsky.social · 04/02/2026

⏳ Why? Time to defervescence on appropriate empiric therapy can be 2–7 days (median ~5 days). Persistent fever ≠ treatment failure³

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Stanford Antimicrobial Safety & Sustainability Program @stanfordasp.bsky.social · 04/02/2026

✅ A: In stable FN patients with persistent fever of unknown origin, current NCCN¹ and ECIL‑10² guidelines do NOT recommend changing empiric Gram‑negative coverage.

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Stanford Antimicrobial Safety & Sustainability Program @stanfordasp.bsky.social · 04/02/2026

🌟 ABX Pearl of the Day: ❓ Q: My patient with febrile neutropenia (FN*) on IV cefepime is hemodynamically stable but continues to have fevers. Do we need to switch empiric antibiotics to IV meropenem? #IDsky #medsky #meded #pharmsky #skyRX #AMSsky

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Stanford Antimicrobial Safety & Sustainability Program @stanfordasp.bsky.social · 22/01/2026

Important: If a new fever* develops after de‑escalation or discontinuation, empiric IV antibiotics should be restarted and a full ID workup initiated. 🔗SHC FN Guidelines med.stanford.edu/content/dam/...

med.stanford.edu

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Stanford Antimicrobial Safety & Sustainability Program @stanfordasp.bsky.social · 22/01/2026

📏 This practice aligns with: NCCN Guidelines ECIL Guidelines ⚠️ Caveat: The degree of applicability to allogeneic HSCT recipients is uncertain because they were under‑represented in the trial.

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Stanford Antimicrobial Safety & Sustainability Program @stanfordasp.bsky.social · 22/01/2026

The evidence: The How Long Study (open‑label RCT) showed that stopping empiric antimicrobials after 72 hours without fevers in hematologic malignancy patients with FN led to: 🔻 Significantly less antibiotic exposure ❌ No increase in mortality or fever recurrence (How Long Trial, 2017)

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Stanford Antimicrobial Safety & Sustainability Program @stanfordasp.bsky.social · 22/01/2026

✅ A: Data support early discontinuation of empiric IV antibiotics at 72 hours in patients with FN who have clinical recovery and fever resolution — regardless of current ANC.

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Stanford Antimicrobial Safety & Sustainability Program @stanfordasp.bsky.social · 22/01/2026

🌟 ABX Pearl of the Day: ❓ Q: My patient with febrile neutropenia (FN*) has been afebrile for 72 hours, is asymptomatic, and we haven’t found an obvious infectious source. How long should I continue cefepime? #IDsky #medsky #meded #pharmsky #skyRX #AMSsky

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Stanford Antimicrobial Safety & Sustainability Program @stanfordasp.bsky.social · 15/01/2026

🧠 TL;DR: Most candiduria = colonization. Fix the risk factors, don’t reflexively prescribe antifungals. Treat only when symptomatic or high‑risk.

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Stanford Antimicrobial Safety & Sustainability Program @stanfordasp.bsky.social · 15/01/2026

🔹 When treatment is indicated: If symptomatic, fluconazole is the drug of choice for patients with Candida UTI. Echinocandins (e.g., caspofungin) do not reach urine concentrations adequate for treatment. (PMID: 21498839)

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Stanford Antimicrobial Safety & Sustainability Program @stanfordasp.bsky.social · 15/01/2026

🔹 When not to treat: Treatment with antifungal agents is NOT recommended unless the patient is clearly symptomatic or at high risk for dissemination — including neutropenic patients and those who will undergo urologic manipulation. (PMID: 26679628)

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Stanford Antimicrobial Safety & Sustainability Program @stanfordasp.bsky.social · 15/01/2026

🌟 ABX Pearl of the Day: ❓Q: Candida in the urine? Should you treat? ✅ A: Usually not. Candiduria almost always reflects colonization, not infx. It should prompt elimination of risk factors- e.g., d/c indwelling catheters rather than antifungal tx🚫 #IDsky #medsky #meded #pharmsky #skyRX #AMSsky

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Stanford Antimicrobial Safety & Sustainability Program @stanfordasp.bsky.social · 08/01/2026

Even in severely immunocompromised pts, Candida pneumonia is exceedingly rare (0.2–0.4%) & usually linked to hematogenous spread (PMID: 8502166).

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Stanford Antimicrobial Safety & Sustainability Program @stanfordasp.bsky.social · 08/01/2026

📊 A prospective study of ICU autopsies (PMID: 19357832): 77/232 pts had positive tracheal aspirate or BAL for Candida spp NONE had histopathological evidence of Candida pneumonia

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Stanford Antimicrobial Safety & Sustainability Program @stanfordasp.bsky.social · 08/01/2026

Candida is part of the normal microflora of the oral cavity & upper respiratory tract. Isolation from respiratory cultures—even BAL—is common in hospitalized patients & almost always colonization, not infection (IDSA Guidelines).

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Stanford Antimicrobial Safety & Sustainability Program @stanfordasp.bsky.social · 08/01/2026

🌟 ABX Pearl of the Day: ❓Q: My patient has isolated yeast (NOT Cryptococcus) from a respiratory culture. Do I need to treat this? ✅ A: In the vast majority of cases… NO. #IDsky #medsky #meded #pharmsky #skyRX #AMSsky

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Stanford Antimicrobial Safety & Sustainability Program @stanfordasp.bsky.social · 16/12/2025

*Other conditions that cause pyuria: recent bladder instrumentation, foley catheterization, acute renal failure, urinary stones, interstitial cystitis, bladder tumor, sexually transmitted infections, appendicitis, or systemic inflammatory syndromes such as lupus [PMID: 25760357].

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Stanford Antimicrobial Safety & Sustainability Program @stanfordasp.bsky.social · 16/12/2025

• Low urine WBC (WBC < 10) almost always excludes the diagnosis of UTI. Exception: remember that in neutropenic or leukopenic patients, the urine WBC count may be low and not accurately reflect presence of UTI.

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Stanford Antimicrobial Safety & Sustainability Program @stanfordasp.bsky.social · 16/12/2025

• Borderline urine WBC counts (6–10 cells/mL) may reflect dehydration and should be expected in patients with oliguria or anuria.

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Stanford Antimicrobial Safety & Sustainability Program @stanfordasp.bsky.social · 16/12/2025

💡A: Not necessarily as bacteriuria or pyuria in a patient without symptoms is not indicative of a UTI. Many other conditions can cause pyuria*. A UTI diagnosis should be based on a combination of clinical sx(particularly focal urinary sx) with supportive laboratory information[PMID: 27066953].

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Stanford Antimicrobial Safety & Sustainability Program @stanfordasp.bsky.social · 16/12/2025

🌟 ABX Pearl of the Day: ❓Q: If the urinalysis (UA) has elevated WBC or bacteria, does this mean the patient has a UTI? #IDsky #medsky #meded #pharmsky #skyRX #AMSsky

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Stanford Antimicrobial Safety & Sustainability Program @stanfordasp.bsky.social · 10/12/2025

References: 1.SHC UTI ABX Guidelines 2.IDSA: Asymptomatic bacteriuria 3.Top 10 myths of UTI (PMID: 27066953)

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Stanford Antimicrobial Safety & Sustainability Program @stanfordasp.bsky.social · 10/12/2025

3️⃣ Colonization is inevitable Foley in place? Bacteria ↑ 3–5% per day → ~100% after 30 days. ✅ Avoid UCx from Foley >4 days → almost always colonized. ✅ If infection suspected: use aseptic technique & ideally replace catheter before collecting specimen.

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Stanford Antimicrobial Safety & Sustainability Program @stanfordasp.bsky.social · 10/12/2025

2️⃣ Colonization vs Infection matters It is important to differentiate these based on the presence of consistent symptoms and not the color/odor of urine or even isolated fever. UTI symptoms = ↑ frequency/urgency (not from diuretics), dysuria (not from catheter removal).

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Stanford Antimicrobial Safety & Sustainability Program @stanfordasp.bsky.social · 10/12/2025

A: Probably not. Here’s why 👇 1️⃣ Cloudy or “smelly” urine ≠ UTI Altered mental status? Also not a reliable sign. (1-3)

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Stanford Antimicrobial Safety & Sustainability Program @stanfordasp.bsky.social · 10/12/2025

🌟 ABX Pearl of the Day: ❓Q: My patient is admitted for heart failure and has a chronic indwelling foley with cloudy urine. Should I send a urinalysis or urine culture (UCx) to assess for UTI? #IDsky #medsky #meded #pharmsky #skyRX #AMSsky

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Stanford Antimicrobial Safety & Sustainability Program @stanfordasp.bsky.social · 03/12/2025

📖References: PMID: 33773631 PMID: 36948555 med.stanford.edu/bugsanddrugs...

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