Antimicrobial Therapy
12 cases on cross-cutting antimicrobial PK/PD and stewardship decisions — extended-interval and TDM-guided dosing, desensitization, de-escalation timing, IV-to-oral conversion, OPAT candidacy, and dosing through renal replacement, obesity, and pregnancy — choose a case below to open its full multi-voice debate.
A single patient, forty-eight hours into septic shock. The disagreement isn't about which antibiotic he needs — it's about whether his own unusually fast kidneys have already outrun the interval it's being given on.
A single patient, nine days into antibiotic therapy that should have worked. The disagreement is whether to measure a drug level before adjusting the dose, or adjust the dose because there isn't time to wait for the measurement.
A single patient, hours after an obstructing stone was relieved. The disagreement isn't whether the antibiotic will work — the organism is fully susceptible — it's whether a dosing interval built for a stable kidney can be trusted on one that's actively changing.
A single patient, two days after a joint-sparing debridement. The disagreement is whether the drug most likely to save his prosthesis is worth re-exposing him to, given a confirmed, not merely historical, IgE-mediated allergy.
A single patient, forty-eight hours into empiric triple coverage for septic shock. The disagreement is whether a reassuring culture result should narrow his antibiotics today, or wait until his own clinical trajectory catches up with it.
A single patient, four days after percutaneous drainage of a periappendiceal abscess. The disagreement is whether a still-visible residual collection means source control isn't complete, or whether the route of antibiotic delivery never depended on that question in the first place.
A single patient, medically ready for six weeks of outpatient IV therapy. The disagreement is whether reliable home support is enough to send him home on, given his own recent history of not showing up.
A single patient, admitted for pneumonia severe enough to need atypical coverage. The disagreement is whether to route around her QT risk on the antibiotic side, or to fix the other QT-prolonging exposure instead.
A single patient, on continuous renal replacement therapy for an unrelated reason. The disagreement is whether to redose vancomycin off a published nomogram, wait for a confirmatory level, or do both.
A single patient, improving on day six of therapy for Pseudomonas ventilator-associated pneumonia. The disagreement is whether to trust the trial that shortened this diagnosis's standard duration, or the same trial's own subgroup finding that argues against applying it to her specific organism.
A single patient, in septic shock from MRSA bacteremia. The disagreement is whether a large actual-body-weight loading dose is the right way to reach target concentration fast, or whether a hydrophilic drug's own distribution argues against scaling it to his full weight.
A single patient, twenty-two weeks pregnant, with a resistant urinary pathogen. The disagreement is whether the human safety data on fluoroquinolones in pregnancy is reassuring enough on its own, or whether it only becomes decisive once her actual access to a parenteral alternative is accounted for.