Making the Correct Diagnosis: The Cornerstone of Antibiotic Stewardship

Neil Gaffin, MD; Brad Spellberg, MD


May 19, 2017

As the crisis of antibiotic resistance continues to worsen across the globe, new emphasis is being placed on "antibiotic stewardship." Antibiotic stewardship is the process of ensuring that antibiotics are used appropriately.

Physicians have a long history of overuse and misuse of antibiotics. More than 70 years ago, Alexander Fleming—the man who discovered penicillin—warned the public that penicillin was being misused.{1] He knew that overuse of penicillin would lead to penicillin-resistant bacteria and that patients would die because of it. Yet, his warning has gone unheeded by society. Seven decades later, up to 50% of antibiotic prescriptions in the United States continue to be unnecessary or inappropriate.[2,3,4,5]

Up to 50% of antibiotic prescriptions in the United States continue to be unnecessary or inappropriate.

Best practices for antibiotic stewardship are built around several fundamental principles.[6] Often these are described as giving the right antibiotic, at the right dose, for the right duration of therapy. Indeed, prescribing the wrong antibiotic, or at the wrong dose, can lead to bad outcomes for patients with bacterial infections. Prescribing the right drug at the right dose, but for an unnecessarily long course, also leads to overuse and selects for antibiotic resistance.

However, often overlooked is a more fundamental principle that must underpin effective antibiotic stewardship: making the correct diagnosis. We present several cases that illustrate this critical principle and the impact it has on appropriate antibiotic usage. These cases are based on real patients we have encountered recently. We present them not because they are unusual but rather because they are typical of clinical situations that happen tens of thousands of times per year in the United States.

Case #1: A Student With Respiratory Complaints

A 21-year-old college student presents with 7 days of sinus pressure, nasal congestion, coryza, itchy/watery eyes, and a scratchy sensation in his throat. He had a similar presentation a year ago that resolved after treatment with a variety of medications, including decongestants, nasal steroids, and antibiotics. He has no fevers, purulent expectorant, headache, nausea, or vomiting. He has no other relevant medical history.

The patient saw an ENT specialist who diagnosed him with acute sinusitis and prescribed an inhaled nasal steroid and 14 days of levofloxacin at 500 mg orally once per day. The next day, he sees you for a second opinion.


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