The Lean Antibiotic Mantra

Sometimes Nothing Is Better Than Something

Neil Gaffin, MD; Brad Spellberg, MD

Disclosures

April 09, 2018

The discovery of antibiotics is arguably one of the greatest achievements of human civilization. Unfortunately, decades of unrestricted use, misaligned societal expectations and perceptions, and limited diagnostic tools, coupled with a progressively more complex and chronically ill patient population, have placed us on trajectory for a postantibiotic era.[1,2]

Realization of this apocalyptic scenario has led to the recent requirement that all acute and long-term care facilities now have antibiotic stewardship programs in place to ensure appropriate antibiotic use.[3,4]

[T]he cornerstone of antibiotic stewardship is making an accurate diagnosis.

A primary goal of antibiotic stewardship is to ensure that the clinician prescribes the right drug, dose, and duration of an antibiotic. However, as we have previously written, the cornerstone of antibiotic stewardship is making an accurate diagnosis.[5] If the patient does not have an invasive bacterial infection, the antibiotic drug, dose, and duration are always wrong.

Making an accurate diagnosis, to distinguish bacterial infections from their many mimickers, is hard. We do not seek to lecture but rather to commiserate. Despite being infectious disease specialists, in our less experienced past we too have treated "urinary tract infections" that were asymptomatic bacteriuria, "pneumonia" that was probably due to viral infections, and "cellulitis" that probably wasn't.

We do not seek to lecture but rather to commiserate.

Here, we present cases based on real patients that represent common scenarios for which antibiotics are often prescribed empirically. These cases exemplify the daily necessity to challenge initial diagnoses in order to achieve the desired outcome of reducing antibiotic prescriptions while optimizing clinical outcomes and minimizing harm (eg, emergence of antibiotic resistance, Clostridium difficile infection, fungal superinfections, and drug side effects).

A Nursing Home Resident Who Fell

An 86-year-old man with multiple medical problems was transferred to the emergency department (ED) from a long-term care facility after a fall. His history was limited owing to confusion. He was febrile (temperature, 101.1° F) and had an oxygen saturation of 94% on room air; he was hemodynamically stable. Chest exam was normal. No obvious traumatic injury was apparent.

The white blood cell (WBC) count was 6000 cells/mL, without left shift. The blood urea nitrogen (BUN) and creatinine levels were 2 mg/dL and 0.6 mg/dL, respectively. Chest x-ray (Figure 1) revealed a "patchy right mid-lung opacity" (no prior film was available for comparison). He was diagnosed with pneumonia and started on ceftriaxone and azithromycin.

Figure 1. Portable chest x-ray revealing a "patchy right mid-lung opacity."

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