The Lean Antibiotic Mantra

Sometimes Nothing Is Better Than Something

Neil Gaffin, MD; Brad Spellberg, MD


April 09, 2018

In this elderly woman who recently started a nonsteroidal anti-inflammatory drug in the setting of a thick-walled bladder (suggestive of chronic bladder outlet obstruction), an acute infection was believed unlikely to be the inciting event that precipitated her gross hematuria and urinary retention. She rapidly improved within 24 hours.

Gross hematuria in frail elderly persons is rarely due to infection but rather is secondary to underlying genitourinary tract abnormalities.[18] This patient received 2 days of antibiotics and was asymptomatic at follow-up 10 days later. Particularly in this patient population, often with multiple comorbidities, it is crucial to weigh the perceived benefits of antibiotic therapy with the potential for serious harm, such as Clostridium difficile infection.

An Older Woman With Syncope

An 80-year-old woman, recently discharged from a subacute nursing facility, presented after a brief syncopal episode. She had developed a dry cough and congestion 3 days before presentation. There was no fever. Her history was remarkable for a recent open reduction internal fixation of a left hip fracture and Parkinson disease.

She was afebrile while in the ED. Oxygen saturation on room air was 91%. Chest exam revealed bilateral wheezes. The WBC count was 7100 cells/µL, without left shift. Chest x-ray revealed an "infiltrate in the left mid-lung field" (Figure 6). Respiratory pathogen PCR assay revealed respiratory syncytial virus, and the serum procalcitonin level was 0.25 ng/mL. She was given ceftriaxone, azithromycin, and nebulized albuterol by the ED physician.

Figure 6. Portable chest x-ray showing a left mid-lung infiltrate.

As the physician seeing her the next day, you note that she appears clinically well, is afebrile on 2 L of nasal cannula oxygen, and has minimal wheezes. She has not received any further antibiotics.


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