How many times has giving empiric antibiotics saved your professional behind?
Physicians who liberally prescribe empiric antibiotics are often maligned as irresponsible or unthinking by condescending colleagues and policy wonks. But are these doctors actually courageous and prudent, saving countless lives every year by refusing to bend to misguided pressure from antibiotic-conserving paper-pushers?
As antibiotic resistance has emerged, many hospitals have begun requiring physicians to provide a rationale for every antibiotic dose prescribed. The Centers for Medicare and Medicaid (CMS) is considering making this standard for every antibiotic dose, at every hospital, on every Medicare patient nationwide.
There's nothing wrong with having a rationale for antibiotics, or any other plan in patient care. But the development is part of what I perceive as a larger "pendulum swing" toward pressuring physicians to avoid prescribing empiric antibiotics whenever possible. That may not be such a great idea, since (unlike a lot of the things we do) antibiotics actually save lives on a regular basis.
At internal medicine training programs (or at least mine), a seductive and self-serving myth reigns: that doctors can usually know whether or not their ill-feeling patients are infected, and in what part of the body, and with what likely organisms. And all this can be done in a few moments, on rounds, with the internist's tools of history, exam, and a few labs! This would be a miraculous feat if even one living physician could do it consistently -- but in training programs, it's presented as routine, a mundane and expected part of any physician's job.
If a concerned resident dared to give empiric antibiotics overnight to a patient not clearly at death's door (and showed up to rounds without a Petri dish in hand growing the responsible organism), often as not the attending's disapproving question would be "But what are you treating?"
It wouldn't take long until you'd hear these same residents responding to suggestions that they give a sick patient empiric antibiotics with the same magic phrase, meant to simultaneously imply their own judiciousness and the colleague's profligacy: "But I don't know what I'm treating!" Someone not-that-clever coined "Vosyn" to half-pejoratively describe the broad spectrum cocktail of vancomycin and piperacillin-tazobactam (Zosyn) that supposedly unthinking physicians would prescribe for patients who were very sick from unclear causes.
But what I always wondered was, how many people got better from those antibiotics?
While there are surely some penicillin-pushers among us, slinging antibiotics at anyone with a chief complaint, I'm pretty sure that the vast majority of physicians prescribe antibiotics to one group of patients: those who they think might have an infection. Maybe even an infection that could get seriously worse if untreated.
So I was glad to read Kent Septowitz at Memorial Sloan Kettering / Cornell's editorial in the July 12, 2012 New England Journal of Medicine. He seems to agree that we physicians are overly apologetic about our supposed crimes of antibiotic overuse, and that by buying into the myth of rampant irresponsible prescribing that needs to be administratively controlled,
We also have promoted the notion that the field of clinical medicine is far simpler than it actually is. Despite our confident claims to the contrary, the diagnosis of infection is anything but an exact science. In the daily tumult that is clinical care, antibiotics have bailed us all out countless times. Blood work, radiology results, and the physical exam declare their limits to the practicing doctor every day. Often, when we are stumped and lost in caring for a patient, we turn, thankfully, to a prescription for an antibiotic. Just in case. Only hubris prevents us from admitting the number of times this approach has saved our patients' health and our reputations.
Of course broad spectrum antibiotics like Zosyn and Cefepime need to be conserved as much as possible, and doctors should offer reassurance--not azithromycin or amoxicillin--to patients with mild, likely viral respiratory infections. But the emergence of antibiotic resistance is an insanely complex phenomenon that has been oversimplified to a story of antibiotic-hungry patients, satiated by customer-service-friendly, lawsuit-averse physicians (cast as the bad guys), with the stingy antibiotic stewards serving as humanity's last line of defense from a superbug plague. According to my far smarter infectious disease colleague Brad Spellberg in his book Rising Plague, it just ain't that simple: physician overuse of antibiotics and "dirty" hospitals are not the main causes of the global rise in antibiotic resistance. (If you want to know what the causes really are, and what we should do about it, buy his book.)
My favorite sarcastic response (under my breath) to someone who argues against giving antibiotics to a sick patient who passes my test of "If this were me, would I want a shot of ceftriaxone?"
Save the antibiotic, not the patient!
Sepkowitz KA. Finland, Weinstein, and the Birth of Antibiotic Regret. NEJM 2012;367:102-103.