Great points but in reality - you also battle ID - the amount of the overbroad coverage - especially zosyn - less Ampc protection, very strong anaerobic coverage (to a point of potentially debilitating the gut microbiome - to battle the next infection - (and ceftriaxone will cover the oral anaerobes). Further pseudomonas even is usually known in the history or has risk factors. Idsa has admitted the “health care facility” designation is overly broad and didn’t change outcomes - seems like any patient even in a 55+ community gets Vanc and zosyn. So you’d think between that and procalcitonin guided data showing early cessation is safe you’d have less but it’s more and more. Am often battling ID even to stop the broad drugs but they are like “pt is on the vent!” It’s hard to swim upstream where a specialist is stating to do more.
Thanks for these insights. We do overuse these agents in many cases and we need a rational framework for this issue. I have also seen ID going overboard presumably from a position of cognitive exhaustion or liability avoidance. (Or “customer service” toward the ICU team).
I’m going to try to tackle that but this was just to inoculate the discussion against the pernicious influence of “population health” which in my opinion does not have a productive place in decisions regarding individual patient care.
I respectfully disagree in some of the points you make. While I do agree that physicians have obligation toward our patient. I disagree on not having obligations toward society. I believe a balance between the two is important to keep in mind. Otherwise it can result in dangerous precedent. I can think of few examples where society benefit outweighs individual benefit. For example, patient with TB or sexually transmitted disease. If the physician believes that patient will not take precautions to limit disease exposure, physician is obligated to report that to health department. This has no benefit to the patient but to others. Another incident, during Covid area. To avoid spreading infection, family members were not allowed to visit sick patients with the virus. That does not help the patient. Social support is important for patient health. But it was still limited to prevent spreading the disease even more.
Also, if “my patient benefit only” principal is applied, then why recommend vaccines to health individuals. I can make an argument that if everyone else get vaccinated then my patient does not need to take the risk since they would be protect by herd immunity so why take a chance with adverse effect no matter how small of it occurring. But if everyone thought that way then no one will get vaccinated.
I can even go into financial consideration of health care cost to individuals and society as a whole, but that can be its own discussion topic
TL;DR. While I agree we should care about our patients first, physician is still obligated to balanced that with societal benefit
These are good points and I know many people agree with your perspective. I have held similar views but mine have changed over time (right or wrong). I have come to see the simultaneous consideration of population health as problematic to the physician patient relationship but that is just my personal opinion. Thanks for commenting.
Great points but in reality - you also battle ID - the amount of the overbroad coverage - especially zosyn - less Ampc protection, very strong anaerobic coverage (to a point of potentially debilitating the gut microbiome - to battle the next infection - (and ceftriaxone will cover the oral anaerobes). Further pseudomonas even is usually known in the history or has risk factors. Idsa has admitted the “health care facility” designation is overly broad and didn’t change outcomes - seems like any patient even in a 55+ community gets Vanc and zosyn. So you’d think between that and procalcitonin guided data showing early cessation is safe you’d have less but it’s more and more. Am often battling ID even to stop the broad drugs but they are like “pt is on the vent!” It’s hard to swim upstream where a specialist is stating to do more.
https://pubmed.ncbi.nlm.nih.gov/38739397/ Is the reasonable study that looked into such.
*also strange that vanc/zosyn and vanc/cefepime does not cover atypicals but that’s a real ID question
Thanks for these insights. We do overuse these agents in many cases and we need a rational framework for this issue. I have also seen ID going overboard presumably from a position of cognitive exhaustion or liability avoidance. (Or “customer service” toward the ICU team).
I’m going to try to tackle that but this was just to inoculate the discussion against the pernicious influence of “population health” which in my opinion does not have a productive place in decisions regarding individual patient care.
I respectfully disagree in some of the points you make. While I do agree that physicians have obligation toward our patient. I disagree on not having obligations toward society. I believe a balance between the two is important to keep in mind. Otherwise it can result in dangerous precedent. I can think of few examples where society benefit outweighs individual benefit. For example, patient with TB or sexually transmitted disease. If the physician believes that patient will not take precautions to limit disease exposure, physician is obligated to report that to health department. This has no benefit to the patient but to others. Another incident, during Covid area. To avoid spreading infection, family members were not allowed to visit sick patients with the virus. That does not help the patient. Social support is important for patient health. But it was still limited to prevent spreading the disease even more.
Also, if “my patient benefit only” principal is applied, then why recommend vaccines to health individuals. I can make an argument that if everyone else get vaccinated then my patient does not need to take the risk since they would be protect by herd immunity so why take a chance with adverse effect no matter how small of it occurring. But if everyone thought that way then no one will get vaccinated.
I can even go into financial consideration of health care cost to individuals and society as a whole, but that can be its own discussion topic
TL;DR. While I agree we should care about our patients first, physician is still obligated to balanced that with societal benefit
These are good points and I know many people agree with your perspective. I have held similar views but mine have changed over time (right or wrong). I have come to see the simultaneous consideration of population health as problematic to the physician patient relationship but that is just my personal opinion. Thanks for commenting.
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No. But we should probably stop them sooner.
My teaching was straightforward- blast away when the sick patient arrives in the middle of the night- but fine tune within 48 hours.
Wholeheartedly agree and that’s what the post was supposed to be about before I got distracted by the philosophical issues :)
Hoping to write another that’s more practical synthesizing the various schemae.