I am no expert in antimicrobial stewardship however I do oversee an infection prevention program so I am modestly conversant in the matter.An article that I handout to all the students, residents and fellows is this 1990 paper titled Antibiotics:The Antipyretics of Choice? by DiNubile. This paper is brief, to the point and timeless as it argues against knee-jerk antibiotic prescriptions for febrile patients. Pulling the trigger on antibiotics is appropriate for neutropenia with fever, sepsis and a confirmed/highly probable bacterial infection. For nearly all other scenarios, there is time to pause for a proper assessment prior to initiating antibiotic therapy.
This recent article, hot off the press and published in JAMA provides a prescriptive framework, to be used in bedside clinical decision making, for re-thinking how antibiotics are prescribed. The key questions are:
- Does this patient have an infection that requires antibiotics?
- Have I ordered appropriate cultures before starting antibiotics?
- After 24 hrs can I stop antibiotics or narrow therapy or change to oral therapy?
- What is duration of antibiotics needed for this patient's diagnosis?
If the above were applied consistently, no doubt, antibiotic use would improve.
So here is my final comment: To truly impact antibiotic use we need an aggressive multi-modal approach, one that provides a simple clinical decision making model with aggressive antimicrobial stewardship programs that employ formulary restriction and prospective audit and feedback.
Anything less will fall short.
