Infectious Diseases in Clinical Practice:
Division of Pulmonary and Critical Care, University of Connecticut School of Medicine, Farmington, CT.
Disclosure: Dr Metersky discloses that he is a registered Democrat, but has been known to vote across party lines.
The author has no conflicts of interest to report.
Address correspondence and reprint requests to Mark L. Metersky, MD, Division of Pulmonary and Critical Care Medicine, University of Connecticut Health Center, Farmington, CT. E-mail: Metersky@nso.uchc.edu.
As experts in infectious diseases, we frequently deal with serious infections such as intra-abdominal infections, pneumonia, and bloodstream infections. Pathogenic bacteria often wield multiple resistance factors and toxins, which render them true weapons of mass destruction.1 These bacteria can win the war if we do not use antibiotics appropriately. Let us be honest-with respect to antibiotic choices, we are the deciders.1
Patients with inappropriate initial antibiotic coverage are more likely to have poor outcomes; thus, experts favor an aggressive initial antibiotic strategy to make sure that the likely pathogens are treated. In patients who do not respond to antibiotics and deteriorate, we would not want to look back and find that we had gone to war on infection with the antibiotics we had and not the ones we later wished we had.
Although it is wise to begin with broad-spectrum antibiotic coverage, once the infecting organism is identified, antibiotic coverage should be narrowed or deescalated to address the specific organism. Unneeded antibiotics should be cut and run3 back to the pharmacy.
In addition to deciding which antibiotics to use, the astute clinician is aware of the affect of the length of antibiotic therapy on the likelihood of resistance developing. Therefore, the historic practice of using a fixed timetable for withdrawing3 antibiotics (ie, 10 days or 2 weeks) is no longer recommended. Instead, clinicians should base this decision on how the patient is doing. When the infection is in its last throes,4 antibiotics can safely be withdrawn. In a sense, we can stand down when the patient is ready to stand up.1
Deciding what to do when a patient is not responding to therapy is often difficult because, as we know, there are known knowns; there are things we know we know.2 We also know there are known unknowns; that is to say we know there are some things we do not know. However, there are also unknown unknowns-the ones we do not know we do not know.2 Sometimes, the lack of improvement is due to patient-related factors, despite otherwise effective treatment, in which case, it is appropriate to stay the course.1 An inappropriate surge1 in antibiotic levels might only encourage more resistance because the bacteria improvise devices5 to counteract the antibiotics. Nonetheless, sometimes, initial antibiotics are not optimum, and an antibiotic regime change1 must be contemplated.
This review summarizes the major challenges in dealing with patients who have life-threatening infections. The use of these simple principles will allow us to make this war winnable and allow us to report to the patient and family, proudly declared, "Mission accomplished!"1
1. President George W. Bush
2. Secretary of Defense Donald Rumsfeld
4. Vice President Dick Cheney
From the editor: the preceding commentary reflects the views of the author and does not reflect any official political opinion of the editorial staff.