I glanced up at the board in the emergency department, looking to see who my next patient would be. It was a busy month, toward the tail end of a respiratory season that seemed like it would never end. The triage nurse had just written "cough and decreased intake" by a patient's name in room 7. Those were fairly typical symptoms for the time of year. I readied myself for yet another discussion of viral upper respiratory infections, encouraging fluid intake and the use of humidifiers.
I walked into the patient's room and obtained a quick history. She had a runny nose, and had been coughing for a day or two. She was a picky eater, but had been eating and drinking even less than usual during the same time period. She had not had any fever and was otherwise normal, according to her father. Except for the runny nose, the results of her examination were normal.
As I launched into the viral upper respiratory tract infection talk, I noticed that the father was becoming flustered. Halfway through, he interrupted me and wanted to know when she was going to get amoxicillin. I explained in even more detail that, in my best opinion, a virus was responsible for his daughter's illness and that an antibiotic would therefore be of no benefit. Although I thought that my reasoning was sound, the father (who was substantially larger than me) thought otherwise. He knew his daughter and her symptoms best, and he knew that in the past she got better almost immediately after a single dose of amoxicillin. He made it dear to me, and to anybody else within earshot of the room, that he was not leaving without an antibiotic. It was going to be another long night in the emergency department.
A couple of months later, I was supervising a general pediatrics ward team. In between calls from the emergency department and various clinics about patients who would be admitted to our team, I received a call from one of the residents in the intensive care unit. There was an 11month-old boy with meningitis who was about to be transferred to us. After a rocky initial course, his condition had finally stabilized and at this point he needed only to finish a course of intravenous antibiotics. I looked through the patient's recent laboratory work on the computer to familiarize myself with him, and noticed that the Streptococcus pneumoniae that grew from his cerebrospinal fluid was a very resistant strain. Gram stains of his fluid had continued to show sheets of organisms and inflammatory cells for several days after starting antibiotic therapy. When he arrived on the floor, I saw that he was taking several antibiotics, including vancomycin, meropenem, and rifampin - big guns for a sick little boy. As I took a moment to think about the problems caused by resistant organisms such as his, memories of the father in the emergency department sprang to mind.
As residents, we are all aware of the very real problems associated with emerging resistance to antibiotics. Certainly all of us have been in situations similar to those described above. In some ways, these two represent the beginning or genesis and die end point or outcome of the sequence of events for resistant organisms. In our resident continuity clinics we often deal with parents who want a magic bullet to cure their child's runny nose and cough. We face pressure to prescribe antibiotics because of this parental or patient anxiety. Sometimes our own anxiety comes into play as well, when we are uncertain of a diagnosis. When you are just not positive whether that tympanic membrane is a little red, wouldn't it just be easier to go ahead and treat it with an antibiotic? If we use the broadspectrum cephalosporin du jour, won't it be safer? We would not want to miss covering a potential pathogen. On the wards and in the intensive care units, we take care of the patients who have complications because of resistant organisms. When we eat at the lunches sponsored by pharmaceutical companies, we hear of the new antibiotics coming down the pipeline that will help us deal with them. But then we have the opportunity to see resistance to these drugs develop as well.
We are in a good position to help slow the development of resistant organisms. Developing sound clinical practices now will go a long way in the future. If an appreciation for evidencebased medicine is incorporated into our training, it is hoped that it will be that much easier for us to make rational decisions about treatment. We can continue to hone our diagnostic skills, both by physical examination and by interpretation of laboratory tests, so that we can be confident of what we treat when we decide to start antibiotics. Most importantly, we can develop the skills to talk with our patients and their parents and present a good case for not using antibiotics when they are not needed. In the end, the bacteria will be easier to kill and we will be better physicians.