Lori Kestenbaum, MD

is a fellow in Pediatric Infectious Diseases at The Children’s Hospital of Philadelphia. She graduated with a BS in Psychology from Duke University and received her MD from the Perelman School of Medicine at the University of Pennsylvania. She completed her residency in Pediatrics at The Children’s Hospital of Philadelphia in 2012.  She is currently a member of the American Academy of Pediatrics, the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Follow her on Twitter @lorikestenbaum.

Antibiotics as anxiolytics

I had an outpatient surgical procedure recently — small enough to be outpatient, large enough to require sending me home with a Jackson-Pratt drain. On discharge, I was given the requisite prescriptions: pain medications, stool softeners, and amoxicillin-clavulanic acid as my “antibiotic prophylaxis” because I was going home with a drain.

The surgery resident handed me the scripts and knew me from CHOP, where we have a robust antimicrobial stewardship program. He knew that had he been treating a child, the child would be admitted postoperatively, and he would have called a pharmacist or ID fellow for approval for antibiotics for “drain prophylaxis.” He also knew we would have said, “There is no evidence to support antibiotic prophylaxis when a drain is in place.” After the child’s perioperative antibiotics completed, additional broad-spectrum antibiotics would only be prescribed with an evidence-based indication.

So as he handed me the antibiotic script, I had not even had time to raise my eyebrows when he said, “I know, I know. You aren’t going to take the antibiotics because there is no indication. But I have to write the script for you and at least make an effort to encourage you to take them, since your surgeon ordered them.” 

I was pleased — somewhat. Our message was getting out! The surgical residents were actually listening to us! Now we just needed to work with the attending ... and, apparently, most of society. My mother jumped in, “You really should take those antibiotics. That’s even one of the really good ones.”

Then the home care nurse came to visit and said, “You aren’t taking the antibiotics? Why not? You know you can still get an infection, even days out of surgery.” Then the PA at the office on the day the drain was pulled said, “You can stop taking the antibiotics now that the drain is out.”

I said, “I never took those. There is no evidence for prophylactic antibiotics when a drain is in place.”

“I know, I know,” he said.

As the patient, I was worried about an infection — really worried. I realize this worry actually drives the antibiotic prescribing. The thought crossed my mind that if I actually ended up with an infection, I would have wished I had taken those antibiotics. But then the academic side of my brain set in, and reminded me that had I actually taken the antibiotics and had an infection, it would have been with an organism resistant to amoxicillin-clavulanic acid. So, I followed the wound care instructions, rested, and ate a normal diet. And I’m infection-free.

So, I challenge you all to practice with the evidence, not with emotion. Antibiotics can’t be used as anxiolytics. We will create too much resistance in the process. If you really know they aren’t needed, don’t hand over the prescription.

Disclosure: The researchers report no relevant financial disclosures.