Residency and antibiotics:
Discovering the dogma of prescription

Bryan R. Fine, MD

Recently, I suggested to an attending physician that we put my patient on imipenem, aztreonam, ceftriaxone, and clindamycin. I meticulously outlined the pros and cons of this particular antibiotic regimen, how the broad spectrum would cover and double- cover all possible pathogens, and how side effects could be managed. A foolproof plan, I figured, smug.

She sat thoughtfully for a moment, nodding as she considered the proposal. Then she spoke.

"Tell me, again, how red was his eardrum?"

Wait. Am I not in the ICU anymore?

With short rotations propelling me quickly through various pediatric disciplines and subspecialties, my mind needs to catch up sometimes. In a three-month span, I have been in the ICU, where we empirically placed patients on quintuple antibiotic coverage; the emergency room, where, it seems, eight of every 10 children had a chief complaint of "fever" and parents wanted a cure literally overnight; and the outpatient clinic, where the attending physicians seemed to have their own eyes for otitis and my concern was figuring out an easier way to fill out those darn school forms.

A hectic journey

So goes the life of a pediatric resident—wildly through the lands of Otitis, Gastritis, Bronchiolitis and Sometimes Meningitis. Along the way, I'm attempting not only to hone my neophyte clinical skills but am sifting through volumes of erudite opinion so that I can create treatment algorithms and a style of my own.

Antibiotic management has proved a particularly difficult subject, with well-described cataclysmic consequences just over each horizon. The Literature, our growing bible, is very clear on this point: Prescribe, and contribute to the creation of a resistant monster that will one day wipe out the inhabitants of the earth, or withhold, and risk promoting an inoperable mastoiditis or mortal pneumonia or even causing Mom or Dad to miss two more days of work.

Maybe one day, I will be supremely confident in my clinical acumen. Until that happens, I will lie awake at night worrying that I may have prescribed an antibiotic for a common cold or that my pursuance of "watchful waiting" has allowed a young respiratory infection to attack multiple lobes. It's enough to make a tyke like me use amoxicillin as an oral rehydration solution. Or to forget about antibiotics altogether.

Right now, I am comfortably situated under the umbrella of academic medicine, where I make my choices and bounce them off people who've already trodden these paths. I hear their experiential biases and incorporate them into my evaluation of patients. There is also great joy in the labyrinthine games academicians play. We rule out lymphoma, tuberculosis, diabetes, sarcoidosis, and hemophagocytosis before prescribing for otitis media. We frequently order blood tests, place PPDs, search for immunoglobulins; only after being overly exhaustive do we send a patient home.

One day to come—in a real world where 15 patients are sitting impatiently in the waiting room and I've got the managed care company on the telephone saying "Deny, deny, deny"—my curbside consult will be Edith the Receptionist (and mother of four) who invariably knows things about sick children that I never learned. Until then, as I claw my way up the learning curve in this pediatric academic environment, I sometimes find myself faced with management techniques that contradict what I've learned so far.

Dial "A" for ...

A woman recently came in with her child, who was irritable and had been breathing rapidly for the past 12 hours. Looking over the medication list, I noticed he had been on amoxicillin for the past eight days.

"Why is he on amoxicillin?" I asked.

Mom, a reasonable-appearing, appropriately concerned woman, shrugged.

"I called my doctor a week ago and told him my son was congested and acting fidgety, and he called in this prescription."

Over-the-phone prescriptions? This shotgun approach—and techniques such as prescribing antibiotics for pharyngitis even with a negative throat culture or to appease a Napoleonic day care director—seems to violate all three tenets of prudent antibiotic prescription:

• It ignores epidemiologic concerns of antibiotic resistance and pushes us toward the apocalyptic production of a wildly resistant strain of something.

• It is costly, pushing us toward the disastrous debasement of an already precarious health insurance system.

• Perhaps most important, it erodes the essence of why I am going through this residency! Staying true to my profession requires that I at least see the kid and let him suckle on my stethoscope before I load him up on the pink stuff.

I recognize that I have not yet faced many of the cost concerns and time constraints of a private practice. What my outpatient experience has shown me, however, is that parents with sick children seem interested not so much in getting antibiotics as they are in getting something. They need some justification for taking time off from work, getting on the bus to come to the hospital, and then sitting too long in the waiting room because I'm spending time trying to justify to the mother of the child ahead of them why I'm not prescribing an antibiotic. Sometimes, reassurance is sufficient; sometimes, it's reassurance plus a lollipop. And sometimes, it seems that only a prescription will do.

From the many options, my plan is to establish a style with some consistency. Maybe I'll give a swig of penicillin to all my patients when they are triaged. Or maybe I'll make them show me a Gram stain result before I succumb and offer an antibiotic. Maybe I'll just do my best and, ultimately, fall somewhere in between.

THE AUTHOR is a second-year pediatric resident at Children's National Medical Center in Washington, D.C. He has written about his residency for The Tampa Tribune, Medscape, AMA Alliance, and others.

 

Bryan Fine. Residency and antibiotics: Discovering the dogma of prescription. Contemporary Pediatrics 2001;10:70.