The patient on the other side of the antibiotic prescription
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“Let’s use broad-spectrum antibiotics … just … in … case” is an all-too-common refrain heard by many an antimicrobial steward. What happens when “just in case” becomes a poor patient outcome?
I want to share three of my experiences with this phrase and how they have led to my firm belief that antimicrobial stewardship is a patient safety initiative. Prior to my current role, I had the honor of leading an inpatient stewardship program at a critical access hospital. The first experience occurred while this program was in its infancy.
The patient was a military veteran of advanced age who had been discharged to complete a week-long course of appropriately dosed ertapenem for a urinary tract infection. His urine culture had been positive for an extended-spectrum beta-lactamase producing E. coli, but there were no symptoms charted. He was prescribed the antibiotic due to his age and concern that he would get sick from the bug.
All was going well until day 7, when he was hospitalized due to delirium. Various theories were proposed, the most prominent of which was that he had developed a UTI with a super-resistant organism. Ertapenem was restarted to ensure it wasn’t simply an incomplete course. The option of hospice was discussed. All the while, I harbored a sneaking suspicion that there was more to this than meets the eye.
I searched for an answer and learned that encephalopathy was a known side effect of ertapenem. I shared my findings with the attending, who stopped the drug. The gentleman was discharged home shortly after. He later would give the attending a gift to thank them for saving him.
One can argue that the ESBL-positive culture without symptoms represents a classic case of asymptomatic bacteriuria. The antibiotic prescription and subsequent admission, therefore, were completely avoidable.
“Just in case …”
My second experience with this phrase involved a gentleman who was hospitalized for a diabetic foot infection with probable osteomyelitis. His ulcer had grown pan-sensitive E. coli. There was concern, however, that anything less than broad-spectrum would lead to clinical worsening. He was discharged to an outside facility on vancomycin and piperacillin-tazobactam.
About 3 weeks later, I received a call from a distant hospital. Our patient had been there for a week due to kidney failure caused by the antibiotics. He was on dialysis, and his vancomycin trough was still supratherapeutic. My heart sank as I thought through the alternatives that could have been tried instead.
“Just in case …”
My third experience with this phrase is one that I recall most vividly. A woman on peritoneal dialysis had been discharged to our ambulatory care unit to complete 2 weeks of renally-dosed cefepime for peritonitis. Despite cultures being negative, the antibiotic had been prescribed to ensure any and all possible infection was covered.
Halfway through the course of therapy, I was called to come and speak to the patient. She was reporting new onset twitching and jerking motions. Due to concerns about potential cefepime-induced neurotoxicity, we notified her provider. She was transitioned to a different antibiotic and sent home; however, I was called back to the unit a short time later. The scene that I walked into was truly heartbreaking.
The patient was now twitching so hard that her sibling had wrapped a belt around her to make sure that she didn’t fall over. I immediately sent her to the emergency department for further evaluation. She was subsequently admitted and seen by multiple specialists, who were unable to determine an alternative explanation for her symptoms.
I still remember coming to visit her on the second day of her hospitalization. I was greeted by the sight of padding on the sides of her bed. She was thrashing and twitching so hard that it had been placed to protect her head. As I spoke to her, she looked at me and asked repeatedly: “What’s going to happen to me?”
She was discharged some days later. I silently grieved as I realized that adhering to stewardship principles could have prevented this.
“Just in case …”
As I’ve reflected on these three cases over the years, I’ve thought about this and another phrase that it frequently partners with — “serious side effects are rare.” I’ve asked myself how the term “rare” is defined and measured. The answer now lies directly in front of me. “Rare” is a military veteran. “Rare” is a gentleman who struggles to control his diabetes. “Rare” is a woman with a sibling who loves her dearly. “How rare is it” has now become “is it avoidable?”
I now wholeheartedly believe that AMS is a patient safety initiative.
My dear reader, the next time that you overhear the phrase “just in case” being whispered in the halls …
Pause.
Think of these stories.
Think about the patient on the other side of the antibiotic prescription.
Editor’s Note: The stock image included with this post is for illustrative purposes only and does not show an actual patient.
