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How do you choose antibiotic treatment?

Leonard Leibovici (leibovic@post.tau.ac.il), chairmana,
Ilana Shraga, physiciana,
Steen Andreassen, readerb

^aSackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Tel-Aviv, 69978 Israel, b Department of Medical Informatics, Aalborg University, Aalborg, 9000 Denmark
^bDepartment of Medical Informatics, Aalborg University, Aalborg, 9000 Denmark
New England Medical Center, Box 302, 750 Washington Street, Boston, MA 02111, USA
Public Health Laboratory Service, London NW9 5EQ
Yale University School of Medicine, 20 York Street, New Haven, CT 06504, USA

Correspondence to: L Leibovici, Department of Medicine, Rabin Medical Center, Beilinson Campus, Petah-Tiqva, 49100 Israel

Accepted 18 February 1999

Even the most common problems in antibiotic treatment do not have simple solutions. Choosing one antibiotic drug from among several candidates entails balancing the benefits and the detriments associated with each. In this article we engage the reader in a common scenario—deciding which drug to prescribe for a patient with urosepsis—which illustrates the dilemmas in antibiotic prescribing.

Summary points

In choosing antibiotic treatment, the benefits and detriments associated with each drug should be compared
Cost effectiveness analysis can serve as a framework for such a comparison
The benefit associated with appropriate antibiotic treatment may be so great that drug costs and side effects become secondary considerations
The development of future resistance is the major concern
In choosing antibiotic treatment, doctors have to choose between the interests of present and future patients

Scenario

You are a hospital doctor. An 83 year old man is admitted to your department at 2 am because of fever (temperature 38.7°C), dysuria, and chills. On the basis of clinical findings and microscopic examination of his urine, you decide that the patient has a severe urinary tract infection and needs intravenous antibiotic treatment.

In people of his age with urinary tract infection, the most common pathogens are Escherichia coli (about 60% of cases), Proteus mirabilis (10%), and Klebsiella pneumoniae (10%). 1 2 The susceptibility of common pathogens to a range of antibiotics is reported yearly by the microbiology laboratory at your hospital. From this you calculate that ampicillin will cover 40% of pathogens, second generation cephalosporins 75%, gentamicin 92%, third generation cephalosporins 95%, and imipenem 100%.

You believe that empirical antibiotic treatment matching the in vitro susceptibility of the pathogen will afford the patient the best chance of survival and an uneventful recovery.3^–5 However, you have been told repeatedly by the head of the department that the …

Correspondence to: S G Pauker

Correspondence to: Professor Duerden