[PedOncoDoc]

I've been following this thread closely and have not yet shared my $.02.

Regarding comments about late toxicities (months to years out from Rx) of antibiotics - I'd like to hear which specific antibiotics to which you are referring, xSFmed, along with the reported late toxicities to further have discussion on this - peer-reviewed medical literature references would be appreciated.

Antibiotic stewardship is a very complex and dynamic area of medicine. In my field of expertise we treat profoundly immunocompromised patients who have no immunologic reserve and can go from well-appearing to dead in a matter of hours, so our treatment algorithms typically start broad and go to narrow - the opposite of what should be done for otherwise immunocompetent patients.

When I did primary care, I was slow to start antibiotics for infections, knowing many would be contained and cleared by the body, after that, I did start narrow and assess response when in an outpatient setting.

In the inpatient setting, things get much stickier, particularly due to insurance company models of reimbursement (bundled payment for hospitalization regardless of duration based upon diagnoses). Doctors have to weigh cost of treatment and, more importantly, duration of hospitalization with potentials for toxicities and emergence of drug-resistant bacteria. The major contributors to drug-resistant bacteria are truncated antibiotic courses (typically due to non-compliance of patients in the outpatient setting), and demand for antibiotics by the consumer for non-serious and non-bacterial infections. If physicians start narrow and slowly broaden in the inpatient setting, hospitals will take huge losses for each prolonged hospitalization due to starting narrow which, ultimately, will lead to bankruptcy and closure of the hospitals which physicians see as more harmful to patients and the general population than starting a "big gun" antibiotic from the start.

In the end, I believe the two major issues are patient demands for antibiotics when they aren't warranted, and patients stopping antibiotics courses early when they feel better, as opposed to completed a prescribed course to ensure clearance of the infection. These, IMHO, far outweigh the preferential use of "big gun" antibiotics up front for infections requiring hospitalization for management.

YMMV...