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Antibiotics
Key Feature 1: In patients requiring antibiotic therapy, make rational choices (i.e., first-line therapies, knowledge of local resistance patterns, patient’s medical and drug history, patient’s context). Skill: Clinical Reasoning, Selectivity Phase: Treatment Key Feature 4: Use a selective approach in ordering cultures before initiating antibiotic therapy (usually not in uncomplicated cellulitis, pneumonia, urinary tract infections, and abscesses; usually for assessing community resistance patterns, in patients with systemic symptoms, and in immunocompromised patients). Skill: Selectivity Phase: Investigation Fever Key Feature 3: In a febrile patient requiring antibiotic therapy, prescribe the appropriate antibiotic(s) according to likely causative organism(s) and local resistance patterns. Skill: Clinical Reasoning Phase: Treatment Infections Key Feature 1a: In patients with a suspected infection: Determine the correct tools (ex: swabs, culture/transport medium), techniques, and protocols for cultures. Skill: Clinical Reasoning Phase: Investigation Key Feature 1b: In patients with a suspected infection: Culture when appropriate (ex: throat swabs/sore throat guidelines). Skill: Clinical Reasoning, Selectivity Phase: Investigation Key Feature 2a: When considering treatment of an infection with an antibiotic, do so: Judiciously (ex: delayed treatment in otitis media with comorbid illness in acute bronchitis). Skill: Clinical Reasoning, Selectivity Phase: Treatment Key Feature 2b: When considering treatment of an infection with an antibiotic, do so: Rationally (ex: cost, guidelines, comorbidity, local resistance patterns). Skill: Clinical Reasoning, Selectivity Phase: Treatment Key Feature 5: When a patient returns after an original diagnosis of a simple infection and is deteriorating or not responding to treatment, think about and look for more complex infection. (i.e., When a patient returns complaining they are not getting better, don’t assume the infection is just slow to resolve). Skill: Clinical Reasoning Phase: Hypothesis generation Pneumonia Key Feature 5: Identify patients, through history-taking, physical examination, and testing, who are at high risk for a complicated course of pneumonia and would benefit from hospitalization, even though clinically they may appear stable. Skill: Selectivity Phase: Diagnosis Key Feature 7: For a patient with a confirmed diagnosis of pneumonia, make rational antibiotic choices (ex: outpatient + healthy = first-line antibiotics; avoid the routine use of “big guns”). Skill: Clinical Reasoning, Professionalism Phase: Treatment Key Feature 8a: In a patient who is receiving treatment for pneumonia and is not responding: Revise the diagnosis (ex: identify other or contributing causes, such as cancer, chronic obstructive pulmonary disease, or bronchospasm), consider atypical pathogens (ex: Pneumocystis carinii, TB), and diagnose complications (ex: empyema, pneumothorax). Skill: Clinical Reasoning Phase: Hypothesis generation, Diagnosis Key Feature 8b: In a patient who is receiving treatment for pneumonia and is not responding: Modify the therapy appropriately (ex: change antibiotics). Skill: Clinical Reasoning Phase: Treatment, Diagnosis Key Feature 10: In patients with a diagnosis of pneumonia, ensure appropriate follow-up care (ex: patient education, repeat chest X-ray examination, instructions to return if the condition worsens). Skill: Clinical Reasoning Phase: Follow-up Key Feature 11: In patients with a confirmed diagnosis of pneumonia, arrange contact tracing when appropriate (ex: in those with TB, nursing home residents, those with legionnaires’ disease). Skill: Clinical Reasoning Phase: Follow-up, Referral Urinary Tract Infection Key Feature 4: In a patient with a diagnosed urinary tract infection, modify the choice and duration of treatment according to risk factors (ex: pregnancy, immunocompromise, male extremes of age); and treat before confirmation of culture results in some cases (ex: pregnancy, sepsis, pyelonephritis). Skill: Selectivity Phase: Treatment When I think a patient is likely to have a bacterial infection, I turn to Bugs & Drugs, the app on my phone that guides me to select appropriate investigations and empiric antibiotics as I await the results. This resources takes into account local resistance patterns and has a whole many other features including how to tailor antibiotics for specific bugs and gold nuggets of clinical information that are concise and ever-so-helpful regarding patient management. It gives you options for first-line choices and second-line choices in case a patient is allergic to the preferred option, or depending how unwell they are or are at risk for becoming. It even has risk calculator scores such as the CURB-65 to help determine patient disposition for those diagnosed pneumonia (Calculate by QxMD is another medical app filled with useful risk score calculators to support clinical decision making). Bugs & Drugs was originally developed to assist physicians in Alberta make appropriate antibiotic selection, but being only one province over, generally the microorganism resistance patterns are similar and so the recommendations also typically apply in the province of BC. There is another app I use called Spectrum that is far less glorious but that has even more targeted antimicrobial suggestions for patients in Vancouver specifically. I use this app to cross-reference Bugs & Drugs if it has information for the same infection. (If there is discrepancy, I make a judgment call all facts considered, but typically I default to Spectrum if I have to make a difficult choice, because it is designed to be more attune to the local microorganism resistance exactly where I am.) Bugs & Drugs unfortunately is not free from the app store, but I GUARANTEE that if you're a physician in Western Canada and you haven't tried it, it'll be some of the best less-than-$20 you'll ever spend on your CME. Got a question on a bug or a drug? Chances are it will solve your woes. Get at it. Does one need to obtain microbial studies prior to starting empiric antibiotics? It is often ideal to know what you're treating to be able to select appropriate antibiotics; empiric antibiotics are designed as a best guess option considering the bugs that are typically responsible for the given infection. However, with some run-of-the-mill infections, the bugs are so notoriously common for the infection that empiric treatment can be started without the need for definitive results from a microbial culture. This would apply to uncomplicated cellulitis, pneumonia, urinary tract infection, and abscesses. Treating empirically is standard of care for these infections. However, a patient should be advised to follow-up if they continue to worsen or simply aren't responding to antibiotic treatment as expected, as there could be more going on than was apparent clinically (ex: microorganisms with antibiotic resistance, atypical pathogens, complication or comorbid disease process, wrong diagnosis, etc.) and they may need further investigations and/or a change in their treatment regimen. If atypical organisms are responsible for the infection then public health authorities may need to be notified in the interest of contact tracing and prevention of outbreaks of infectious disease. Some types of infection may not need treatment at all in an otherwise healthy person with a good immune system, or at least can be postponed with clinical observation as their resolution with and without antibiotics is just not significantly different, or worth the side effects of the medicine. If, on the other hand, the patient appears unwell or would be at risk of decompensation, obtaining microbial cultures and providing empiric treatment is warranted even for infections that usually have the typical and well-characterized bacterial causes, because the stakes are just higher. Another time to consider getting microbial cultures would be if there is an active public health strategy to characterize regional infection rates, with corresponding microbial sensitivities to assess local microorganism resistance patterns.
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