Intrigued by the plot of Kent Sepkowitz’ perspective piece on antibiotic stewardship in the NEJM

This is a guest-authored piece by Dr. Tom Gottlieb (Senior Specialist in Microbiology and Infectious Diseases, Concord Hospital, New South Wales, Australia), wherein he discusses Kent Sepkowitz's latest commentary in the NEJM.

This is writ in the genre of a thriller in which a new generation of ID physician villains (the previous heroic ID generation’s illegitimate offspring, it seems ) abound as ‘fervent’ ‘chastisers of antibiotic overuse and abuse’. These ‘self-pitying’, ‘inept’, ‘feckless’ ‘prohibitionists’, ‘gnawed with regret’, indeed ‘deranged’, threaten to undermine and disenfranchise the orderly world of antibiotic prescribing, by seeking to banish miracle antibiotics forever from the world. Indeed their quest, (in cahoots with the loonies of the anti-vaccination lobby), is so dangerous, it is spelt out in the more sophisticated French; “an idée fixe”. These antibiotic nihilists cannot appreciate the true contribution antibiotic chemotherapy has made to individual patient care and also to the global well being of humanity.

Now I too enjoy debunking zealotry, and would not deny that there is plenty about antibiotic stewardship that is worth challenging in a balanced discourse. And stewardship, (or is it shepherd-ship?) can be clearly problematic. As ID physicians, we are frequently left in a schizoid situation where, as on one hand we attempt to control unnecessary use, on the other, in individual care we often contribute to broad-spectrum prescribing. Moreover some clever contrarianism never goes astray. But Sepkowitz’ pendulum swings beyond healthy scepticism, past contrarianism, to something akin to denialism.

Damn it, I too need to reach for the French dictionary. Un agent provocateur? Peut-être, saboteur? Because there is significant damage caused when worthwhile attempts, not as suggested by Sepkowitz to deny antibiotics for patients, but to preserve antibiotics into an uncertain future, are derided by ID doyens. But without him providing us with any cogent examples of groups or policies that would support the existence of these villanous ‘antibiotic prohibitionists’. And the very simplistic, polemical, good versus evil like vision he paints, creates a disservice to the antibiotic debate. (Or is it that for the sake of a good argument, as Oscar Wilde wrote, Sepkowitz feels that “in matters of great importance, style, not sincerity is the vital thing”)

I agree with Sepkowitz that “just in case” prescribing, often saves the day in settings of uncertainty. But one of the banes of our clinical existence is ‘just in case’ prolonged orthopedic prophylaxis, ‘just in case’ ceftriaxone in heart failure, ‘just in case’ stat gentamicin dose pre catheter removal, just in case treatment in case confusion is caused by a urine infection, or a few more days of treatment ‘just in case’, etc..; situations in which antibiotics are used to treat the prescribers’ anxieties rather than the patient’s condition.

I find Sepkowitz’s piece in the NEJM more a diatribe than a commentary. But it is a very useful piece too. It is a wake-up call that if we fail to convince other ID physicians regarding the merits of prudent antibiotic use, we have a long way to go to change attitudes amongst medical peers or in the community.

Image: Nicolas Poussin's Adoration of the Golden Calf. "The Golden calf of Stewardship" paraded in front of idolatrous ID physicians?