I recently got an up-close and personal tutelage on what's new since I left the field of medicine and went into public health.
My 69-year-old wife of 47 years was suffering from rigors (severe shaking often associated with fevers) but had a normal temperature. A trip to the emergency room (ER) revealed a normal white blood cell count (WBC) and normal temperature, a clear X-ray but a huge elevation in her sedimentation rate and C-reactive protein (CRP) — two non-specific tests that measure inflammation in the body.
She recently had a spinal fusion, so the first bet was a bone infection around the hardware, with spurts of methicillin-resistant Staphylococcus aureus (MRSA) into the bloodstream.
She was started on a third-generation intravenous (IV) cephalosporin after blood cultures and urine cultures were obtained, and she was hospitalized.
Two days later, her WBC was still normal, the fever got up to 104 degrees F, rigors resembled a seizure, a chest X-ray showed a huge infiltrate that indicated pneumonia and her CRP was even higher.
Fortunately, this old country doc had seen Legionnaires' pneumonia before all the fancy testing like CT scans, etc., was available, so back then I had to rely more on a good history and physical.
I suggested a test for Legionnaires' and initiating IV doxycycline, a tetracycline seldom used in human medicine anymore. (I sheepishly remembered all those talks and blogs I authored saying the huge use of tetracyclines in animal health did not worry me, because they were seldom used in human health.) The test came back positive. There just aren't many pneumonia causes that present like that and still maintain a normal WBC.
Here is a little background information on this potent bacteria. In July 1976, the American Legion was holding its 56th annual convention in Philadelphia, Pa., to honor our country's 200th birthday, after which 182 Legionnaires became ill, and 29 died. That was the first we knew of this bacteria, and it was named Legionella pneumophilia.
When more than one person becomes sick, we can often find the source of the bacteria, which is usually waterborne and inhaled. However, 80% are sporadic, as my wife's will most likely be, and the source will never be known.
My wife left the hospital the day after I penned this, but she spent five days in the critical care unit for respiratory support and assistance.
There are only 10-15,000 cases of Legionnaires' per year in the U.S., but 10% die. You don't ever want to get it.
So, what did I learn about antibiotic stewardship that is new, and why do I think the readers need to read about it?
For one, many in the animal agriculture industry blame all antibiotic resistance on inappropriate use of antibiotics in human medicine to treat viral illnesses, some of which is true. However, those antibiotics are not the big guns such as methicillin, vancomycin and carbapenem, which are all associated with deadly antibiotic-resistant superbugs.
While Jane was still in the ER, she had a nasal swab that tested for 20 viral respiratory illnesses like influenza, adenovirus, coronavirus, etc. All came back negative. I didn't know this modern medicine test had been developed.
She also had a blood test done that I had never heard of called procalcitonin. The lab explanatory note read that a level above 0.25 ng/mL would suggest a "possible benefit from appropriate antibiotics." Jane's was 0.80 ng/mL.
When things were at their worst 48 hours later, her procalcitonin was 4.0. Not only did this confirm that it was a bacterial pneumonia, but it also indicated that the cephalosporin was doing nothing to control it.
I am pretty certain that in a primary care physician's office, where patients present with less severe infections, these expensive new interventions will not be used, but neither will the cephalosporin or those other broad-spectrum drugs that are administered the IV route. This should help reduce the increase in nosocomial (hospital-acquired) infections by antibiotic-resistant bacteria.
Another recent intervention was twice-a-day nasal swabbing with a bacitracin ointment to reduce the risk of acquiring MRSA.
In my early days as a country doc, we would swab the throat of a youngster with a fever and sore throat and send it to the state lab to test for strep. The kid would be put on penicillin until the results came back negative. Then, the rapid strep test was invented, and we knew in five minutes if antibiotics were indicated or not.
Now, we have procalcitonin to reduce inappropriate use of antibiotics in hospital settings.
This is progress in the fight against antibiotic resistance, but I sure wish we could have had these two tests when I was still earning an honest buck.