Do we know how to give antibiotics?

There are several current and politically correct maxims regarding antibiotic use which include:

1.We must reduce the use of antibiotics for several categories of respiratory tract infections ( e.g. sinusitis and acute bronchitis) which will mitigate the rising tide of resistant organisms
2.It is more cost effective and therefore of course better to use less expensive antibiotics first and save the more expensive ones for more serious infections.
3.It is imperative that we take steps to decrease bacterial antibiotic resistance
and somewhat strangely
4.Resistance does not seem to matter in regard to clinical outcomes. (This perhaps has not risen to maxim level but there is evidence to that point)

In the premiere issue of Chest Physician, the new publication of the American College of Chest Physicians (subscription required) the Pulmonary Perspective section has some interesting thoughts.Let me preface with a caveat, the two authors are employed by Oscient Pharmaceuticals , which fortunately or unfortunately because of recent events may make the reader more skeptical than in the good old days.

The authors quote some interesting data ( Price et al, Respir Med 2004: 9817) from Great Britain regarding efforts there to decrease the use of antibiotics in respiratory infections. The bottom line is there was a 50 % increase in mortality from the beginning to the end of the two times periods studied concomitant with a 30% reduction in antibiotic use. The effect of the incidence of influenza was controlled for statistically. Association does not equal causality and this is a very broad brush analysis wherein lies many ways to reach the wrong conclusion. Still it is thought provoking . Was the unintended consequence of "educating" physicians not to use antibiotics responsible for an increased number of pneumonia death? Were folks considered to have viral bronchitis given the history of green phelgm who really had pneumonia and were not treated.Well, with this type of study we will never know.

The authors comment that simply cutting back on antibiotics may not be the right solution to mitigating microbial resistance. The WHO supports the authors ' suggestion to " hit hard and hit quickly" or more professionally put "use the most pharmacologically potent member of the relevant class of antibiotics for a short period to decrease the chance of developing resistance".

Is the key to managing what does appear to be a growing problem of drug resistance giving less antibiotics or it is giving the appropriate antibiotic in the correct dose? The problem is, of course, we are still working on the issues of what is appropriate and how long should we give antibiotics.