The adult presented with 1 week of non-productive cough (yes, a good history was taken), and had no signs of sepsis other than fever. CRP moderately raised, CXR normal. The clinician documented a vague differential diagnosis and started vitamin C3 (ceftriaxone). 

This arises frequently on our antimicrobial rounds and really indicates that the threshold for using antibiotics is still set too low. Non-specific respiratory symptoms often arise from viral infections and other conditions- perhaps better for us to have a lower threshold for direct viral testing (now that we have excellent PCR tests for most respiratory viral pathogens for instance) rather than shooting from the hip with an antibiotic that may well cause adverse effects .

At a more general level, always  ‘think whether your patient has really earned an antibiotic’  i.e. is there sufficient evidence of either local site bacterial infection or systemic sepsis.  Determining whether a local site is infected with pathogenic bacteria will depend on the clinical syndrome and/or microbiological or other testing results.   If in doubt, be prepared to wait watchfully and delay antibiotics until later assessment– this is safe to do in the patient without evidence of sepsis.

In Australian paediatric patients,  Haemophilus influenzae type B, meningococcal and conjugate pneumococcal vaccination is the norm and exceedingly few patients present with bacteraemia due to these major pathogens. If meningococcal sepsis is suspected, then benzylpenicillin is warranted NOT ceftriaxone. Benzylpenicillin or amoxycillin also remains our first line agent for paediatrc pneumonia.

Adverse effects of antibiotics are much more considerable than previously recognised and include super-infection with antibiotic-resistant organisms, C. difficile infection and prolonged changes to bowel flora that may impact on a diverse range of non-infective conditions.

For further information about local epidemiology of blood culture-proven sepsis events across Hunter New England region, see the Pathology North website, epidemiology page.

See also these previous postings:

•  https://aimed.net.au/2015/08/18/inducing-ceftriaxone-deficiency-in-hospitals-practical-stewardship-insights/
• https://aimed.net.au/2015/07/03/diagnostic-error-is-a-major-factor-leading-to-inappropriate-antimicrobial-use-recent-landmark-paper/