The Art of Antibiotic Selection

(A 10 year old post about and old doctor and an old drug)

Jacques Johndreau did not look like his usual self when I saw him in the office a few weeks ago. He looked part retired bank manager and part Disney cartoon chipmunk.

He spoke with hardly any facial movements:

“Holy Boys, my wife said to me this morning, you look like you’ve got the mumps again!”

I was aware that Jacques had an atrophic testicle from catching the mumps as a teenager. This time, it was not likely the mumps, but a bacterial parotitis. He was afebrile, and could open his mouth when asked to. I could not palpate a stone in Stensen’s duct and he didn’t experience any worsening of pain when eating acidic foods, so I wasn’t so sure he had a stone.

This was an early, mild case of parotitis and I thought he had a good chance of beating the infection with oral antibiotics. The majority of these infections are caused by staphylococci, but sometimes gram-negative bacteria are the culprit. Whatever I chose, I needed to consider that Jacques takes a blood thinner, warfarin, which interacts with many antibiotics, particularly ones with gram negative coverage.

I e-prescribed a high dose of Ceftin, or cefuroxime, a second generation cephalosporin with good coverage for both staph and gram-negatives and no effect on warfarin.

“If you get worse instead of better on this”, I explained, “you’ll need intravenous antibiotics. So, by Saturday, 48 hours from now, you’ll know if you need to go to the hospital or not.”

Monday morning came. There were two ER reports with accounts of late Friday and Saturday visits with intravenous administration of ceftriaxone, a third generation cephalosporin. There was also a CT scan report with a hedged opinion that there was no frank parotid abscess. The third ER note, from late Sunday night, described how the doctor on duty had selected clindamycin and instructed Jacques to see me Monday morning for a referral to an otolaryngologist.

Monday morning Jacques definitely looked worse than the week before. His cheek was bigger and firmer, although not red. It seemed warm, but he didn’t have a fever. He had trismus; his mouth opened very little.

“Wait right here”, I said. “I’m going to call Dr. Ritz, the ENT specialist over at the hospital.”

I logged on to UpToDate and quickly looked at half a dozen treatment regimens for parotitis, and all were multi-drug intravenous protocols with oral step down alternatives.

“He’s in Danderville today, seeing patients at the Outpatient Clinic and tomorrow he’s in surgery all day”, his nurse said. She agreed to double book Jacques for Wednesday morning.

I called the Danderville clinic and asked to talk to Dr. Ritz.

After reassuring me that he never minded taking calls from a colleague, he listened to my story, and said “you’re old enough to remember Duricef, cefadroxil, right?”

“Sure”, I said. “I haven’t used it for years, though.” I remember we used to think of it as having better tissue penetration than other first generation cephalosporins.

“These are all staph. And Duricef works better than any other oral antibiotic. In thirty seven years, I’ve never had to operate on one of these.”

I thanked him and mentioned that I had scheduled Jacques to see him two days later, just to be safe.

“Oh, I’m happy to see him, but he’ll be fine”, the old otolaryngologist told me.

I related my phone conversation to Jacques and told him about his Wednesday appointment with Dr. Ritz at his office, thirty five miles away.

“If I can make it there. It’s going to storm, you know.”

Jacques’ usual drugstore didn’t have any cefadroxil in stock, but the other pharmacy in town did, so I e-prescribed it there.

“I’ll see you back here if the roads are too bad, but if you spike a fever or feel worse, go back to the hospital”, I concluded our visit.

I had a vague, uneasy feeling about just switching from one cephalosporin to another, but Ritz has a lot of experience and he’s the only ENT within a hundred miles.

Wednesday morning brought eight inches of snow with a thin layer of ice. After a slow commute in four wheel drive, I stomped the snow off my boots inside the clinic back door and hung my thick leather coat on the back of Autumn’s and my office door. I changed to my indoor shoes and booted up my desktop and tablet computers.

“Jacques Johndreau is coming in at nine”, Autumn told me, “he didn’t dare driving down to Dr. Ritz’ office.”

At nine o’clock I knocked on the door to room 2 and entered. Jacques stood up from his chair and greeted me with a handshake.

“I wanted you to confirm”, he said, and paused to show me how far he could open his mouth. “But I am definitely better.”

There was no question. His gland was half the size it had been 48 hours earlier.

“You didn’t need me to tell you that, even. This is very good news, that such an old drug worked better than two newer ones that I and the ER tried, even intravenously. I’ll call Dr. Ritz to let him know just how dramatic the difference is”, I said and patted Jacques on his broad shoulder.

The experience of an almost seventy year old solo doc beat the Boston medical Brahmins this time. I was fortunate to have my senior consultant to back me up.

And as for antibiotics, too, sometimes newer isn’t better.