When should a patient with a sinus infection be given an antibiotic? When does a patient’s sore throat suggest a bacterial, rather than viral, cause? Which antibiotic should be given to a septic patient who needs rapid resuscitation?
When emergency room physicians face questions like these, they need answers quickly, concisely and right the first time. The busy emergency department is not the place to comb through a textbook or search an online database.
In 1991, the Emergency Medicine Residents’ Association (EMRA) published its first pocket-sized reference guide on the use of antibiotics in the emergency department and put it in the hands of thousands of emergency medicine residents.
Since 2005, Christiana Care Associate Chief Academic Officer Brian Levine, M.D., has edited the book with the help of a changing cast of emergency medicine residents.
In addition to getting its name on the cover of a widely used guidebook, Christiana Care’s authorship of these guides educates its residents in the finer points of antibiotic use and stewardship, ultimately benefiting patients here and elsewhere.
Christiana Care physicians also have developed two other EMRA guidebooks. Jeremy Berberian, M.D., created the EMRA EKG Guide, released in 2017, and Robert S. Hsu, M.D., is leading a team authoring a guide to treating orthopedic injuries in the emergency department.
The antibiotic guide, which remains EMRA’s most popular publication, is given to each of the organization’s more than 16,000 members and is used on every continent except Antarctica.
It was this challenge of finding simplicity in the complex, combined with his long-time interest in pharmacology, that first led Dr. Levine to pursue and earn the right to edit the 12th edition of the antibiotic guidebook, released in 2007.
More than a decade later, the decision has echoed through the professional lives of hundreds of Christiana Care emergency medicine residents and medical students, and the health of countless patients.
Dr. Levine uses the guide as a learning opportunity for Christiana Care’s 60 or so emergency medicine residents. Working with Executive Assistant Sherrill Mullenix, he assigns chapters to each of them. Residents are responsible for looking through the literature to revise their own sections with the latest guidelines.
“This is a lesson with lasting value and unique rewards,” said Dr. Levine. “Our residents throughout their careers will see colleagues carrying around dog-eared, well-worn copies of the very antibiotic guide they edited.”
To prescribe or not to prescribe
Most antibiotics are widely available, so for decades doctors saw them as a commodity. But their effectiveness is more like a shared resource to be parceled out carefully.
Infections are some of the most common reasons patients come to emergency departments, and finding an effective antibiotic among scores of options isn’t as straightforward as it seems. There are side effects and drug interactions to consider, and patterns of resistance change constantly.
The guide also shines at telling caregivers when not to use antibiotics. Patients with a facial muscle weakness called Bell’s palsy only get antibiotics if they have a high likelihood of Lyme disease.
Similarly, antibiotics won’t help most patients with a sore throat or sinus infection, but some with underlying medical conditions may need them to avoid dangerous consequences.
Antibiotic stewardship is a major goal of the guide, which is careful to note when an antibiotic isn’t appropriate. The digital version of the guide is updated as resistance patterns change.
Because the guide helps caregivers avoid treatments their patients don’t need, many of its recommendations this year bear the logo of the Choosing Wisely initiative, which seeks to cut down on unnecessary care.
Concise, and easy to read
The guidebook is the result of hundreds of decisions about what details are necessary and what would only add to the word count. The guide, for example, recommends considering antivirals if serious symptoms accompany Bell’s palsy, but trusts the clinician already knows what “serious” means. And the guide doesn’t bother describing what areas are endemic for Lyme disease — it figures providers already know that too.
Improvements through the years include those from Laura Quint, M.B.B.S., who came to the United States after beginning her medical training in England, and is a chief resident in emergency medicine at Christiana Care. She has a background in medical textbooks at Oxford University Press, and she improved the guide’s grammar, typography and design.
The result is a book that’s not only concise but easy on the eyes. The guidebook is organized and color-coded by body system, with the antibiotic options and dosing for each condition.
EMRA hears appreciation echoed in the praises of its members, said Valerie Hunt, managing editor.
“Christiana Care’s model is to give you exactly what you need to know to care for your patient without getting bogged down,” she said. “It’s written in a way that everyone from a brand-new learner to an attending physician can pick it up and find relevant information quickly.”