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All good thoughts gentlemen.
As far as the "big guns" I agree with appropriate antibiotic stewardship and reserving the big guns for sepsis. In this case it does not pay to start narrow. Remember that if the patient has sepsis then broad spectrum antibiotics are appropriate and studies suggest that a patient's mortality increases ~7% per hour that they are not appropriately covered.
I would like to throw out C.diff into the equation as well. I bring it up in every one of my talks with patients regarding antibiotic treatment vs conservative treatment. C.diff colitis ranges from bad diarrhea, to severe dehydration and renal failure, to sepsis and even megacolon with colectomy. It is not that rare and we see that whole spectrum regularly. There's even "community acquired" C. diff and I've seen people without recent antibiotic treatment get it.
The discussion about C.diff helps more than the resistance talks because it is a more tangible consequence. I can not tell you how much time is spent explaining to people that antibiotics are not needed for their "cold" they have had for 2 days or 3 hours because their primary doctor or pediatrician has "always done that". I tell them that they should see them then. It doesn't sit well but we have to fight the good fight or become part of the problem.
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