Thursday, October 17, 2013

Author Question: Antibiotic Usage

Amanda Asks:

I thought it would be good conflict to give my nurse protagonist TWO patients with rival needs. The fast facts:

A) Fugitives from the law.
B) No access to medical treatment.
C) The nurse does have some Amoxicillin but just enough for about another week for Patient #1 (the man she loves), who has been on it for almost five days now (fever broke, lucid now, still sick though.) He has bacterial pneumonia, rib fractures, and malnourishment.

They're running for their freedom if not their lives. In comes Patient #2, who dug a tracking device out of his body with a non-sterile instrument and now has cellulitis (red streaks from the wound, low-grade fever, awesomeness.)

My nurse has to give him antibiotics or he could die.

But if she gives them to Patient #2, Patient #1 could relapse. And die.

So . . . Nurse Jordyn . . . which patient truly needs the medicine the most? Is there any use whatsoever in giving each of them half of it?

If she gives the whole dose left to Patient #2, will Patient #1 necessarily relapse? Is it unrealistic if he doesn't?

If she gives the whole dose left to Patient #1 will Patient #2 necessarily die?

And now for the big question: as a nurse, what would YOU do?

Thank you, you are awesomely awesome.

Jordyn Says:

Wow, Amanda. This is a very intense question and not as hard an answer as you might think.

The issue you've given these two patients . . . Patient #1 has presumed bacterial pneumonia because I'm assuming no chest film was taken (which would be a definitive diagnosis) since they are running from the law. Patient #2 has cellulitis. 

The reason this is an easy answer is that Amoxicillin is typically not used to treat skin infections. What is generally used is an antibiotic called Keflex. This uber-smart nurse would know that and continue to give the Amoxicillin to the man with the pneumonia-- particularly if he was improving. If the patient improves it can be a logical assumption that the antibiotic had something to do with it and he should finish the course of treatment.

That being said--- let's consider your questions.

Is there a benefit in giving each half the dose? Yes and no. This could be effective and also dangerous. Under dosing an antibiotic could lead to partial treatment and some bacteria still being left alive. Now, the bacteria have been exposed to the antibiotic and may mutate leading to a resistant strain which could ultimately put them both in danger.

Would patient #1 die if treatment stopped half-way through? Again, yes and no. He could survive and be fine but also develop a more resistant infection later on.

Would patient #2 die without treatment? Yes, this is probable with a bad cellulitis. Likely, what would happen eventually, is the bacteria gets into his blood and he dies from blood-borne sepsis or blood poisoning as it is sometimes called.

I do hope one of these fine gents lives.


  1. Jordyn, Good answer. It would take a cephalosporin or similar Rx to help the cellulitis. The amoxicillin would be a decent choice to treat pneumonia. Rather than doing nothing for the cellulitis, she could treat it with local hot packs, maybe an antibiotic ointment applied to the wound site if there "happened" to be some in her back-pack. Might keep things in check for a day or two more.

  2. Glad to have a physician's input here. Thanks for leaving your insight, Richard!