You may already know the names: vancomycin-resistant Staphylococcus aureus (VRSA), carbapenem-resistant Pseudomonas aeruginosa (CRPA), extended-spectrum beta-lactamase (ESBL) Escherichia coli. These are just some of the next-generation “superbugs” that are popping up in emergency departments across the United States. In 2018, 12 of the most concerning multidrug-resistant organisms (MDROs) were ranked by lethality, earning the nickname “the dirty dozen.”¹ More concerning is that some of these bacteria, like the carbapenem-resistant Klebsiella pneumoniae that recently resulted in fatal sepsis for a woman in Reno, Nevada, are resistant to all available antibiotics. In other words, they are invincible.²

Or are they? The antibiotic pipeline has largely dried up in recent years, so what can emergency physicians do to combat MDROs?³ Antibiotic stewardship.⁴ As Benjamin Franklin said, “An ounce of prevention is worth a pound of cure.”

When we unnecessarily prescribe antibiotics for viruses, misdiagnose noninfectious conditions (eg, pseudocellulitis), or provide suboptimal antibiotic regimens, we exert selective pressure on our local community’s biome. Selective pressure encourages resistant bacteria to thrive by killing off weaker bacteria.

It is not too late. We are living in a crucial time. The prevalence of superbugs remains low in most communities. By practicing what we call the “5 D’s of antibiotic stewardship”—right diagnosis, right drug, right dose, right duration, right de-escalation—we can reduce the prevalence of MDROs in our hospitals and communities.⁵ Future generations will thank us—or better yet, they won’t even realize they have to.

Meet the 5 D’s

Here are the 5 D’s applied to emergency medicine practice.

• Right Diagnosis: Take a diagnostic stand and call a virus a virus. Acute otitis media, bronchitis, sinusitis—all of these entities are far more often viral than bacterial. When the patient is not seriously ill, is not immunocompromised, and clearly had a recent viral prodrome, you can usually avoid antibiotics.
• Right Drug: For patients with uncomplicated bacterial infections that require antibiotics, consult your institution’s ED antibiogram to identify the most common causative organism and narrowest spectrum agent that is typically effective (eg, nitrofurantoin for Escherichia coli).
• Right Dose: Practice weight-based dosing of antibiotics for pediatric patients, and for noncritically ill adults, err on the low side of the suggested dose range.
• Right Duration: It is a poorly-kept secret in medicine that the recommended length of most antibiotic regimens was chosen arbitrarily in initial studies and has been subject to inertia ever since. When offered a range of duration of therapy, choose the shortest duration. If you are prescribing any antibiotic for more than seven days, favor a shorter course.^6–9
• Right De-escalation: Antibiotic de-escalation is a new trend in emergency medicine. Emergency physicians make decisions that generate therapeutic momentum for inpatient antibiotic prescribing. The act of simply writing in the chart, “These broad-spectrum agents should be narrowed to a single-effective agent once culture results have returned,” can save your patients days of unnecessary antibiotics.

For those looking for more specific ways to implement the 5 D’s, we have provided our five tips you can use on your next shift (see Table 1).