As much as we rely upon life-saving antibiotics, we must heed the stewardship nannies and their ever-important mission of harm reduction. Unfortunately, when the prevailing interest is preventing poor acute patient outcomes, prudent antibiotic prescribing falls by the wayside. A randomized controlled trial from the primary care literature attempts to gently reduce excess prescribing with personalized feedback and peer comparison—and fails.¹¹ It is absolutely possible to change physician behavior, but the means of doing so are likely more Draconian than most would find palatable.

There are some low-hanging stewardship fruit, however, addressed by trials such as “SCOUT,” looking at the duration required for antibiotics.¹² In this trial, children with a urinary tract infection were randomized to either five or 10 days of oral antibotics. Nearly every child improved and treatment failures were rare, but they were clearly more common in those receiving short-courses of antibiotics. It is likely the most appropriate strategy for prescribing is to start with a short course, but to remain adaptable to the occasional need for longer-course therapy.

In a bit of an odd trial attempting to tease out the best candidates for antibiotic therapy in those children with acute sinusitis, a trial explored clinical and microbiological predictors of treatment outcomes.¹³ The most interesting finding is the failure of the “color of nasal discharge” finding used by many to guide clinical management. This clinical manifestation was not shown to correlate with the presence of underlying pathogenic bacteria. While this trial was “positive” in the sense amoxicillin/clavulanic acid treatment was a bit better than placebo, the mean symptoms scores improved rapidly in both arms. Any benefit to antibiotics was restricted to the fraction whose testing proved presence of pathogenic bacteria. The most prudent strategy for mild acute sinusitis in children is almost assuredly still watchful waiting.

A Closing Treasure

Medicine is littered with perverse incentives to do “more” instead of “less.” Because of this, each gem in which an established dogma is challenged is greatly appreciated. The so-called “NINJA” trial evaluates whether children with nail and nailbed injuries benefit from replacement of the nail into the nail fold, or whether cosmesis and function are retained if the nail is simply discarded.¹⁴ While anatomic re-approximation sounds good in theory, these authors do not report any advantage to doing so. It turns out humans have at least some small remaining regenerative power, and the nail will grow back without any additional deleterious effect.