From time to time, I determine that an antibiotic will be helpful in resolving whatever ill is present in my patient. For example, folks with dental infections, and who are not allergic to beta lactam antibiotics (those related to penicillin), get amoxicillin. It is what our dental colleagues have directed me to employ as first line, and pretty nearly always gets the job done.
So, TINS, TIWFDASL, and my patient-du-jour had a dental infection. I presented my spiel, winding up with the observation that I would be sending over a prescription for amoxicillin.
This soul stated that they had received amoxicillin several years ago, and “it didn’t work”.
May I step back for a little bit of dental anatomy? Any surgeon (and, dentists are surgeons of a particular specialty) will tell you that antibiotics are wasted on any abscess, due to the fact that the overwhelming majority of the pathogens are afloat in the pus filling the abscess, and, since no abscess has any sort of circulatory system, any antibiotic will only make it to the periphery of the lesion, and not the the seat. Indeed, surgeons generally are of the opinion (an opinion probably developed during years of residency and 20,000 to 40,000 hours of patient contact) that the foundation of resolving an abscess is to drain the abscess. That will both greatly, greatly reduce the population of germs remaining to cause mischief, but also place those germs in close proximity to tissue that, indeed, has circulation, and therefore provide the antibiotic the ability to access, and damage, the germs.
GUM abscesses are potentially susceptible to intervention by clinicians such as I myself am. TOOTH abscesses, including dental pulp and/or dental root infections, are immune to my attentions.
Therefore, plausibly, this soul’s historic experience with amoxicillin could have been due to the infection remaining inaccessible to the antibiotic.
Back to my story. This child of God requested “something stronger” than amoxicillin.
Two competing thoughts sprang into my mind: First, amoxicillin is the drug of choice. Prescribing something else is akin to purchasing a full ton passenger van to transport your gravel, because “big vans are stronger!”, or something. Really, using the proper tool for the job makes so much more sense.
Secondly, there are several reasons why clinicians do not simply “prescribe something stronger”. One if them is NOT that we are all assholes, who want people to be/stay sick. Rather, for example, gentamicin is used all the time in ICUs for patients who are terribly sick. (wonder if that has anything to do with the reason that they are in ICU to begin with?) These folks get regular blood draws, to be sure that the concentration of drug in the blood is within certain bounds. Too little, and it is less effective than needed. Too much, and deafness and/or kidney failure can result, among other bad things.
So, for certain values of “stronger”, gentamicin is, indeed, “stronger”. On the other hand, deafness as a consequence of your long delayed dental care appears, to me, to be a risk out of proportion to the anticipated benefit. Particularly when I can anticipate the same benefit, with rare risk, from, gosh, er, um, oh, I dunno, AMOXICILLIN.
Back to my story, backing away, a little, from my rant-du-jour: I asked this soul what antibiotic had been beneficial, for past dental infections?
The answer, I swear to Crom, was, “I don’t know. You’re the doctor, don’t you know?”
Words. They fail me.