Antimicrobial stewardship is everywhere—but best approaches are still debated.
In this episode, Don and Steve separate fact from fiction around antimicrobial stewardship – taking a closer look at how antibiotics are used in everyday practice—and where common beliefs may fall short.
- 🦠 Does antimicrobial stewardship actually reduce antibiotic resistance?
- ⏱️ Are shorter outpatient antibiotic courses—like 5 days—enough for most common infections?
- 💊 When does the choice of antibiotic, route, or mechanism really matter?
To answer those questions, we’ll narrow the spectrum of rumors and uncover the truth about these claims:
- Stewardship isn’t reducing overall antibiotic resistance
- Most outpatient infections only need 5 days of antibiotics
- IV antibiotics are better than oral options
- Bactericidal antibiotics are better than bacteriostatic ones
🏷️ 10% off a new or upgraded subscription with code rvt1026b at checkout.
TRC Healthcare Editor Hosts:
- Stephen Small, PharmD, BCPS, BCPPS, BCCCP, CNSC
- Don Weinberger, PharmD, PMSP
Guests:
- Madeline King, PharmD, BCIDP
- John Turtle, PharmD, MBA
CE Information:
For the purposes of disclosure, Dr. Madeline King reports a relevant financial relationship with Shionogi (speakers bureau for cefiderocol).
The other speakers have nothing to disclose. All relevant financial relationships have been mitigated.
TRC Healthcare offers CE credit for this podcast for subscribers at our platinum level or higher. Log in to your Pharmacist’s Letter, Pharmacy Technician’s Letter,or Prescriber Insights account and look for the title of this podcast in the list of available CE courses.
Resources:
- Toolbox: Antimicrobial Stewardship
- FAQ: Antibiotic Therapy: When Are Shorter Courses Better?
- Chart: Urinary Tract Infections
- Chart: Antibiotics in Pregnancy and Lactation
- FAQ: Managing Beta-Lactam Allergies
- Chart: Considerations for IV-to-PO Conversions
Email us: [email protected]
The content of this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment.
Find the show on YouTube by searching for ‘TRC Healthcare’ or clicking here.
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Transcript:
This transcript is automatically generated.
Introduction
Narrator
This transcript is automatically generated. Welcome to Rumor vs Truth, your trusted source for facts, where we dissect the evidence behind risky rumors and reveal clinical truths. Today, we’ll narrow down the spectrum of rumors around antimicrobial stewardship.
Don Weinberger
Steve, there are some days I just wonder, are we dispensing antibiotics based on the patient or just broad spectrum vibes?
Steve Small
Uh yes, the feels bacterial vibe. I know exactly what you mean. But when does it just become antibiotic astrology at that point, Don? Antibiotic astrology. I need to come with something.
Don Weinberger
The pills in our stars, right? Um you might be onto a new field there, Steve.
Steve Small
Yikes. Let’s hope, Don, that that doesn’t become an idea that’s infectious and spread. And before Don comes up with more ideas, I’m Steve the pharmacist. And I’m Don the pharmacist. And in this episode, we’re looking at antimicrobial stewardship because the best antibiotic decision isn’t always the strongest one. And the wrong one we know can cause harm long after the infection is gone. Right.
CE Information
Don Weinberger
So it’s an antibiotic that stays in the right orbit, which is most likely to help, least likely to harm, and least likely to create downstream problems. And in terms of CE, this podcast offers continuing education credit for pharmacists, pharmacy technicians, prescribers, and nurses.
Steve Small
Yeah, just log into your pharmacist letter, pharmacy technician’s letter, or prescriber insights account, and look for the title of this podcast in the list of available CE courses. And for the purposes of disclosure, our guest, Dr.
Overview
Don Weinberger
Madeline King, reports a relevant financial relationship with Shionogi by serving on the Speaker’s Bureau for Cepheiderical. The other speakers have nothing to disclose. All relevant financial relationships have been mitigated. All right, let’s get down to it. So no, antibiotics are the most common and most consequential meds we use. When the right drug meets the right bug, it can be life-saving.
Steve Small
Yeah, and you know, there’s a common thought here that antibiotics are low risk, and if they’re not needed, then they’re not harmful. Uh, but they’re one of the fastest ways to create avoidable harm when we use them for the wrong indication, the wrong duration, or the wrong route. Yeah.
Don Weinberger
Patient perceptions play a role here too, right? Some prescribers fear that not prescribing antibiotics lowers patient satisfaction. But withholding or de-prescribing antibiotics, if they’re not needed, might actually be the best course in many cases. Uh, a good example of this is watchful waiting, where we start antibiotics only if a patient worsens or doesn’t improve in a few days. Uh, you know, we see this with sinusitis and ear infections, which more often than not are caused by viruses.
Steve Small
Yeah, it’s a great strategy. And stewardship isn’t necessarily just no antibiotics, right? It’s also using the right antibiotic at the right dose, right duration for the right patient, plus reassessing as new information comes in.
Claim: Stewardship isn’t reducing overall antibiotic resistance.
Don Weinberger
Correct, Mr. Wright. So let’s go ahead and jump into that first claim, right? So the big picture claim that I’ve heard from some colleagues, and it may sound a tad gram-negative, uh, it is stewardship isn’t reducing overall antibiotic resistance. Well, boy, that that is cynical, Don. And that’s coming from me. Sigma. I know, yeah, it’s a you know, big shock there. So I’m surprised I haven’t heard this claim from you yet, Steve, right? But I could see where the sentiment may come from. Resistance is a major global problem, and we’ll always be dealing with resistance since it is a natural phenomenon. It’s due to natural natural selection, after all. So naturally, it can feel a little daunting.
Steve Small
And we do need to face the fact that resistance has indeed worsened in the 2020s. Uh, but CDC attributes this to the COVID-19 pandemic, derailing a lot of prior progress, like it derailed a lot of things. In fact, in December 2019, uh CDC actually reported that some resistant infections decreased throughout the 2010s in the US, likely due to improved stewardship. Uh, for example, phencomycin resistant enter cocci infections decreased by 41%, and multidrug resistant pseudomonas decreased by 29%.
Narrator
All right.
Don Weinberger
So what you’re saying really is stewardship can work, right? But implementing these practices can be difficult depending on the setting, especially if you’re working in a community pharmacy or clinic.
Steve Small
Yeah, that’s that’s a good point. Working in the hospital, I was lucky to have an entire infectious diseases team literally on speed dial to help us use antibiotics appropriately. And that luxury is rare in the community pharmacy setting. Uh, but you’d be surprised what community pharmacies can do in terms of stewardship.
Don Weinberger
Plus, stewardship also isn’t just about resistance in the abstract, it’s patient safety, so more concrete, right? So fewer adverse effects like GI upsets, uh, fewer drug interactions, fewer C. difficile cases, fewer patient costs, and fewer complications from throwing the kitchen sink at an infection.
Steve Small
I totally agree. And stewardship isn’t just one single intervention, it’s a bundle, verifying indication, choosing the narrowest effective option, setting a stop time, and even converting to uh oral from IV antibiotics when appropriate, and of course, reassessing the patient. Right.
Don Weinberger
Well, good points. So let’s go ahead and go back to that claim, which is stewardship isn’t reducing overall antibiotic resistance. And the verdict is rumor.
Steve Small
I think the mistake is expecting stewardship to just solve global resistance overnight. Uh, it’s really about harm reduction. Fewer unnecessary antibiotic days equals less selective pressure on that bacteria and less harm.
Don Weinberger
All right. Not for the immediate gratification crowd, right? When it comes to that. So uh let’s pause here. So we should also keep in mind that stewardship isn’t just about antimicrobials that target bacteria. It’s also important for antifungals, antiparasitics, and antivirals too. They do not get a free pass on this. Yeah.
Steve Small
Accounting for the whole microbial kingdom they’re done. They’re equally important as well.
Don Weinberger
And if steeroship seems daunting, we by starting with small steps that apply to both community and hospital settings. That can make a big difference. Uh, for example, ensuring every antibiotic order has an appropriate indication and a planned duration or stop time. Either is missing, that is a fixable problem.
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Steve Small
And there are tons of opportunities to help improve antimicrobial use, including in community pharmacies. So find strategies using our antimicrobial stewardship toolbox, which also features links to many infectious disease resources. Yeah, and talking about resources here, something to make your professional life easier. You betcha. Not subscribed yet or thinking about upgrading, access more trusted clinical insights and save 10% with our exclusive listener promo code RVT1026 at checkout.
Don Weinberger
Details and links are in the show notes, so don’t miss out.
Claim: Most outpatient infections only need 5 days of antibiotics.
Steve Small
And you know, Don, I’m glad you mentioned antibiotic stop times just a moment ago as a good quick intervention. There’s so many different infections out there. It can be really tricky to keep optimal therapy duration straight. So one interesting claim I recently heard is most outpatient infections only need five days of antibiotics. Sounds simple, five days, right? Or is it simply too good to be true? Exactly what I was thinking. So to help us with this claim, I reached out to Dr. Madeline King PharmD. She’s a board-certified infectious diseases pharmacist and is the co-director of outpatient antimicrobial stewardship at Cooper University Healthcare in Camden, New Jersey. And you may recognize her from the recent stewardship episode of our sister podcast, Medication Talk, back in March 2026. Let’s see what she had to say on this. Thank you for joining us, Dr. King, for this question. I’m really curious what is your take on this claim that most outpatient infections only need five days of antibiotics? I’m sure a lot of audience members are thinking, boy, that that’s pretty short.
Madeline King
Yeah, thanks for having me. And I think it’s a great question. Um I think it really depends on the infection type. But for the most part, yes, a short course of antibiotics is appropriate for most things that we see in the outpatient setting. Um, you know, upper respiratory tract infections, urinary tract infections, things that are pretty mild to moderate is um where we would think about shortening the course.
Steve Small
Great. Are there any exceptions to maybe point out that you see in practice that maybe the five-day rule doesn’t fit?
Madeline King
Yeah, I would say, you know, five days is pretty appropriate for most upper respiratory tract infections, UTIs, even shorter three days for some things. Um, there’s a few exceptions um in these mild to moderate outpatient infections where you might treat for seven days. So something like hylonephritis, so a more complicated, um more complicated UTI essentially. Um for sinusitis or pharyngitis, there is some data to suggest that seven and up to 10 days, depending on the specific infection and what antibiotics you’re using to treat it, might be more appropriate.
Steve Small
That’s great. And I’m sure a lot of folks are wondering does using a shorter course potentially worsen outcomes? For example, do infections, are they more likely to come back? I’m sure people are worrying about that.
Madeline King
Yeah, that’s also a great question. I mean, nobody wants to take antibiotics and then have a recurrence of their infection, right? So what we found, there’s a lot of literature now, which there really wasn’t 20, 30 years ago, showing them shorter versus longer courses when compared in clinical studies. Shorter courses are typically fine for most of these mild to moderate infections. Like I said, there’s obviously some exceptions when we’re talking about patients with bone infections, definitely not that short. We’re talking weeks. Right. Um, but with these mild to moderate things that are just concerning skin and soft tissue, the lower urinary tract um and kind of mild respiratory tract infections, we don’t see worse outcomes when we give shorter courses.
Steve Small
Well, that is reassuring. And I’m looking forward to bringing this back to Don and see what he thinks. And thank you so much for helping us with this claim.
Madeline King
Yeah, thank you so much.
Don Weinberger
Okay, wow, she really had some great points there. Uh, and regarding those upper respiratory infections or URIs, uh, the short duration is only if the infection is actually bacterial, right? In most cases, as we know, aren’t. And Steve, you cheater. Don’t think I didn’t hear you on that medication talk episode. But don’t worry, no averse reactions here.
Steve Small
Don, it’s not you, it’s stewardship. I’m just going where the topic leads me. But seriously, here, if you’re a pharmacist or a tech, the length of therapy is a great place to intervene on a prescription. Uh, look for prolonged durations and help clarify them at the point of dispensing, especially when the quantity doesn’t match typical guideline durations. And if you’re a prescriber, keep indications in mind that only need typically five days of treatment and help educate your colleagues. So, when it comes to this claim that most outpatient infections only need five days of antibiotics, the verdict is true.
Don Weinberger
Okay. So, important thing to remember, this is this claim is that most outpatient infections only need five days. And what I like about this too is that five days is such an easy name to remember, right? I’m counting pills in fives.
Steve Small
After all. Yep, pretty convenient. And I like that caveat you made, Don. Be aware that there may be times patients need longer therapy. So we need to be ready to tailor durations. For instance, patients discharged from the hospital for a more severe infection may need seven days of antibiotics instead of five.
Don Weinberger
All right, on the exception train here, watch for other exceptions any longer therapy, such as strep throat, right? Or infections in kids younger than two years old. We do have our resource antibiotic therapy, when our shorter courses better chart as a quick guide on optimal durations.
Steve Small
Yeah. Speaking of quick guides, before we dive into our other claims, how about we do some stewardship fast facts?
Don Weinberger
This is where we jump into some common bite-sized claims about stewardship and give them our seal approval or debunk them quickly.
Fast Fact: Asymptomatic bacteriuria (ASB) shouldn’t be treated with antibiotics.
Steve Small
Okay, here we go. The first one is asymptomatic bacteria or ASB shouldn’t be treated with antibiotics. Now, this one is true with conditions. In most non-pregnant patients with bacteria in their urine, but without symptoms, antibiotics provide no benefit and can actually cause harm, things like side effects, resistance from that unnecessary exposure.
Don Weinberger
In fact, evidence shows that using antibiotics for ASB actually increases your risk of UTIs in the future. You might be thinking that’s weird, right? Well, studies show that in women with reoccurrent UTIs, the bacteria hang out in the bladder without causing symptoms or actually protecting against more pathogenic bacteria. So it’s like your bladder’s own bouncer, right? Truth antibiotics, and you’re in trouble. Sort of a bitter iony there.
Steve Small
But there are important exceptions to remember here. Pregnant patients and certain urologic procedures, those patients actually do benefit from ASB treatment. So keep that in mind.
Fast Fact: Most penicillin-allergic patients can use cephalosporins.
Don Weinberger
Right. So review more tips on ASB and pregnancy and UTIs in general using our urinary tract infections chart. We also focus on fetal safety in our antibiotics in pregnancy and lactations resource. All right. Next up, another common claim we hear is that most penicillin allergic patients can use cephalosporins.
Steve Small
Now remember, cephalosporins include our cephantibiotics. Think cephalxin, cefazolin, cef triaxone. The list really goes on and on. Right.
Don Weinberger
So this claim is also true with conditions, but 90% of reported penicillin allergies aren’t really true reactions. And caros activity depends on the chemical sidechain similarity, not just cefalosporins as a whole class.
Claim: IV antibiotics are better than oral options.
Steve Small
And you can use our managing beta-lactam allergies and our investigating possible drug allergy resources to help you sort out whether a reported allergy is the real deal before moving to alternative antibiotics that may be riskier. Well, that was fun. But let’s slow it down for our remaining claims here, Don. I agree with that.
Don Weinberger
All right. So next slow claim would be so one I bet you still hear a lot in the patient side, Steve. And it is IV antibiotics are better than oral options. Yes. Oh boy, we hear this all the time, Don. You’re totally right. So now we know that IV antibiotics can be necessary, especially if someone can’t take oral meds, is unstable, or there’s no reliable oral option.
Steve Small
Right. But for many infections, once the patient is clinically improving and can take oral meds, properly selected oral therapy can perform just as well. Route doesn’t automatically equal more effective here.
Don Weinberger
Right. There’s a lot of things considered too, such as whether the antibiotic gets to the infection site. And also think about absorption. Some antibiotics are very well absorbed in the GI tract. A mesolid, for example, has nearly 100% oral bioavailability, meaning oral and ivy achieve virtually identical blood levels. Quinolones like leofloxin aren’t really far behind that. And removing to oral therapy more for certain infections, right?
Steve Small
Yeah, you’re absolutely right. A good example here is gram-negative bacteria or having certain bacteria such as E. coli in your blood. Uh, we used to treat this with a couple weeks of uh IV antibiotics in the hospital, but now evidence supports considering early step down to oral antibiotics in certain uncomplicated patients. And when we look at studies, they suggest this doesn’t appear to worsen important outcomes such as mortality and infection relapse or reinfection.
Don Weinberger
Right. I love having a hospital dude on with this. So another one for you is what are some complications with IV therapy?
Steve Small
Yeah, we have to weigh those risks too. We know IV therapy uh brings its own risks that we need to avoid if we can. Things like Lyme complications. Uh, it also requires more monitoring. It’s also more costly and potentially longer length of stay. Uh, those are some things that come to my mind, which is why IV to PO conversions is such a common storage of focus in the hospital. Great.
Don Weinberger
All right, so let’s go ahead and go back to that claim, which is IV antibiotics are better than oral options. And the verdict is rumor.
Steve Small
Yeah, so don’t assume just because something is IV that it’s automatically better for an infection. Oral antibiotics may be more appropriate in many cases, both clinically and also economically, to be honest.
Don Weinberger
All right, and to pitch another one of our resources, we have our considerations for IV to PO conversion chart to help you decide when and what to switch to if a patient is on IV antibiotics.
Steve Small
And now with that in mind, let’s convert over to our next and last claim here. And I feel like this one is spread faster than, frankly, well, resistance. It’s that bactericidal antibiotics are better than bacteriostatic ones.
Don Weinberger
Okay, let’s hold the phone here for a second. Uh let’s break down sytal versus static antibiotics for our listeners.
Steve Small
Yes, you bet. So bactericidal antibiotics kill bacteria outright. These include betalactans like penicillins and cephalosporins, quinolones such as levofloxicin, and immunoglycosides like uh gentamycin. But on the other hand, bacteriostatic ones inhibit growth. So our thinking is the immune system that needs to do the rest of the job of actually killing the pathogen. All right.
Don Weinberger
So thinking back to my infectious diseases days as a student and as a resident. But uh, and static antibiotics, I think of wrong are limezolid, right? Trammethoprims, sulfamethoxazole, and tetracyclines, such as doxycline, right?
Steve Small
Yep, those are all classic. And there are even some antibiotics where we think they may even do both, such as forfampin, kind of interesting. Uh, but keep in mind these designations are only based on lab data from growth in test tubes. So it’s really hard to translate the cytostatic uh approach to how these antibiotics work in the human body, which then makes it hard to even extrapolate this to patient outcomes for that matter.
Don Weinberger
Right. And actually, growing evidence suggests bacteriostatic antibiotics are generally no better or worse than bactericidal ones for many infections.
Steve Small
Right. Let’s go back to lanazolid, you mentioned as an example. Evidence supports that this bacteriostatic option is no better or worse at treating pneumonia or skin and soft tissue infections compared to vencomycin, a very commonly used bactericidal IV option we use all the time in the hospital. And this is also seen with lanazolid in certain bloodstream infections, too, where bactericidal agents have been historically preferred to rapidly kill bacteria. So pretty interesting there. So with that, when it comes to this claim that bactericidal antibiotics are better than bacteriostatic ones, the verdict is rumor.
Don Weinberger
All right, so maybe the goal isn’t to find an antibiotic with the license to kill. Sometimes putting the bacteria growth on pause is plenty in some cases.
Steve Small
I agree, especially when we’re talking about mild to moderate infections. So rather than hinging your antibiotic choice on -cidal versus -static, focus on what actually changes outcomes first.
Don Weinberger
So think about susceptibility and spectrum, dosing, site penetration, and also patient-specific factors, like things like age, weight, organ function, kidney, liver, how are those doing, right? That can impact drug choice and dosing.
Summary / Bottom Line Truth
Steve Small
And of course, we can’t forget adverse effects, interactions, and even just feasibility of giving them that. Plus, within cidal drugs, performance can actually differ by bug and situation. So this -cidal -static label should not do the clinical thinking for you. So, with that, the bottom line truth here today is don’t let habits and dogmas make antibiotic decisions for you. You got to tailor choices using the right drug, right route, right dose, right duration for the right patient based on good evidence.
Don Weinberger
And don’t think of stewardship as being the antibiotic police. Uh, it is a safety process. Antibiotics are powerful tools, and stewardship is how we use that power responsibly without over-treating, under-treating, or defaulting to outdated habits.
A few more things…
Steve Small
I like that, Don. And if you take one thing from today, avoid autopilot prescribing and dispensing. Build in a pause to think about the indication duration route, and you’ll prevent harm while still treating infections effectively.
Don Weinberger
Right. Great point. So before you go, claim CE credit and access evidence based resources from Pharmacist Letter, Pharmacy Technician’s Letter, or Prescriber Insights.
Steve Small
And if you’re not yet a subscriber or you just want to upgrade, you can save 10% with our exclusive listener code RVT1026 at chat. Check out and there’s an easy link in the show notes.
Rumor vs Truth Mailbag: Does AI protect patient health info?
Don Weinberger
And are you a subscriber? Keep those good times rolling and tap the claim credit link in the show notes or search or see organizer for this episode. And now, before we officially sign off, we got time for one quick follow-up from last episode. Our River Versus Truth Mailbag.
Steve Small
Great point. This one came in after our AI episode, and it’s an important privacy question. They ask Does AI actually protect patient health info? Now to help answer this, I was able to bring back our informatics expert, Dr. John Turtle, Farm D MBA from our prior AI episode. So let’s see what he had to say on this. John, welcome back. Glad you could join us again. I’m glad you can help us out with a follow-up question from one of our audience members. It’s that uh they’re questioning Does AI protect patient health information? What’s your take on this?
John Turtle
This one is a bit mixed, Stephen. So um as a clinician working with certified healthcare technology, that there’s a thing in our country, this is what they don’t teach us in in pharmacy school, Stephen. There’s a thing called the Office of the National Coordinator that certifies healthcare technology. And so if you’re a clinician working within an EMR, any of the big EMRs, they have to go through a rigorous process of credentialing. That information, there are plenty of AI tools with embedded within those uh systems that we use on a daily basis, either knowingly or not knowingly. All of that information is 100% safe, compliant, no risks, all of that stuff. Um where we get into some muddy water are, you know, in the last 10 to 15 years, patient health applications. Anything that’s outside of patient care, that patients are willingly putting their information into, that is beyond the scope of of really uh professional practice a lot of the times, and also uh out of the scope of uh of the walls of what we can provide. So um as far as patient information, a lot of that is just platform. Yeah, I can’t just blanketly uh blanketly make a statement that says yes or no to that. Right. Um I will say AI does have a lot of tools uh when you get into working with data sets to de-identify information um and encrypt information automatically, but uh you know, without knowing more context, it’s it’s a mixed answer.
Steve Small
Yeah, that’s a great point. And how do we make sure patient info stays protected as we use AI more in practice? Any tips there?
John Turtle
Uh well, I mean, stick stick with applications that are uh recognized and certified by either the organization or uh have gone through some sort of vetting process. I know there’s there’s uh URAC, um, which is an accrediting agency that stands for Utilization Review Accreditation Committee, uh Commission, excuse me. Um they have just released recently a process of qualifying um AI tools that clinicians use. And so I’m excited to see uh where their scope goes because that’s an it’s an incredible organization that I’m looking forward to. You know, if you’re seeing like a you uh a URAC stamp on any sort of technology. And then, like I said, the Office of the National Coordinator also certifies the applications. So um, yeah, I mean, this is a a budding field that’s growing, leaps and bounds. But by the time I talk to you next time, everything will have changed. But uh those are my immediate answers with patient help information. I would be very wary.
Steve Small
Yeah, great caveats there and good things to look out for, uh seals of approval and things like that. So thank you so much, John. Good to see you again. Of course.
Don Weinberger
Ah, it’s good to see Dr. Turtle again. And I’d like his points once again. Uh patient privacy is everyone’s responsibility. So we need to make sure we use these AI programs carefully.
Steve Small
Exactly. And always follow your organization’s policies for protected health information. If you’re not sure what’s allowed, ask before you paste anything sensitive into any tool.
Don Weinberger
Yeah, definitely. But there’s no need to keep your questions private for our next show. If you like our stewardship question about this episode answered next month, send us a message. Uh feel free to keep it abroad.
Closing
Steve Small
Good one, Don. And we also use your uh suggestions to plan our episodes. Email us at rumor vs truth@ trchealthcare.com or the send us fan mail link right from the podcast show notes. Uh, and now you can leave us a voice message, and we’d love to actually hear from you. So join us next time where we’ll tackle gossip around gabapentin.
Don Weinberger
Yeah, and have a good discussion about neuropathic pain if we have the nerve for it. So thank you for joining us on Rumor vs Truth, your trusted source for facts, where we dissect the evidence behind risky rumors and reveal clinical truths. See y’all next time.
Narrator
Want to put faces to these voices? Catch the video version on YouTube. Just search TRC Healthcare or click the link in our show notes. While you’re there, check out our other TRC podcasts like Medication Talk and Clinical Capsules.
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