Many readers know that I favor empiric antibiotic treatment for adolescent/young adult pharyngitis when the clinical signs and symptoms strongly suggest a bacterial infection. I favor narrow target antibiotics and only in the patients with Centor scores of 3 or 4 (and perhaps some 2s when the patient looks very ill). This would exclude over 50 percent of patients from antibiotics.

Most organisms already have developed resistance to penicillin, amoxicillin, and first-generation cephalosporins. Macrolides should not be used for pharyngitis in this age group.

Even if we overused these antibiotics, we are unlikely to contribute to the antibiotic resistance problem.

In the hospital and ICU, we regularly bring out the “heavy artillery” to fight presumed infections. When we assume sepsis, we throw a market basket of antibiotics (and often antifungals) in an effort to treat an unknown infection.

The antibiotic resistance problem is not a problem secondary to giving amoxicillin to sore throat patients.

The problem that we do not identify as often is antibiotic selection in very ill hospitalized patients. We use our big guns too indiscriminately — because the patients are so sick, and we are frantically trying to treat a mystery infection. Often infectious disease specialists write these orders.

We need an honest discussion of careful, appropriate antibiotic use in the hospital and especially the ICU.

We should not overuse antibiotics for sore throats, but we should not refrain from using antibiotics to prevent devastating potential complications (like Lemierre’s syndrome). We should not use antibiotics for colds or bronchitis (other than when complicating COPD). Antibiotic stewardship should focus on thoughtful use of antibiotics, understand the risk and potential benefits. That principle should not differ from the office setting and the hospital environment.

Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.