Ancient history


Treatment of pneumonia with 2-(p-aminobenzenesulphonamido) pyridine, by G. M. Evans et al. [1]

 

I bet a pint of beer with any of you, dear readers, that you ever imagine you were about to read a discussion regarding a 1938 article. The path to enlightenment has no sense of time. I also bet that nobody born in 1938 or before is reading these schizophrenic lines. The year of 1938 was pretty surreal: World War II was cooking, Adolf Hitler was the Time Magazine Man of The Year, a gallon of gas would cost 10 cents, first appearance of Superman on a comic book and the Italian actress Claudia Cardinale was born. I already feel like I was living in the 30’s, smoking my pipe, dressed like a gentleman and the Lancet’s studies were only 4 pages long.

But we are here to work, right? So, here we go. In 1937 a new antibiotic drug was discovered, the 2-(p-aminobenzenesulphonamido) pyridine, a.k.a. M&B 693, a sulfonamide antibiotic. One year after its discovery it was already available for human use (suck it FDA). Dr Evans, alongside other doctors, decided to use all top of the edge technology available to them, like X-rays, and designed a randomized (alternate days) trial comparing M&B 693 against the “usual routine non-specific treatment” in patients with lobar pneumonia. The bottom line is that the intervention group had a mortality rate of 8% vs 27% in the usual care. Nowadays the overall mortality of community acquired pneumonia is something around 14%, but it’s not fair to make any comparison. I think the authors won’t mind if I use their table.

Ok. Although I digressed a bit, as I usually do, the point here is not about the efficacy of an 80 years old antibiotic, instead, the beauty of this study lies on the bottom right corner of this table. Almost eighty years ago, the mortality rate of untreated patients with pneumonia was 27%! Meaning, that 73 out of 100 patients went back to their miserable lives like nothing had ever happened. Why is this important? Well, from the early stages of medical school until the end of our lives, we will hear that adrenaline and antibiotics save lives, and I think they do, but not the way they were sold to us. Now, someone probably will gonna throw the Kumar’s article [2] and the magical 7% increase in mortality for each hour we delay the antibiotic in my face. Stay tuned because this will be discussed here in the future, but I’ll give you a hint: in my opinion, it’s a pretty crappy study.

There is a myriad of factors influencing our patients’ outcomes, including antibiotics. The fact of the matter is, we do prescribe antibiotics. Sometimes the wrong ones, maybe in the wrong dosage, we don’t have a clue about their pharmacokinetics in our critically ill patients, we don’t really know for how long we should keep them, neither if two antibiotics are better than one or even if the patient really has a infection. Now it doesn’t seem so crystal clear anymore, does it? So, spend some time rationalizing about this, try to put all you’ve been thought aside, and try give this an impartial consideration. And please, don’t even think about treating your patient with M&B 693 because a Lancet article said so!

 

1- Evans GM, Gaisford WF. Treatment of pneumonia with 2-(ρ-aminobenzenesulphonamido) pyridine. Lancet. 1938; 2:14–9.

2- Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. 2006;34(6):1589-1596.

 

Photo Credit

Larisa Kozlova


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