Source Control is not a Backup Plan

Antibiotics are powerful drugs.

They just don’t work very well on pus that nobody has drained.

A young woman with a long-term abdominal catheter developed a draining sinus tract along the catheter route.

For months she had been treated with antibiotics.

Amoxicillin–clavulanate. Metronidazole. Meropenem. Vancomycin.

Despite the pharmacologic enthusiasm, the tract continued draining.

The infectious diseases consult recommended something surprisingly simple.

Drain the collection. Stop the antibiotics. Send the pus for culture.

Abscess cavities have poor perfusion and extremely high bacterial density. Antibiotics delivered through the bloodstream penetrate poorly.

Pus under pressure is a fortress.

The tract was surgically drained. The catheter was removed. The fevers disappeared within days.

Another patient had an open tibial fracture with external fixation.

Weeks later the wound became infected.

Meropenem was started.

Three months later it was still running.

Despite the antibiotic, the wound remained inflamed and intermittently draining.

The infectious diseases consult recommended surgical debridement.

Devitalized tissue is an ideal environment for bacteria. Antibiotics reach it poorly.

The surgeons removed necrotic tissue and cleaned the wound.

Healing began soon after.

The antibiotic had not failed.

It had simply been asked to solve the wrong problem.

A third patient arrived with necrotizing fasciitis.

Emergency surgery removed extensive necrotic tissue. Broad-spectrum antibiotics were started.

Five days later she was stable.

No fever. No spreading infection. The wound looked clean.

The team debated continuing antibiotics for another two weeks, just to be safe.

The infectious diseases consult recommended stopping them.

Once source control has been achieved and systemic infection resolved, prolonged antibiotics add little to no role.

She recovered without recurrence.

Three infections.

Three moments where surgery accomplished what antibiotics alone could not.

A surgeon once told me: “The best antibiotic is a knife.”

He wasn’t being dramatic.

He was being literal.

These are stories from the wards about microbes, medicine, and the decisions that shape antimicrobial stewardship.