Sometimes antibiotics fail or appear to fail, and the clinician must determine the reasons for a suboptimal response. However, before concluding that an antibiotic has failed, it is important to remember that, even when antibiotics have their desired effect, the patient's response may not be immediate. Most immunocompetent patients will show some clinical response to appropriate antibiotic therapy within 24 to 48 hours, although various objective parameters of the infectious process may lag behind the overall clinical response. For example, patients with Rocky Mountain spotted fever often feel better within 24 to 48 hours, but their fever may not begin to respond for an additional 2 to 3 days. Similarly, patients with pneumonia frequently experience a diminution in fever and toxicity in the first few days after institution of antibiotics, but the chest radiograph does not immediately reflect the patient's improvement and may actually appear to worsen before it ultimately improves. A similar observation describes cerebrospinal fluid during therapy for bacterial meningitis, which may temporarily worsen (ie, manifest a greater leukocytosis) even as the patient improves. Some classic parameters of infection are atypical on presentation. For example, patients with severe infection may develop leukopenia instead of leukocytosis, while others present with hypothermia instead of fever. Such patients will “respond” to treatment of their infection by an actual rise in white blood cell count or temperature.
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