Cocktail treatment of antibiotic, steroid, and analgesic in a tubercular case; the urgency to set up antimicrobial stewardship practices in the community

Tuberculosis is a well-known entity in India with many implemented policies to ensure the cost-effective early management. Missed, delayed, and complicated presentations do occur, requiring expensive tertiary level of health care. Among many contributing factors, lack of antibiotic stewardship is at the top. We report a case of 65-year-old man who presented with on and off fever for six months, receiving cocktail treatments of antibiotics, analgesics, and steroids from a local dispensary. Our initial investigations revealed microcytic anemia with high erythrocyte sedimentation rate, leukocytosis, and bilateral pleural effusion on chest X-ray. Contrast enhanced computer tomography of chest and abdomen suggested disseminated tuberculosis including bilateral empyema. Frank pus was drained on thoracocentesis, which was negative for Gram stain, Ziehl–Neelsen stain, and bacterial culture, but positive CB-NAAT for tubercular bacilli with no resistance to rifampicin. Mantoux test and stool occult blood were positive. This case highlights an unusual presentation of tuberculosis and the ongoing lacunae in the society with importance to the primary care providers in the effective management of tuberculosis focusing on antimicrobial stewardship.