choosing wisely

Monday, February 3, 2014

After two weeks of being inundated with expert analysis, the unexpected Seahawk domination in the Super Bowl was a reminder that no matter who predicted what, the game still needed to be played to learn the final score. The same situation happens daily in medicine, where no matter what approach statistics recommend, it’s what happens to the patient that really matters.

Every couple of months, I get a print out telling me the most common bacteria that cause a variety of infections in my hospital and what antibiotics are most likely to work. If I make the right diagnosis and write the proper prescription, the odds are that the patient will get better. It is a leap of faith that both the patient and I, as the physician, need to take since aside from clinical judgment, there usually is no black and white evidence that the treatment choice is correct.

Most people can figure out that they have an infection; the harder part is deciding whether it is caused by a virus that will usually get better on its own or whether it is caused by a bacteria and may need an antibiotic. Most people suffer through cold and flu season and survive by drinking plenty of fluids, resting and letting the body’s immune system fend off a virus. Some infections need medical care and if the decision to prescribe an antibiotic is made, the choice is very much like betting on the Super Bowl. All you have to do is pick a winner.

Some choices are relatively easy. Most uncomplicated bladder infections are caused by the bacteria E.Coli and there are many antibiotics that are effective. In women, the diagnosis is often made by history (frequent urination that burns) and a urine sample that looks infected under the microscope (containing white blood cells and bacteria). Choose a sulfa drug, quinolone or furantoin and likely the infection will be cured, but there are potential complications. Quinolones like Cipro and Levaquin can damage bone growth plates and should not be used in kids younger than 18. They also can also rupture tendons, so should not be used in people who have had recent strains. Pregnancy can also affect the antibiotic choice. And in males, urinary tract infections are not routine and need more investigation.

Pneumonia, an infection of the lung, is often treated as an outpatient, especially in younger patients. Symptoms include fever, chills and cough that brings up yellow/green sputum, then add the doctor hearing crackles or wheezing when listening to the lungs and perhaps a chest x-ray to make the diagnosis. The first cousin to pneumonia is acute bronchitis, an infection of the breathing tubes that tends to be caused by a virus and the treatment is supportive meaning, no antibiotics. But for those with pneumonia, the antibiotic choice often is regional depending upon those infectious disease statistics. Doxycycline is a reasonable first choice but can’t be used in kids because it discolors tooth enamel. It can also cause a sun sensitivity rash, not a problem in the frozen tundra of Wisconsin during winter months but could be an issue if you live near the beach. Augmentin, a souped up amoxicillin, and quinolones are other options. The treatment is based on a leap of faith because most times, the offending bacteria is never found or even tested for. Blood cultures take days to return and by then treatment has begun. Even for patients admitted to the hospital, if those cultures are obtained, the bacteria may not be isolated and even if it is, the result doesn’t routinely change treatment. The best guest antibiotic is usually right guess…usually.

Skin infections and abscesses are tougher. The most common bacteria culprits are strep and staph, including the MRSA (methicillin resistant staph aureas) that gets all the press. In some cirmcustances, the infections co-mingle and patients are routinely prescribed antibiotics that will treat both. If an abscess needs to be lanced and drained, there is some controversy in the literature about what to do. Some doctors advocate using antibiotics while other say that draining pus is enough to allow the body to heal itself. Sometimes statistics are less than helpful in guiding the way.

So why the big deal about picking the right antibiotic and perhaps picking no antibiotic at all. Bacteria have a tendency to adapt to their environment, evolve and develop resistance when exposed to antibiotics. The over prescribing of antibiotics has become a public health emergency. While expert recommend the indication, the type and the duration of an antibiotic prescription, the message is often a difficult sell for the doctor to make to the patient. Patient satisfaction increases when doctors take the time to discuss what they are thinking and how the diagnosis and treatment plan were made. However, it may be easier to give the patient a prescription rather than take the time to explain why antibiotics are not necessary. The patient may be a little irritated in not getting a pill to take to make things better, thinking that their visit was a waste of time. Both patient and doctor get frustrated when the first treatment option fails and another prescription may be needed.

It all comes back to playing the odds. No matter how much data an analyst crunches, the Super Bowl needs to be played to determine the final score. The same is true for being sick. No matter what the latest data provided by the local infectious disease committee, even with the right diagnosis, the choice of treatment may not work and a new game plan is needed.


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