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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the skinny on mrsa

Monday, October 14, 2013

Instead of working on offense, defense or special teams, the Tampa Bay Buccaneers are developing a game plan to control MRSA infections, and recent headlines made it sound like an invasion from outer space. In reality, it’s just another bacterial infection that has taken on celebrity status. Methicillin resistant staphylococcus aureus is no longer the rare bacteria that only attacked hospital patients, but instead has morphed into a routine cause of infections in the general population.  MRSA has become so common in situations where people share close spaces and contact, that the Centers for Disease Control and Prevention has a dedicated website for teaching coaches and athletic directors.

The story of MRSA is similar to many other bacteria in the era of antibiotics. Over prescription, often for inappropriate indications, has caused certain bacteria to adapt and mutate to become resistant to drugs that a few years ago would have been very effective. The problem begins with a patient expectation and continues with a doctor wanting to please their customer. It takes longer to explain why antibiotics don’t work against viruses, then add a doctor’s concern that the patient won’t be satisfied without a slip of paper to take to the pharmacist and the result is a plethora of antibiotic prescriptions. Other sources of antibiotic use can also filter their way into the human body. A study of Canadian agriculture found MRSA in 10% of pork products, in 70% of pigs and 45% of pig farm workers.

MRSA is a common cause of skin infections, along with streptococcus. The names have to do with what the bacteria look like under the microscope. The difference has to do with the complication potential. MRSA can spread more deeply, developing abscesses and occasionally causing wide spread infection in the body, affecting a variety of organs including bone, joints, heart and lungs. As with any infection, prevention is better than treatment and the Buccaneers have been trying to deep clean their training facilities to prevent infection spread. Good intentions sometimes don’t succeed.

As it turns out, people can be colonized with MRSA and it can be found in the nose of more than 2% of the population. There it sits, waiting for an opportunity to pounce and infect a laceration, scrape or other break in the skin. And athletes are at increased risk for transmitting the infection from person to person, especially in sports like wrestling and football. Studies looking at high school football in Nebraska found that almost 15% of players had an MRSA infection. The CDC has reported of recurrent MRSA infections in college football teams with teams reporting up to an 8% infection rate; it’s especially high among linemen.

While cleaning equipment, mats and turf can decrease the risk of MRSA infection, the problem infection resides in the athlete and that makes MRSA infection control tough.  Historically, hospitals tried to limit the MRSA infection rate by intensive cleaning, plus culturing and treating all patients who presented for admission. Those patients were discharged MRSA-free from the hospital only to be infected by family members who were also carriers or because they were living in a nursing home or other care facility where MRSA lived. On return for their next visit, these patients re-infected the hospital.

The CDC recommends a five step approach to controlling MRSA in athletes:

  • Any athlete with a suspected skin infection should be referred to a health care provider
  • Those with a potential or confirmed infection or open wound should avoid whirlpools or therapy pools that are not cleaned between each athlete use
  • Educate athletes about cleaning and disinfecting guidelines
  • Educate athletes about ways to prevent spreading infection
  • Consider excluding athlete from participation pending health care provider evaluation

The good news is that MRSA can be treated with a variety of antibiotics. The bad news is that bacteria continue to mutate. The arsenal of antibiotics that works this month or this year may become obsolete. MRSA is just one type of bacteria that is on the public health radar. Both doctors and patients need to be on the same page when it comes to antibiotic use. There should be a reason for an antibiotic prescription and not just because it meets the patient’s consumer satisfaction standard. Similarly, increased agricultural use of antibiotics needs to be considered when it comes to food safety and the spillover that may occur with mutant bacteria.

These are the issues that lurk in the background that make it even harder as the Tampa Bay Buccaneers try to sort out their training facility infection woes.  No matter how well the team trainers and doctors do their job, unless, they stop playing the game, the player risk for the next infection is always there.

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