My name is Gabby and I am a ARNP working in a rural health care setting in southern Washington and newly blessed with a county jail assignment. I oversee 300 + inmates in a county jail setting and was turned onto your website by one of the RN’s in the medical office at the jail. Thank you so much for the wonderful information that you share. I have some questions that I am hoping you can give me some guidance with today.
The population of patients that we deal with the most are heroin and meth users with extensive histories of dental decay and abscesses and multiple complicated skin infections from muscling heroin. After reading your most recent posting on MRSA and misuse/overuse of antibiotics I was wondering what your thoughts would be regarding my jail’s protocols on dental abscess treatment plan with amoxicillin and skin infections/abscess treatment plan with Keflex and Bactrim. These protocols are for the staff to use in between my visits twice a week. A significant number of the inmates that I see are frequent flyers and often are treated with above stated protocols over and over again. I am wondering if I need to request that these protocols be reevaluated. And if so, what would be the new treatment recommendation that I would present look like? Comments?
I am going to answer your questions with my opinions on these topics and invite others to answer also via comments.
The two basic principles in the fight against antibiotic overuse which leads (among other things) to antibiotic resistance are:
- Don’t use antibiotics when you do not have to. We’ll call this rule “Don’t Overprescribe.” I think that for years there has been the feeling in the medical community that antibiotics “Can’t hurt and might help,” so they were prescribed in lots of questionable settings. In fact, antibiotics can hurt. Besides microbial resistance, antibiotics have all sorts of side effects, ranging from nuisances to serious.
- When you do prescribe an antibiotic, use the narrowest spectrum antibiotic that will do the job. We’ll call that the “Sledgehammer Rule,” as in “Don’t use a sledgehammer to hang a picture on your wall—you are more likely to cause damage than to do a good job.”
So let’s apply these rules to your cases, first, the dental infection case.
- Don’t overprescribe. The danger here is over diagnosing infections that don’t exist. Don’t prescribe antibiotics for a simple toothache. Reserve the antibiotics for some objective evidence of infection: facial or gum swelling, visible abscess, purulent gums, something. Just because the patient has a toothache does not mean they have an infection. Simple toothaches need some sort of pain management and certainly need a dental referral, but not usually an antibiotic. Look carefully. If you are not sure and can’t get them in to see the dentist right away, then recheck them again tomorrow.
- The Sledgehammer Rule. The organisms that tend to cause oral infections are usually still sensitive to plain penicillin, as in Penicillin VK 1000mg po BID. There is no advantage in most cases to using broader spectrum agents like amoxicillin, Augmentin or Keflex. We want to reserve these agents for infections already resistant to penicillin. Similarly, plain penicillin is still the recommended first line agent for strep throat.
Second question–MRSA. MRSA infections are increasingly becoming resistant to the very few agents available to treat them, so I think it is especially important to apply the two rules to these infections.
- Don’t overprescribe. There is quite a lot of literature supporting the idea that you do NOT have to prescribe antibiotics following MRSA abscess I&D. The treatment for any abscess is adequate incision and drainage. You do not get any better resolution in most MRSA patients if you follow I&D with antibiotics.
- The Sledgehammer Rule. I think that it is seldom good practice to prescribe both Kelfex and Bactrim simultaneously. I know this is done outside of corrections, especially in ERs. The rationale is that without a formal culture, you are not 100% sure if this particular cellulitis is caused by methicillin resistant staph (resistant to Keflex, sensitive to Bactrim) or methicillin sensitive staph (resistant to Bactrim, sensitive to Keflex), and so, to cover all your bases, you prescribe both. However, personally, I think it is pretty easy to tell the difference between most cases of MRSA and non-MRSA infections just by looking at them. The MRSA organism is an abscess former, and so, even early on, MRSA infections tend to form an abscess or at least show a central “spider bite” core. Meth sensitive cellulitis usually does not have either. Make your best guess, maybe based on a picture the nurses send you if you are not right there, and re-evaluate as needed tomorrow or the next day. You will pick correctly 95% of the time.
Finally, what about those patients who get recurring MRSA abscesses? The patients who get recurring MRSA abscesses are typically MRSA carriers, and your goal then is to eradicate their carrier status. There are several ways to do this according to MRSA guidelines (such as these by the Infectious Disease Society of America)—here are three:
- Apply mupiricin (Bactroban) 2% ointment to both nostrils (where MRSA tends to hang out in carriers) twice a day for ten days.
- Chlorhexadine body wash once a day for 5 days.
- Rifampin 600 mg po BID for five days in addition to your primary MRSA drug, whether Bactrim or Doxycycline—don’t prescribe rifampin alone.
We are talking here about typical young healthy patients. Patients who have chronic health problems or are immunocompromised must be approached differently.
Also, The opinions here are my own. I could be wrong; feel free to disagree! But if you do, please comment so Gabby will have the benefit of other opinions and approaches.