Monthly Archives: July 2012

Reader Question About Antibiotic Use. What’s Your Opinion?

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?

Thanks for the questions, Gabby!  And welcome to Correctional Medicine.  You’re going to love it!

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:

  1. 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.
  2. 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.

  1. 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.
  2. 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.

Antibiotics? NO! Incision and Drainage!

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.

  1. 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.
  2. 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:

  1. Apply mupiricin (Bactroban) 2% ointment to both nostrils (where MRSA tends to hang out in carriers) twice a day for ten days.
  2. Chlorhexadine body wash once a day for 5 days.
  3. Rifampin 600 mg po BID for five days in addition to your primary MRSA drug, whether Bactrim or Doxycycline—don’t prescribe rifampin alone.

Disclaimers:

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.

Interesting Study of the Week–MRSA

Antibacterial drugs and the risk of community-associated methicillin-resistant Staphylococcus aureus in children. Schneider-Lindner, et.al., Arch Pedicatr Adolesc Med, 2011 Dec:165(12):1107-14.

This is a great study done in England, where a database of medical treatment for the whole country is available for research (unlike in the US).  These researchers asked the question, “If you are prescribed an antibiotic, does that increase your risk of subsequently contracting a MRSA infection?”  So the researchers reviewed records for children between 1994 and 2007, including ~300 MRSA cases and >9000 controls.

Not surprisingly, they found that a child who is prescribed an antibiotic does, in fact, have an increased risk of a subsequent MRSA infection.  The surprising thing is how much of an increased risk this represents.

If you receive one antibiotic prescription, your risk of MRSA infection within the next 6 months more than doubles. If you receive two antibiotic prescriptions within 150 days, your risk of MRSA more than triples.  Then the risk really goes up.  If your receive three antibiotic prescriptions within 150 days, your risk of subsequent MRSA infection goes up eleven fold.  Four antibiotic prescriptions and your risk for MRSA rises more than 18 fold.

Quinalones are particularly prone to increase the risk of subsequent MRSA infections.

These researchers had previously studied adults and found the same thing.  (Antimicrobial drugs and community-acquired methicillin-resistant Staphylococcus aureus, United Kingdom).

Perfect lawn

I’m going to prevent weeds by killing the grass.

This, of course, makes sense.  A great analogy that I like to use with inmates who want an antibiotic prescription for their viral syndrome is of a lawn of grass.  The grass itself prevents noxious weeds, like thistle, from sprouting.  The grass chokes them out.  But if I were to kill the grass by spraying Roundup, what are the odds that thistle will grow now?  The grass is like our normal, healthy colonies of bacteria.  They help us in many ways, including “choking out” noxious bacteria like MRSA. There has been some great recent research into the beneficial effects of our personal bacterial colonies, such as this report on the  Human Biome Project.

Using antibiotics is very like using grass killer.  Antibiotics are a great medical tool when used properly, but they also have the potential to cause great harm.  If you prescribe an antibiotic for a viral syndrome, like a typical case of sore throat or bronchitis, your potential for benefit is zero.  It’s a virus!  But your potential for harm is the same as it always is.  This study shows that one unnecessary prescription doubles your patient’s subsequent risk of MRSA.  If you prescribe Augmentin, the risk of diarrhea is one in six!  So you cannot help this patient with a virus by prescribing an antibiotic; you can only harm them.

The CDC has published excellent guidelines on the proper use of antibiotics for sore throats, bronchitis and sinusitis.  I have written about these guidelines previously here (Evidence-Based Use of Antibiotics Can Save Your Jail Money! and here (Don’t Use Antibiotics for Most Cases of Pharyngitis!, although my focus then was how inappropriate antibiotic prescribing wastes money.

The more important message is that inappropriate antibiotic prescribing harms your patients.  According to these studies, if you reduce your antibiotic prescribing by following these guidelines, you may find that your MRSA infection rate goes down, too! Bonus!

 

 

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Education for Correctional Medicine

One of the challenges I see for those of us who practice Correctional Medicine is that there are too few educational opportunities specifically designed for us.

There are a few:  NCCHC has great conferences.  The Society of Correctional Physicians puts on wonderful conferences.  In fact, perhaps the overall best correctional medicine conference I personally have attended was an SCP conference.  The next SCP conference is October 16th, information here.

Mike Puerini, coincidentally the President of the Society of Correctional Physicians, organizes a conference twice a year for the Oregon Department of Corrections which anyone can attend.  His next conference is September 12, 13 in Salem, Oregon.  Interested?  Contact him directly:  mike.t.puerini@doc.state.or.us .

The Academic Consortium on Criminal Justice Health organizes a yearly conference in the spring, geared towards academic issues and research. Information can be found here.

But that is not enough.  Even with these conferences, we Correctional Medical Specialists been forced to obtain much of our ongoing medical education and updates from other specialties.  I tend to go to emergency medicine events, since that used to be my specialty.  But now, my specialty is Correctional Medicine.  And Correctional Medicine is a specialty in its own right.  We need more conferences designed for us, Correctional Medical Specialists!

So to this short list, add Essentials of Correctional Medicine, scheduled this year, November 7,8, and 9th in Salt Lake City.  The Essentials of Correctional Medicine website is found here.

Essentials of Correctional Medicine. November 7, 8, 9. Salt Lake City, Utah.

Essentials of Correctional Medicine is an intensive 3-day, no-fluff course dealing exclusively with clinical problems in correctional medicine.  The course is designed to give Correctional Specialists the essential information they need to care for patients in jails, prisons and juvenile facilities.

I have helped organize this conference and I am quite excited about the faculty we have been able to put together!  I myself am speaking and I just well may be the weakest link!  I don’t anticipate any “snoozer” classes. We plan on putting this conference on every year, each year emphasizing different clinical themes.  Our goal is to have engaging, passionate and knowledgable speakers, so if you know of someone who is a great speaker on correctional medicine topics, please let us know so we can sign them up for future conferences!

Target Audience

Essentials of Correctional Medicine is designed for medical professionals who work in jails, prisons and juvenile detention facilities.   Correctional Physicians, PAs, Nurse Practitioners and Nurses will all find the material engaging and useful.

Venue

Essentials of Correctional Medicine will be held in the beautiful Hilton Salt Lake City Center in downtown Salt Lake.

Speakers

Marc Stern, MD, MPH.  Amazingly prolific consultant in Correctional Health Care, Assistant Professor, School of Public Health, University of Washington.

Deana Johnson, JD. General Counsel MHM Correctional Services and one of the few full-time practitioners of correctional law.  Outstanding speaker.

Katie Clark, RD, MPH, CDE. Assistant Clinical Professor of Nutrition at the University of California, San Francisco (UCSF), San Francisco.  Great speaker, blogger (http://fiberisthefuture.com/) and a dietician actually interested in operations in correctional facilities.

Jeffrey Keller MD FACEP. Medical director of the Ada Co. Jail in Boise, Idaho along with 12 other jails and juvenile facilities in Idaho.  Frequent speaker and writer on correctional health care.

Keith Karren, PhD.  award-winning educator, conference director, and author.  Wonderful speaker.

Scott Eliason, MD.  Director of Psychiatric Services, Idaho Department of Corrections and at the Ada Co. jail, Boise, Idaho.  Scott has a great approach to correctional psychiatry.

Tawnya Constantino, MD. Medical Director, Neurophysiology Laboratory and Epilepsy Services, Intermountain Medical Center, Murray, Utah

Charles Diviney 111, PhD. MC, LPC,NCC,CCMHC-CLD3 Counseling, CEO and Executive Director. Specialist in suicide and Suicide Prevention.

Martin Gregory, MD.  Professor of Medicine, University of Utah, Hypertension specialist.

N Lee Smith, MD. Specialist in Integrative Medicine, Internal Medicine, Pain Management, Lifetree Research and Pain Clinic, Salt Lake City, Utah

Jason Andersen, DO.  Specialist in Adolescent Psychiatry and Drug Withdrawal, Utah Valley Regional Medical Center, Provo, Utah.

Nancy Howard, RN. Specialist in Diabetes treatment and control. Utah State Gov. Correctional Facilities.

Dave Young, Pharm D. Professor, University of Utah College of Pharmacy.

Briam Mecham, LCSW.  Director of Mental Health Services, Badger Correctional Medicine. Years and years of experience working with inmates.  Great speaker.

Matt Young, Pharm. D. Correctional Pharmacist, Idaho Falls.

Registration

To register for Essentials of Correctional Medicine online, visit the website at

http://essentialsofcorrectionalmedicine.com/

To request a conference brochure, please email your name and address to

info@essentialsofcorrectionalmedicine.com

Don’t Get Burned by Serotonin Syndrome (like I did)

A 46 year old man comes to the medical clinic complaining of muscle aches and twitching, which he first noticed two days ago.  He had been booked two weeks ago and his prescribed outside medications were continued:  sertraline 100mg a day, amitriptyline 100mg at bedtime and lisinopril.

He walks into clinic with a stiff legged gait. His vital signs show a heart rate of 124.   He has sweat on his forehead and a noticeable tremor of the hands.  His speech is pressured.

So what is going on with this patient?  The answer, as you may have guessed from the title, is Serotonin Syndrome.  If you tap on his knees, he will have exaggerated reflexes.  Fortunately, he has only a mild case.

Serotonin Syndrome is a constellation of symptoms caused by an excess of the neurotransmitter serotonin. It ranges in severity from mild cases (like the one above) to fatal.  In my opinion, all medical personnel in correctional facilities should be aware of Serotonin Syndrome.  It is not as uncommon as you might have been taught; if you look carefully for it, you will find cases.

Serotonin Syndrome Defined

Serotonin Syndrome is characterized by a trinity of abnormalities:

  1. Neuromuscular hyperactivity:  Muscle twitching, tremor, hyperreflexia.
  2. Autonomic effects:  tachycardia, hypertension, hyperthermia, sweating, shivering.
  3. Mental status effects:  anxiety, agitation, hypomania, confusion, hallucinations.

Mild cases of Serotonin Syndrome may only manifest as tremor, hyperreflexia, tachycardia and sweating and shivering.

Moderately severe patients will additionally have an increased temperature, clonus and agitation.

Severe cases are usually confused and hallucinating, and have very high temperatures (sometimes over 106F) which can lead to all sorts of very bad effects, like rhabdomyolysis, seizures, renal failure, and, yes, death.

Treatment of Serotonin Syndrome

The most important treatment of Serotonin Syndrome is to immediately stop all of the serotonergic drugs the patient is taking!  Benzodiazepines are helpful in treating the agitation and neuromuscular effects of moderate cases.  Severe cases, of course, need to go to the ER for big time supportive care and treatment.

Causes of Serotonin Syndrome

So what causes Serotonin Syndrome?  The answer is that Serotonin Syndrome is caused by drugs that act by increasing serotonin levels. These are mostly psychiatric drugs, of course.  The Big Three Categories of serotonergic drugs are:

  1. Selective Serotonin Reuptake Inhibitors (SSRIs).  There are lots of these.  I won’t list them; you know what they are.
  2. Tricyclic antidepressants (TCAs), which act by blocking serotonin reuptake as well as norepinephrine reuptake.  The ones I see used most are amitriptyline, imipramine and doxepin.
  3. Serotonin-norepinephrine Reuptake Inhibitors (SNRIs).  This group includes Trazodone Venlafaxine and desvenlafaxine (Effexor and Pristiq), and duloxetine (Cymbalta).

You should memorize that list!  However, many other drugs increase serotonin levels besides those in The Big Three Categories.  Interesting examples include amphetamines, Buspirone, Tramadol and tryptans.

There are two main ways that the drugs in the Big Three Categories can cause Serotonin Syndrome.  One way is just to use large doses of a serotonergic agent, usually an SSRI.  Big dosing of SSRIs was done in the past more than it is now.  My psychiatrist mentor here in Boise, Dr. Estess, told me that when Prozac was first introduced and doctors were experimenting with big doses, like 80mg a day, he used to see lots of mild-moderate cases of Serotonin Syndrome.  It is less common to see large doses of SSRIs used nowadays, since it has been pretty well established that you get little, if any, additional anti-depressant benefit from SSRIs by using big doses.  But still, occasionally, someone will arrive at one of my jails taking, say, 200mg a day of sertraline.  If you see a patient like that, check their reflexes and look carefully for a tremor and you may indeed find evidence of systemic serotonin effect.

However, the more important cause of Serotonin Syndrome, by far, is by combining agents from two different categories.  This practice is very common; I see this all the time. For example an SSRI is prescribed along with Trazodone as a sleeper or an SSRI is combined with a tri-cyclic antidepressant like amitriptyline on the dubious premise that two anti-depressants are better than one.  However, try this:  plug an SSRI and a TCA or trazodone into a drug interaction checker (like this one that I like to use)A big red stop sign will pop up saying (approximately) “Major potential drug interaction!  Risk of Serotonin Syndrome! Do you really want to do this?”  And the risk here is real.

Serotonin Syndrome Develops Quickly

One thing that I did not mention yet about full-blown Serotonin Syndrome is that it tends to develop quickly.  I personally learned this the hard way.  I had a patient in one of my jails die from Serotonin Syndrome.  Dead.  The patient was a middle-aged man who came to the jail taking Paxil and Imipramine prescribed by his outside psychiatrist.  I continued these medications.  A couple of months into his incarceration, in the middle of the night, he developed agitation, hallucinations and vomiting.  He became unresponsive.  An ambulance was called.  At the ER, he had a temp of 107F, intense muscle rigidity, and full blown shock.  He died there in the ER.

Benefits?  Risk!

This tragic case occurred early in my correctional medicine career.  It has made me vigilant in looking for evidence of Serotonin Syndrome—and I have found a few mild-moderate cases since.  It also made me question whether the benefit of combining two serotonergic agents in one patient ever outweighs the risk.  I personally don’t believe so.

Whether you agree or disagree with this conclusion, please remember the danger of Serotonin Syndrome when you combine serotonergic agents.  You may have used this combination a hundred times and have never seen ill effects.  That does not mean you never will.  Consider whether the benefit of the drug combination you are considering truly outweigh the risk of Serotonin Syndrome.

Have you had a case of Serotonin Syndrome in your facility?

What is your opinion of combining serotonergic drugs?

 

Thoughts on an Untreated Type 2 Diabetic

Staged medical clinic at the Bonneville County Jail, Idaho Falls, Idaho. (The “patient” is actually one of the medical staff)

We recently had a 46-year-old male patient booked into our jail who reported a history of diabetes but who had not seen a physician or taken any medications for “years.”  He said he used to take a medication for diabetes “a long time ago” but he could not remember the name.  He also could not remember the name of the doctor he had once seen.  He reported basically no other medical history. Continue reading

“Bath Salts,” A Review.

It used to be that “Bath Salts” were, well, salts that you would use in a bath.  Not anymore!  Nowadays, “Bath Salts” refers to a designer drug of abuse that is marketed like traditional bath salts to give legitimacy to the transaction.  They are also marketed as computer screen cleaners, jewelry cleaners and bug spray.  They are, of course, not intended to be used for any of these purposes; they contain synthetic designer drugs used to get high. Continue reading