Category Archives: Infectious Disease

A Better Way to Drain Abscesses: The Berlin Technique

One of the consequences of the heroin epidemic we all are experiencing is a marked increase in the number of skin abscesses presenting to the jail medical clinics.  Jails have always had to deal with skin abscesses.  In fact, the single most popular JailMedicine post has been the Photographic Tutorial on Abscess I&D (found here).  But since the heroin epidemic, the number of skin abscess we see has exploded.  It is not unusual nowadays to lance an abscess every day!

The reason for this big increase in skin infections, of course, is that heroin users tend to share needles to shoot up, and these dirty needles leave behind the bugs that cause abscesses.  And since shooting up causes the abscesses, they tend to be found where addicts commonly shoot up–like the inner elbow, the forearm and even overlying the jugular veins of the neck.

Fortunately, just in time for this onslaught of abscesses, my good friend Neelie Berlin PA taught me a new method of lancing simple abscesses that is quicker and easier—yet just as effective—as the method I had been using for my entire career. I’m going to call this new method of draining abscesses “The Berlin Method.”

Who says you can’t teach an old Doc new tricks?  I have wholeheartedly gone over to the Berlin procedure.  It is THE method I use now to drain simple abscesses.

Today’s JailMedicine post is a pictographic tutorial on how to do this new easier method of lancing simple abscesses. Continue reading

How Effective is the Influenza Vaccine? How About Tamiflu?

One of the greatest concepts I have run across since I finished school is the Number Needed to Treat (abbreviated NNT). NNT was never taught back when I went to medical school (we had barely given up The Four Humors!). Instead, we were taught “the p-value.” Does anyone else remember the p-value? The p-value of a study, it turns out, is a relatively poor measure of study validity, partly because it implies an “all-or-nothing” kind of understanding of studies: either the study is “valid” (meaning a p-value of >95%) or it is not. Either the treatment being studied works or it does not. And if a treatment works, it must work for all people.

Of course, in real life, this is not the case. No drug is universally good or bad. All drugs help some people, harm some people (with adverse side effects) and make no difference one way or another in some people. These numbers can be derived from any study’s data. There is even a fabulous website devoted to this where you can look up the NNT and its corollary, the Number Needed to Harm (NNH) for all sorts of drugs and treatments (found here).

Since it is influenza season and time for us to get our flu shots (I got mine yesterday), I thought it would be a great time to see how beneficial the flu vaccine is.  What is the NNT for the flu vaccine?  And while we are at it, why don’t we also look at the data on oseltamivir (Tamiflu) while we’re at it?

Influenza Ward, Great Pandemic 1919

Influenza Ward, Great Pandemic 1919

Continue reading

Hepatitis C: Between a Rock and a Hard Place

As you probably know, Sovaldi (sofosbuvir) is an important new treatment for Hepatitis C infection that was released this last December and has been aggressively marketed by its maker, Gilead, ever since. The problem is that Gilead is charging an unheard of, jaw-dropping, $1,000.00 per pill for Sovaldi. This translates into a MINIMUM of $84,000.00 for Sovaldi alone for the simplest course of Hep C treatment. Add on the other necessary drugs and take into consideration more complicated cases, and a single course of therapy for Hepatitis C will cost between $100,000.00 and $250,000.00.

This price has placed prison systems in a no-win situation–and not just prisons, but also Medicaid, insurance companies, and HMOs. On one hand, Sovaldi is a good drug that, in fact, represents a significant advance in Hepatitis C treatment. Lots of Hepatitis C patients could potentially benefit from Sovaldi. On the other hand, no one can afford Sovaldi. Treating every potential Hep C patient using Sovaldi would bankrupt everyone. There is no good way out of this dilemma. 20120321 Continue reading

Price Check! Genital Herpes. How Much is Nursing Time Worth?

It is worthwhile to check drug prices now and then (once a quarter seems about right) to see what is happening in the pharmaceutical world.  When you do this, you will find some drugs that have inexplicably shot up in price.  One recent example was doxycycline, which went from around ten cents a tablet to over two dollars a tablet in a couple of months.

On the other hand, drugs that we think of as expensive in the back of our minds sometimes are no longer expensive.  Olanzapine (Zyprexa) is now cheaper than haloperidol.  Risperidone is cheaper still.

And sometimes, a drug that is a bit more expensive than its alternative is still the most cost-effective treatment based on “the hassle factor,” meaning frequency of dosing, ease of administration, potential for diversion–that sort of thing. Drugs prescribed for outbreaks of genital herpes are like that, in my opinion.  Valacyclovir can be more cost-effective than acyclovir for the treatment of recurrent genital herpes.herpes1 Continue reading

Antibiotic Over-prescribing and The Looming Threat of Resistance

I ran across a couple of interesting articles about antibiotics recently.

In the first article, entitled We Will Soon Be in a Post-Antibiotic Era, CDC researchers predict that the end of the antibiotic era is coming quickly. Antibiotic resistance is developing so rapidly now, that it is only a matter of time until antibiotics just don’t work anymore. This actually is not surprising when you think about it. If we kill all of the microbes that can be killed by our antibiotics, then of course the only ones left will be those that cannot be killed by antibiotics, in other words, that are resistant. The fact that this will happen eventually is a no-brainer.imgres Continue reading

Beware the Fecal Veneer

Over the weekend, my family and I went to see the “Mummies” exhibition at the local museum. One display invited participants to feel squares of leather that were said to feel like mummy skin. As I watched the family of six ahead of me all caress the leather, I wondered how many hundreds of people had fondled this exhibit. I wondered if it ever was cleaned. I wondered how many viruses were lurking there. It reminded me that the world is a dirty place. I remembered that one of my professors in medical school had referred to the dirtiness of the world as “The Fecal Veneer.”HiRes

The theory of the Fecal Veneer states that the whole world is covered with a thin layer of, well, shit (Sorry! I will use that crude term only once). When I say ‘the whole world,” I mean every place and every surface, including floors, chairs, desk tops, clothes . .  and even swimming pools, according to this report! In some places, the fecal veneer is thick—like the gas station public restroom I was in recently that must have last been cleaned when it was built. In other places, the fecal veneer is quite thin, like in a hospital surgical suite. But it is still there! Most places are someplace in between. How thick the fecal veneer is depends on how often it is cleaned.

agar ecoliThe theory of the Fecal Veneer is scientifically demonstrable! All you have to do is to wipe down any surface and plate the residue onto agar. You will inevitably grow fecal bacteria, like E. coli. Even the wall of the surgical suite will grow an occasional E. coli. Since the Fecal Veneer does not just include feces, but any and all human secretions, you can also find viruses, MRSA and all sorts of other nasty things.

People interact with their environment and hence with the Fecal Veneer mainly with their hands. That is how we transfer the Fecal Veneer to our own persons. In other words, like every other surface, we people are covered with a fecal veneer–but it is thickest on our hands. Our hands are the vectors that transfer the fecal veneer from place to place.

Many diseases, of course, are transmitted from person to person via the Fecal Veneer. Sick people excrete the virus infecting them into one or another of their secretions. They deposit these secretions on their hands, which in turn deposit the infectious secretions on something they touch, like a doorknob. Someone else touches the doorknob, gets the infected goobers on their hands and then transfers the virus into their mouths, say, when they eat.

Yes, some diseases like TB are transmitted by aerosolized droplets . . . but this is uncommon. The flu and the common cold, for example, are mostly transmitted via the fecal veneer.  I guess they can be transmitted via the air—but not in the same way as TB, where the micro-droplets can float in the air for a long time and for long distances. Instead, if influenza is transmitted through the air, it occurs like this: an infected person coughs or sneezes and launches a mucous goober through the air. This arcs across the room and lands directly in someone’s face or into their food. This can and does occur (which is why you should cough and sneeze into your elbow), but it is more likely that the mucous bomb will land on some surface, like a desk top. However, even more likely than this aerial bombardment would be that the ill person coughs or sneezes infected mucous onto his hands, which touch something (like a doorknob), which you then touch with your hand, and those dirty hands then transfer the virus to your mouth when you eat.

The bottom line here is that hands contaminated by the Fecal Veneer are the source of many common illnesses. Think back to the last time you got sick with a bad cold or the flu. That is likely how you got it—via dirty hands

The solution, of course, is to wash our hands a lot. We tend to underestimate how contaminated our hands get by contacting the items around us. By cleaning our hands, we accomplish two ends—we make it less likely that we ourselves will become infected by pathogens in the Fecal Veneer and we also will be less likely to transmit pathogens to others.

Of course, it is possible to go overboard and wash our hands too often. I was taught to wash my hands after each and every contact with a patient—up to 40-50 times a day sometimes. This much washing can cause skin breakdown in the form of rashes and cracked skin that I used to get especially on my knuckles. The problem is that bacteria counts on damaged skin actually go up. The solution is to use hand sanitizers in addition to washing.

What if you wear gloves? They keep your hands free of contamination, don’t they? Well, not entirely. Here is a study that showed that significant hand contamination occurred 13% of the time despite surgical gloves.  Gloves help, but sometimes the Fecal Veneer can creep even through surgical gloves.

I suspect that most of us remember to clean our hands often when we are working around patients.  However, often, we forget the presence and danger of the Fecal Veneer in the wide world. And we often mistake where the greatest danger of contamination lies.  Remember that dirty public bathroom I spoke of earlier?  As bad as it was, that bathroom was probably not the greatest threat I faced that day, partly because I recognized that it was dirty.  In the news recently was a report that said that Women’s Handbags May Contain More Germs Than the Average Toilet Flush .

It is clear that the more insidious dangers to our cleanliness are those surfaces that we do not recognize as being really, really “fecal veneered.”  So, along those lines, here is an extra-credit quiz for you:

What is the dirtiest surface that people touch all of the time without cleaning their hands afterward (including you, probably)?

Hint: this surface is handled by hundreds, maybe thousands, of people and usually is never cleaned. Answer: Continue reading

Abscess Incision and Drainage, a Photographic Tutorial

Skin abscesses are quite common in correctional facilities, especially in the MRSA era, and so all correctional practitioners need to be comfortable with the procedure of abscess incision and drainage, also known as “lancing” the abscess.  Also “Let’s cut that sucker open.”  However, I’m going to be professional and call this procedure “I&D” for “Incision and Drainage.”

When I was just starting out in emergency medicine, I&D seemed to be quite a daunting task.  I was afraid of making a mistake and hurting someone or making them worse.  However, in actual fact, I&D is quite easy.  You can potentially hurt people more by not doing an I&D than by doing one.

But, like all medical procedures, it is possible to do the procedure poorly and inefficiently or to make outright mistakes.  The subject of today’s post is how to do a simple I&D of a skin abscess.  The opportunity to take pictures of the procedure arose when a fireman friend of mine walked in to my office and asked me to look at a lump on his back that had been there for a few days.  It was quite sore.  Here is a picture of the lump:

This appears to me to be a MRSA abscess.  Statistically, MRSA causes approximately 75% of all community acquired skin abscesses.  But beyond the statistical likelihood, this looks like a MRSA abscess.  It has lots of pus for its size along with a central area where the lesion is “pointing.”  This appearance is commonly mistaken for a “spider bite” by the lay public.

Why did my friend get a MRSA lesion on his back?  I don’t know.  Why does one member of a family get strep throat but not the others?  It just happens.  Usually, the only way to pinpoint the source is when multiple patients with a common background get MRSA, like members of a wrestling team or inmates housed in the same dorm.  A single, isolated case like this just happens—and not infrequently.

The treatment for MRSA abscess is Incision and Drainage, so I am going to cut this sucker open to let it drain—oops!  I mean I am going to perform an I&D procedure and document the process with pictures and discuss each step.  The process of I&D consists of these steps:

  1.  Skin cleaning.  I did this using alcohol wipes.  It is important to remember that this is not a sterile procedure—even if you do a surgically prep and drape the skin and use sterile gloves, they will not remain sterile once everything is covered by pus from the abscess!  Instead, this is a clean procedure.  You want everything to be clean, but you do not have to perform a formal surgical prep.
  2. Anesthesia.  I prefer to use 0.25% bupivicaine (Marcaine) with epinephrine.  Why Marcaine instead of lidocaine?  Well, they are comparable in price and Marcaine has the advantage of lasting 3-4 times longer, so the area stays numb for 12-16 hours instead of 4 hours.  Why use epinephrine?  The main reason to use epinephrine is that it constricts skin blood vessels so there is much less bleeding.  This makes the procedure that much easier to perform.  Epi also makes the anesthesia last longer—another bonus for the patient!
  3. Make the incision.  I prefer to use a #15 blade scalpel rather than the traditional #11 blade—but either will work.  The most common mistake made when incising an abscess is not to make the incision big enough.  The incision needs to be long enough and deep enough to allow access to the abscess cavity later, when you explore the abscess cavity.  Note that my incision stretches the whole diameter of the abscess—all the way from the top edge of redness to the bottom edge of redness.  Notice also that I have chosen in this case to make the incision run across the lines of tension of the skin by incising from top to bottom.  Typically, you would make an incision run the same direction as the skin creases if you want to minimize the scar.  I don’t care too much about a scar in this case, since the lesion is on the patient’s back.  I am more concerned with adequate drainage of the wound.  By making the incision perpendicular to the creases, the skin will naturally gape open after the procedure and allow pus to drain.  Not allowing the skin edges to touch and potentially re-seal is also the reason for placing packing in the wound, which we will discuss later.
  4. Squeeze out the pus.  This abscess had quite a bit of pus.  By the way, you do not have to routinely send this pus for culture in the majority of young healthy patients, especially if you are not going to prescribe an antibiotic (discussed later).  Culture is a good idea in complicated cases, such as immunocompromised patients, or large complicated abscesses.
  5. Explore the abscess cavity.  There are several reasons to do this.  The first is to see how deep the abscess goes.  Some abscesses are like icebergs—what you see at the surface is only a small portion of the whole abscess.  Some can run amazingly deep.  You should find the full extent of the abscess cavity.  Second, many abscesses have multiple chambers and your incision may have only drained one.  By exploring the cavity, you will break any remaining abscess walls and make sure the entire abscess has drained.  Finally, many abscesses have thick, adherent pus stuck to the walls that does not drain easily.  By rubbing the inner walls of the abscess, you will loosen that thick pus and get it out.  How to explore the abscess cavity depends on the abscess size. I have found that the best instrument for exploring bigger abscess is my gloved finger, as I have done here (as long as you are sure there are no foreign bodies in the abscess).  I have seen surgeons get their whole hand inside really big abscesses (of course abscesses that big probably should be sent to a surgeon).  On the other hand, you may not be able to get your finger into a small abscess.  A curved mosquito forceps with some gauze at the tip works well in those cases.
  6. Irrigate the interior of the abscess with saline.  This is done to make sure that we have all of the pus out.  When the saline draining out of the abscess is clear, the abscess cavity is clean.
  7. Insert a packAbscess packing is perhaps the single most misunderstood aspect of abscess I&D.  The purpose of the packing is to prevent the skin edges from re-sealing.  It is a mistake to think that the packing aids healing.  It does not.  There needs to be enough packing in the interior of the abscess cavity to prevent the wick from falling out, but there is no benefit to stuffing a ton of packing into the abscess.  In fact, that is detrimental, because the packing is a foreign body and because if the packing is packed so tightly so as to exert pressure, it can cause tissue necrosis.  In fact, not every abscess needs to be packed.  If the opening is gaping so widely that there is little chance of the edges re-sealing together, there may be no need for packing.  This point is so important that I will say it again:  abscess packing material is a foreign body.  It can delay healing and resolution of the abscess.  Its only function is to prevent the skin edges from re-sealing. The packing I place today will be removed tomorrow.  I don’t want it in there very long.  It is a foreign body.
  8. Place a dressing.  The first 24 hours after an I&D, the abscess will continue to weep, so it is nice to have an occlusive dressing to prevent he wound from weeping all over clothes and bedding and the inmate’s roommate.
  9. The next day, remove the packing.  Since the packing is a foreign body, it should be removed as quickly as possible.  Notice that this abscess seems reasonably dry after one day.  If the wound were still draining pus, that might mean that I had not fully cleaned out the abscess interior, and I might need to re-explore the abscess to see what I missed.
  10. Leave the abscess openPatients at this stage can shower and I encourage them to let the water wash out the interior of the cavity.  Over the next week or two, the abscess will heal in from the bottom out.
  11. Antibiotics? There is a large body of literature that says antibiotics should not be routinely prescribed for MRSA abscesses as long as they can be fully drained and as long as the patient is otherwise healthy and there is no accompanying cellulitis.  This patient is healthy and I see no cellulitis surrounding the abscess, so I am not going to use antibiotics.

This entire procedure took literally about 10 minutes to do.  It turned out well.

ADDENDUM (12/12/12)  This is a picture of the site one week post procedure.  It appears to be healing well.  The skin rash reaction to the dressing tape looks worse than the wound!IMG_0189

Mandatory disclaimer:  The technique I used here is a result of my Emergency Medicine training, my experience and my preferences.  Other practitioners may use other techniques that are just as effective.  Some may even disagree with what I have said here!  You should develop your own technique based on your training, experience and preferences!  A very good official source for the technique of abscess I&D is Roberts: Clinical Procedures in Emergency Medicine, 5th ed.  Chapter 37, Incision and Drainage.  Also, I am talking here about simple abscesses.  Abscesses in complicated areas such as the hands, neck or anus or abscesses of the face where the inevitable procedural scar will be visible may be best sent to a specialist to drain.

Do you have a different technique that you use to I&D abscesses?  Please comment!

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Interesting Article of the Week: Gonorrhea, Superbug.

The Emerging Threat of Untreatable Gonnococcal Infection.
Bolan GA, Sparling PF, Wasserheit JN
N Engl J Med 2012;366(6):485

This article was generated by the CDC and is about the increasing incidence of drug resistance of Neiseria gonorrhoeae, as well as the CDC’s newest recommendations for the treatment of gonorrhea.  Gonorrhea has slowly and inexorably conquered an impressive list of antibiotics, including penicillin, tetracycline and, most recently, flouroquinalones.  Currently, only two antibiotics remain for treatment of gonorrhea, and sure enough, signs of resistance to these two drugs are cropping up in Asia. Continue reading

Question of the Week: STD’s–Test or Just Treat?

Reader Question of the Week:

How do I go about convincing the management team to allow me to treat inmates for STI’s.  It is common practice to obtain a UA for c/o burning etc per protocol.  But, I am not allowed to move forward with determining if they have an STD if the UA is negative and s/s persist.  I am told there was previous funding for this, but was lost with budget cuts.  I am tempted to treat these inmates per WA State Department of Health Guidelines for STD management anyway.  Would this be wrong?  How would I know what to give them? I would be guessing.  I am thinking azithromycin 1 gm and flagyl 500 mg po bid x 7 days?  Comments? Continue reading

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.