Category Archives: Infectious Disease

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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Should the Flu Vaccine be Mandatory?

Recovering at home with Ed the dog.

So I caught the flu last week and I have been pretty miserably sick for going on 7 days; fever, achy, cough.  Also cranky, peevish, and insufferable.  My hair hurts!  Is that even possible?

I usually get a flu shot, but I didn’t get one this year.  Why not?  I just didn’t get around to it.  It would have been easy.  All I had to do is ask one of the nurses to give me one back in the fall when we were doing them.  Duh.

The CDC announced the official onset of influenza season a couple of weeks ago.  Flu season is extraordinarily late, probably due to the mild winter most of us (me included) have experienced this year.

Coincidentally, around the same time as this announcement (and before I myself caught the dreaded bug), I ran across a couple of thought-provoking articles dealing with the flu that are relevant to our institutionalized patients. Continue reading

What’s the most cost-effective way to treat scabies? The answer might surprise you . .

Tiny, itchy red dots! Yowser!

All correctional medical people should be able to recognize scabies by sight. 

Just to review, scabies is a tiny mite that burrows beneath the skin and causes intensely itchy lesions. Since the mite wanders (as little animals will do), scabies tends to spread with time, and can be passed from individual to individual.  Weirdly, scabies does not cause lesions above the neck, probably because of the increased blood supply there. If you are interested, you can find more detailed information on scabies in Wikipedia.

Scabies is found commonly in correctional facilities.  Both nurses and practitioners need to be able to spot scabies, hopefully before it spreads throughout a housing dorm! Continue reading

Don’t Use Antibiotics for Most Cases of Pharyngitis!

I have practiced medicine for over 18 years and have gotten a lot of CMEs over that time. The lectures I have enjoyed the most have tended to be those exposing the myths of modern medical practice.  You probably know the ones that I mean.  These are the lectures comparing some common medical practice with the literature only to find that the practice doesn’t work—belief in its efficacy is a myth.  In fact, just prior to its lamentable demise, The Western Journal of Medicine had a regular series devoted to debunking medical myths.

Myth-busting like this is part of the overall movement toward evidence-based medicine.  In a nutshell, evidence-based medicine states we should compare all of the stuff we do as doctors with the scientific evidence of its effectiveness.  When we do that, we will find there is a solid base in the evidence for only some of the things we do.  Some of our practices have inadequate support in research—nobody really knows whether they are truly effective or not.  And some of what we do is flat out contradicted by the evidence.  Every year, important research emerges that should make us change the way we practice medicine.  However, we too often do not change.

We all know doctors who seem frozen in time; practicing medicine the way it was taught to them in medical school and residency.  We ask ourselves, “Why is he still doing THAT?”  However, that doctor is most of us.  If we critically compare many of our habits with the medical literature, we will invariably find that we ourselves have habits we should abandon.

In fact, failure to change practice based on new findings has been identified by many sources as a major problem with modern medicine.  There is a gap, sometimes of many years, between what is known and what is practiced.  Over the years, some information in medicine’s knowledge base is verified, and some is refuted.  Whenever a new “fact” has been added to the overall medical knowledge base through good and repeated research, it usually takes many years until that knowledge is incorporated into most physicians’ practice.

Even a casual review of medical textbooks and the literature will demonstrate several well-demonstrated medical facts that are not widely practiced by US physicians.  One area getting a lot of press is the overuse of antibiotics.  We doctors still commonly prescribe antibiotics (and often very expensive antibiotics) for viral illnesses such as pharyngitis, bronchitis and sinusitis despite the enormous amount of literature condemning the practice.

We all have heard about the emergence of resistant bacteria as a consequence of our national over-prescription of antibiotics.  We don’t so often hear of another downside to prescribing unneeded antibiotics—it is expensive.  In fact, most evidence-based medicine principles are like that—if you adopt them, you will save money.  What could be better than that?  We provide better medical care to our patients, and save money to boot!

One great example is evidence-based treatment of pharyngitis, the infamous “sore throat.”  It seems like this is one of the single most studied topics in medicine.  There have been literally hundreds of articles published on this topic.  Fortunately, the Centers for Disease Control (CDC) in Atlantahave published an excellent review article along with their recommendations that can serve as a basis for your jail’s “Sore Throat Protocol.”  It was published in the March 20, 2001edition of the Annals of Internal Medicine, along with similar guidelines for the treatment of sinusitis and bronchitis. It can also be found online at www.cdc.gov/ncidod/dbmd/antibioticresistance/.

In their article, the CDC makes the point that only around 10% of cases of sore throat are caused by Group A Beta Hemolytic Streptococcus (the so-called “strep throat”).  Almost all of the remaining 90% of cases are viral in origin.  Despite this, 75% of adults who present to a doctor with a sore throat will be prescribed antibiotics!  What is the rate of antibiotic prescriptions for sore throat at your facility?  It would be well worth the effort to pull the last 100 charts where the chief complaint was “sore throat,” and see how many of these patients received antibiotics.

The CDC recommends instead that antibiotics be limited to those patients who are most likely to have strep throat based on four easily evaluated clinical findings:

(1)  tonsillar exudates;  (2) tender anterior cervical lymph nodes;  (3) fever;  and (4)  absence of cough.

You then use these four criteria to determine who gets antibiotics in one of the following ways:

1.  If the patient has 0, 1, or 2 of the criteria, no antibiotics should be prescribed.  If a patient has 3 or 4 criteria, then antibiotic treatment may be used.  I prefer this strategy at my jail because it does not require the use of rapid strep screens, which cost $5.00 to $10.00 each.

2.  If you prefer to use the rapid strep test, the CDC recommends no treatment for patients with 0 or 1 criterion, and rapid strep testing for those with 2, 3 or 4 criteria.  You then treat those where the rapid strep test comes back positive.

The CDC recommends throat cultures NOT be routinely performed.  This is important because many lab facilities routinely follow up all rapid strep screens, whether positive or negative, with a $60.00 culture.  Throat cultures should be reserved for special circumstances, such as tracking epidemic outbreaks of streptococcal disease, or if there is a suspicion of another bacterial pathogen, such as gonococcus

Finally, the antibiotic preferred by the CDC for the treatment of strep throat is plain penicillin.  Not amoxicillin.  Not Keflex.  Definitely not Augmentin!  If the patient is penicillin allergic, erythromycin should be used in its place.  This point is important enough to say again:  do not use expensive, broad-spectrum antibiotics to treat routine strep throat.

These guidelines do not apply to complicated patients, such as immunocompromised patients, or those with other significant medical problems, such COPD or a history of rheumatic fever.  The guidelines also assume the practitioner will carefully exclude other serious throat disorders, such as peritonsillar abscesses or epiglottitis.  Still, at my jail, the guidelines apply to over 95% of the patients who present to our medical clinic with sore throat.

Here is how these guidelines apply to a typical case.  A healthy 35-year-old male presents to the jail medical clinic with a sore throat.  His temperature is 97.6F.  He has large red tonsils but no exudate.  He has 2+ tender anterior lymphadenopathy.  He has been coughing frequently.  Physical exam shows no evidence of abscess or other complications.  This patient has only one of the CDC’s four clinical criteria.  According to the CDC guidelines, he should not have a rapid strep screen performed nor a prescription for antibiotics.  Instead, he would be treated symptomatically with acetaminophen, increased fluids and rest.

I would like to encourage everyone to read the original CDC report.  It is concise, well written, and authoritative.  The four basic clinical criteria are easy to incorporate into a clinical decision model or a flow chart for your facility.  I believe that if your facility adopts these guidelines, the quality and consistency of your medical care for sore throat will improve and your medical costs will fall.