abx for strep pharyngitis?

[Birdstrike]

What are you going for here? If you don't practice EBM *every*single*time*, you're a hypocrite for doing it at all? Sometimes there's gray areas, sometimes it's easier to do the wrong thing and it's pretty much without harm. It doesn't mean we should stop trying to do the right thing.



Which textbook are you referring to? Rosen's says antibiotics shouldn't be routinely used in strep throat (and following that textbook gives you added protection against Dr. Rosen should he target you to pad his bank account as a prosecuting expert witness). Looking over other professional organization websites, I'm not seeing any of them that say you should absolutely treat strep throat. They're all hedging, at the very least, and it looks like the pediatricians and family practice societies acknowledge that there's probably not much benefit to treating with antibiotics, even if their official policy still advocates testing and treatment.

I don't get railing against EBM. Sure, some errors are made, and I'm cool with people acknowledging that while what they're doing isn't in line with the latest EBM, they're going to do it anyway, because they're not comfortable changing their practice until more data becomes available. But using it like it's a bad word is the mindset that has the population pushing for laws to teach creationism instead of evolution in schools and failing to immunize their children.

You're so confident in these guidelines, and the ones writing them are so confident in their absolute correctness, that they feel the need to "hedge," as you admit they "hedge"? If you're own concrete and unbendable guidelines are hedging, which side of the hedge are you on, on which day?

I'm not saying that you should abandon the scientific method, for Pete's sake, but have some common sense in your practice and realize Medicine isn't, never was, and never will be, an exact science like Math. There is, was, and always will be that Art of Medicine. I will say, that does bother some people.

If you have trouble seeing this, just review Medical history and how much guidelines change year to year, decade to decade, and how studies done to answer the identical clinical questions often routinely contradict each other.

Steroids in spinal cord injury; they help, but they don't...tPA is good, but no, it's bad...Lipitor reduces cholesterol, so it must prevent heart attacks and death in people who haven't yet had them, but "oops," it doesn't, but not before it became the #1 selling drug on a planet of 7 billion people..Opiates were addictive, then they weren't anymore, now they are again.....I could go on for pages.

EBM is valuable. It's certainly better than blindly following dogma or asking a Witch Doctor what to do. But it's track record (and drug companies have a lot do with this, as do poor research technique, interpret and application) is actually exceedingly embarrassing if you step back and review it as a whole. It don't think the baby should be thrown out with the bath water, but I think this needs to be kept in mind.

If you stick around long enough, you'll see "unquestionable truth" in Medicine turn out to be false, then end up "true" again. Don't lose faith, just stay skeptical, and keep the latest and greatest at an arm's length.

---

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[xaelia]

This is my favorite citation for NNTs in routine ambulatory infection:
"Protective effect of antibiotics against serious complications of common respiratory tract infections: retrospective cohort study with the UK General Practice Research Database."
http://www.bmj.com/content/335/7627/982.long (free fulltext)

NNTs of >4000 for suppurative complications of each based on a database of 3.36 million GP visits.

 

[Birdstrike]

This is my favorite citation for NNTs in routine ambulatory infection:
"Protective effect of antibiotics against serious complications of common respiratory tract infections: retrospective cohort study with the UK General Practice Research Database."
http://www.bmj.com/content/335/7627/982.long (free fulltext)

NNTs of >4000 for suppurative complications of each based on a database of 3.36 million GP visits.

Interesting but the clinical question that's asking is, "How often do antibiotics prevent suppurating complications in "common respiratory infections?" which are far an away VIRAL. So, to take that result and extend it to your practice with a broad brush to say antibiotics don't work for definite BACTERIAL illness, not weeding viral sources out, is completely invalid and classic data misinterpretation.

The NNT for using antibiotics for common respiratory infection (nearly all VIRUSES) has zero bearing on the NNT for antibiotics in bacterial infections, not to mention the fact that you can't lump the many different strains of bacterial pneumonia and bacterial pharyngitis, bacterial sinusitis (to the extent it exists), bacterial otitis all together and come up with a valid NNT, anyways.

There's so much sloppy "garbage in garbage out," it turns my stomach. People read these studies, not realizing how valid or invalid they even are, or whether the clinical question applies to their patients or practice, and have a false sense of security that what they're doing is right, scientific and "evidence based," when a significant part of the time the results are no more accurate than flipping a coin, no more accurate that their own clinical gestalt, or don't apply to their subset of patients.

 

[xaelia]

Fair critique – at least for sore throat, for which providers may or may not attempt to verify at least the presence of Group A strep prior to treatment. The other ambulatory infections do not have specific viral vs. bacterial POC testing available, however, and far too many receive antibiotics in current practice.

 

[Birdstrike]

For those of you paralyzed when faced with a clinical decision not answered by clear cut evidenced based medicine I'd like to ask you a question. What level one evidence do you have, proving that intubation is life saving for your apneic, non-breathing patients?

How do you really know, and what journal article will you cite, that tested placebo vs intubation in a randomized double-blinded fashion, that proves it's the right thing to do? What's your NNT? What's your NNH?

You don't have answers. And I'm not being funny, because you don't NEED evidenced base medicine for some things. In some instances it's a hindrance to what you already know to be true. Question dogma, but question EBM just as vigilantly.

If you think absence of evidence is proof of ineffectiveness, please, please, I beg you to spend 10 seconds reading this very brief, landmark British Medical Journal abstract from 2003:

http://www.bmj.com/content/327/7429/1459

"Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials

BMJ 2003;327:1459

Abstract

Objectives To determine whether parachutes are effective in preventing major trauma related to gravitational challenge.

Design Systematic review of randomised controlled trials.

Data sources: Medline, Web of Science, Embase, and the Cochrane Library databases; appropriate internet sites and citation lists.

Study selection: Studies showing the effects of using a parachute during free fall.

Main outcome measure Death or major trauma, defined as an injury severity score > 15.

Results We were unable to identify any randomised controlled trials of parachute intervention.

Conclusions As with many interventions intended to prevent ill health, the effectiveness of parachutes has not been subjected to rigorous evaluation by using randomised controlled trials. Advocates of evidence based medicine have criticised the adoption of interventions evaluated by using only observational data. We think that everyone might benefit if the most radical protagonists of evidence based medicine organised and participated in a double blind, randomised, placebo controlled, crossover trial of the parachute.

...

Funding None.

Competing interests None declared.

Ethical approval Not required"

 

[deleted109597]

For those of you paralyzed when faced with a clinical decision not answered by clear cut evidenced based medicine I'd like to ask you a question. What level one evidence do you have, proving that intubation is life saving for your apneic, non-breathing patients?

If they're having a concurrent cardiac arrest, it's actually harmful. Coding patients don't need advanced airways, they need CPR.

And if you don't base your practice on evidence, what do you base it on? Eminence? Inertia? Book chapters?
I'm not saying you should jump both feet in, and I'm not saying all literature is worthwhile. Sadly, a lot of it is crap. But that doesn't mean we should ignore the good ones because bad ones exist.
Yes, many people thought steroids were good for spinal cord trauma. Thankfully, because people looked at the data, and didn't just read the conclusion part of the abstract or the title of the paper, further studies were conducted that showed it was harmful (but not because of the spine, because of pneumonia).
Your tPA one is laughable. The only 2 positive trials got that way by moving the goalposts. The 4 negative ones were downplayed, and the 4 neutral ones were massaged by subgroup analysis.
Today's xkcd is very timely.

 

[deleted109597]

Flesh this one out a bit for me, if you please. How does "neo hippie crunchy idiot parent that doesn't get their kids immunized" equal "community medicine"? What I know is docs going blue in the face exhorting vaccines, and doltish, misinformed parents saying "NO!"

Hippy crunchy idiot argues with doctor about what's best for "their snowflake", and the doctor allows it. Just like they allow antibiotics for viral URIs, as it's easier than arguing. If every doc was really going blue in the face about vaccines, more kids would have them. Unsurprisingly, many doctors have learned they can make more money playing those fears in parents than practicing good medicine.

 

[Birdstrike]

If they're having a concurrent cardiac arrest, it's actually harmful. Coding patients don't need advanced airways, they need CPR.

And if you don't base your practice on evidence, what do you base it on? Eminence? Inertia? Book chapters?
I'm not saying you should jump both feet in, and I'm not saying all literature is worthwhile. Sadly, a lot of it is crap. But that doesn't mean we should ignore the good ones because bad ones exist.
Yes, many people thought steroids were good for spinal cord trauma. Thankfully, because people looked at the data, and didn't just read the conclusion part of the abstract or the title of the paper, further studies were conducted that showed it was harmful (but not because of the spine, because of pneumonia).
Your tPA one is laughable. The only 2 positive trials got that way by moving the goalposts. The 4 negative ones were downplayed, and the 4 neutral ones were massaged by subgroup analysis.
Today's xkcd is very timely.

Evidence Based Medicine is useful. Evidence base medicine is necessary. But evidence based medicine will always be flawed, as it relies on inherently imperfect human beings to create, interpret, fund and apply it. We must fill in the gaps, the very large gaps, with (you guessed it!) clinical judgement. Remember: your clinical experience is evidence that guides your practice, also.

That's why doctors exist, for the ever-intangible thing called "Clinical Judgement." Otherwise, an untrained guideline-technician would be able to do our jobs, by plugging patient complaints into a EBM-guideline decision tree.

EBM is a tool. But you can't be paralyzed by it, or paralyzed without it. You have to realize it's changing and bendable over time, and not unquestionable Gospel, since those creating, interpreting and applying it are imperfect including ourselves. Also, experimental conditions, rarely are seen in exact replication in real world conditions.

 

[GeneralVeers]

Without patient satisfaction we would be free to practice EBM. Unfortunately every complaint letter, and every low score could potentially cost me my job. I practice EBM when I can, but pick and choose my battles carefully. It's ironic that doing the right thing based on evidence, and trying to prevent harm to a patient could get one fired.

 

[deleted109597]

Evidence Based Medicine is useful. Evidence base medicine is necessary. But evidence based medicine will always be flawed, as it relies on inherently imperfect human beings to create, interpret, fund and apply it. We must fill in the gaps, the very large gaps, with (you guessed it!) clinical judgement. Remember: your clinical experience is evidence that guides your practice, also.

That's why doctors exist, for the ever-intangible thing called "Clinical Judgement." Otherwise, an untrained guideline-technician would be able to do our jobs, by plugging patient complaints into a EBM-guideline decision tree.

EBM is a tool. But you can't be paralyzed by it, or paralyzed without it. You have to realize it's changing and bendable over time, and not unquestionable Gospel, since those creating, interpreting and applying it are imperfect including ourselves. Also, experimental conditions, rarely are seen in exact replication in real world conditions.

EBM ends up being like religion in this respect. It's funny how those that are on the bleeding edge, as it were, are seen as "unwavering" while those that still practice in the stone age think they're amenable to change. When's the last time you put lido with epi in a digit? Are you afraid to? Was there ever a shred of evidence supporting that it was harmful, or was it infallible clinical judgement? While those that practice judgement are often resistant to any change, regardless of the evidence behind that change.
My favorite is when people tell me "You don't believe in Tamiflu" as if it's a belief system. Instead of what it is, which is good data skewed by Roche showing that it isn't beneficial, and is actually harmful to many, but Roche had to make those dollars.

The biggest issue I find is in situations like this. Where there *is* evidence that shows what we do isn't useful, but people argue that either there isn't. In these situations, when I say there's no evidence to support that practice, it isn't like there's no evidence there is a God/FSM. It's that there is evidence that says what we are doing isn't useful. Hence the sheer number of papers sited by Sal and David.
Or that it isn't externally valid because it wasn't done at their site. Which do you follow, EGDT from Rivers, or the results from ProCESS/ARISE?

Of the papers I've seen that are well done, only one isn't applicable to where I practice, and that's the FEAST trial. Because our septic kids don't have malaria, so they need fluids. But if I were in Africa and didn't have access to a ventilator, I would practice based on that data while there.

 

[BoardingDoc]

When's the last time you put lido with epi in a digit? Are you afraid to? Was there ever a shred of evidence supporting that it was harmful, or was it infallible clinical judgement?

I know this wasn't the main point of your post, but to answer this question: I use epi in digits all the time. There are no data to indicate that this is a generally unsafe practice and the issue has been studied multiple times (as you're clearly aware from your post). I'm fortunate enough to work at an institution where most of my attendings prefer EBM over traditional dogma, so we use epi in digits whenever we think it would be useful.

 

[Apollyon]

I know this wasn't the main point of your post, but to answer this question: I use epi in digits all the time. There are no data to indicate that this is a generally unsafe practice and the issue has been studied multiple times (as you're clearly aware from your post). I'm fortunate enough to work at an institution where most of my attendings prefer EBM over traditional dogma, so we use epi in digits whenever we think it would be useful.

I as an attending also do it frequently. No issues.

 

[jl lin]

Don't Podcast Yourself To Death

Antibiotics for copd never was a big stretch for me. They're a group with a serious morbidity, they're very prone to pneumonia, and they have so much mucous production I can easily see there being subclinical bacterial involvement there, without it necessarily ever forming detectable consolidation on a CXR, or ever being demonstrable on a pure RCT done with gold-standard bronchalveolar lavage technique.

For ----s sake, can we not ever do anything that makes sense anymore, or use clinical judgement, ever, without first bowing at the alter of EBM, which itself is far, far from being pure of corruption, drug company influence, and numerous types of bias including publication bias and other severe flaws?

You became a doctor to treat sick people, and amongst all the straphangers wandering into your ED who aren't really sick, you've finally got a documented bacterial infection with symptoms in front of you? Treat it.

Treat it!

I don't care what the NNT/NTHs are. Those analyses are not statistically perfect in any sense of the word, any more than are the papers they were derived from. Pretty soon you're seeing mastoiditis from the untreated otitis (was a real entity before antibiotics), more peritonsillar abscesses (from untreated bacterial tonsillitis) and so on.

Yes, there's a push to reduce unnecessary testing and over treatment and we should be cognizant of that. I'm all for the scientific method and questioning dogma, but medicine will never be a perfect science like nuclear physics or mathematics. Argue all day long and podcast yourself to death, but some things ...just...make...sense...

Do them, for God's sake.

Seriously, this is one of the most sane and intelligent posts I have EVER read on SDN. Sigh of relief at some sanity. I was beginning to really worry.

 

[jl lin]

Interesting but the clinical question that's asking is, "How often do antibiotics prevent suppurating complications in "common respiratory infections?" which are far an away VIRAL. So, to take that result and extend it to your practice with a broad brush to say antibiotics don't work for definite BACTERIAL illness, not weeding viral sources out, is completely invalid and classic data misinterpretation.

The NNT for using antibiotics for common respiratory infection (nearly all VIRUSES) has zero bearing on the NNT for antibiotics in bacterial infections, not to mention the fact that you can't lump the many different strains of bacterial pneumonia and bacterial pharyngitis, bacterial sinusitis (to the extent it exists), bacterial otitis all together and come up with a valid NNT, anyways.

There's so much sloppy "garbage in garbage out," it turns my stomach. People read these studies, not realizing how valid or invalid they even are, or whether the clinical question applies to their patients or practice, and have a false sense of security that what they're doing is right, scientific and "evidence based," when a significant part of the time the results are no more accurate than flipping a coin, no more accurate that their own clinical gestalt, or don't apply to their subset of patients.

Kudos to you again, Birdstrike.

Where is the balance in thinking and in critical thinking? EBM has it's place, but it is not the beginning and ending of all things, b/c there is so much that can be contradicting and incomplete. And certainly not every thing will be is amenable for RCT--and even some Cochrane reviews have bents that leave out other important factors. If you don't real and study carefully, you could miss this. Who will ever have the money, time, and availability to complete the high-line testing on every illness or health issue known to man or beast?

Evidence Based Medicine is useful. Evidence base medicine is necessary. But evidence based medicine will always be flawed, as it relies on inherently imperfect human beings to create, interpret, fund and apply it. We must fill in the gaps, the very large gaps, with (you guessed it!) clinical judgement. Remember: your clinical experience is evidence that guides your practice, also.

That's why doctors exist, for the ever-intangible thing called "Clinical Judgement." Otherwise, an untrained guideline-technician would be able to do our jobs, by plugging patient complaints into a EBM-guideline decision tree.

EBM is a tool. But you can't be paralyzed by it, or paralyzed without it. You have to realize it's changing and bendable over time, and not unquestionable Gospel, since those creating, interpreting and applying it are imperfect including ourselves. Also, experimental conditions, rarely are seen in exact replication in real world conditions.

 

[Rendar5]

Speaking of complications of strep, I just treated a peritonsillar abscess this week. Pt had been treated just 4 days before for strep with bicillin and decadron. And of course wound culture came back today as strep with full sensitivity to penicillins. No resistance whatsoever. Just goes to show antibiotics don't even prevent suppurative complications of strep.

 

[future_dr_house]

I understand your point. But once the case goes to qi everyone will point fingers that you didn't give abx and now you're "monitored" for adverse events. To each his own, but I'd rather err on the side of giving medications that improve pain symptoms may decrease risk of suppurative complications and is a satisfier. If you convinced my bosses that we don't have to treat it or that there's a better standard of care then I'd change practice.


Sent from my iPhone using Tapatalk

 

[Birdstrike]

"Just goes to show antibiotics don't even prevent suppurative complications of strep..."

Here, let me finish your sentence for you, "...once abscess formation has already started."

You're welcome

 

[Rendar5]

exactly, if the abscess starts on day 1, which is when the patient first came to the ED for strep, then that explains why there may not even be significant reduction in suppurative complications. Why antibiotics don't do **** for abscesses. So not sure giving strep throat antibiotics is useful with that line of thinking.

As for future Dr House, do you give a z-pack and Tamiflu to all your productive cough patients? So that someone who has post flu pneumonia can't send a case to QI? Or do you also go to QI if someone vomits from Tamiflu or has an allergic reaction to a medicine you prescribed. Seems you have a very scary QI. Everything you do or don't do in medicine has potential adverse effects. We're all probably going to get sued for something we did or didn't do.

Think about it, do you xray everyone with neck pain from acar accident, ct everyone's head who bumps their head, xray everyone with back pain just cause they have it? No rule is perfect and I guarantee you that at some point there will be someone with a significant neck injury with a negative nexus, a head bleed with a negative PECARN rule, and a mass who shows up with 3 days of back pain w/o red flags. Probably won't be you because the odds are so low, but it will happen. Same as rheumatic fever. It'll probably happen to someone somewhere, but probably not you because the odds are ridiculously low nowadays.

 

[Rendar5]

As far as I'm concerned, if I have an irrational patient (who'll throw a fit, kill me on press gainey, write to my boss, or just rack up a 2nd ED bill after leaving me and going to another hospital), a 3rd world patient (where rheumatic fever still exists), or someone who desparately needs to be non-contagious and improved in a certain time period for an important reason (e.g. Bruce Springsteen and I have tickets for his concert in 5 days), I'll give em antibx +/- steroids. If I have a rational patient (I don't usually have someone give me a hard time for suggesting that "it's probably not strep and even if it is, if you really want to feel better I have a better medicine than antibiotics for ya"), it's not an issue and I won't even check for it.

 

[xaelia]

Above, as Rendar5 states.

Taking a few seconds to talk it out with patients can change a lot.

Now, the "rational patient" clearly doesn't apply to parents bringing in their kids at 3am ....

 

[styphon]

Without patient satisfaction we would be free to practice EBM. Unfortunately every complaint letter, and every low score could potentially cost me my job. I practice EBM when I can, but pick and choose my battles carefully. It's ironic that doing the right thing based on evidence, and trying to prevent harm to a patient could get one fired.

All of my complaints (and verbal assaults) are based on not giving antibiotics for likely viral infections despite our wall posters/hand outs/signs about viruses - I cannot imagine making these numbers even higher by not giving it for strept. At least I can rationalize to myself about URIs that I am saving them from harmful adverse effects and that it was worth the complaint.

 

[coachB]

All of my complaints (and verbal assaults) are based on not giving antibiotics for likely viral infections despite our wall posters/hand outs/signs about viruses - I cannot imagine making these numbers even higher by not giving it for strept. At least I can rationalize to myself about URIs that I am saving them from harmful adverse effects and that it was worth the complaint.

That's the same reason for not giving them for strep. The potential harms outweigh the potential benefits.

 

[Birdstrike]

Next time y'all are on the phone with your ENT, ask him/her this question:

"If I have a patient come in with a sore throat that turns out to be strep, what should I do?"

I'd love to hear/see the responses/facial expressions.



My faves would be:


"Uhhh...is this a trick question?"

"Uhhhh...you're joking, right?"

"Dude, you okay?"

"This is cute, but can you put the doctor on, please?"

 

[Rendar5]

How about don't swab the throat in the first place. If it's pharyngitis, it's pharyngitis. It doesn't become strep until you swab it.

Same with the flu. If you don't check a flu swab, you get to d/c home with tylenol, motrin, and PO fluids for flu-like illness. Don't even get tamiflu involved.

I had fluid in my ear for 2 weeks with swollen lymph nodes. I asked my ENT if it needed drainage or antibx. She told me most ER docs or PMD's would've just given me antibiotics just because it looked borderline and they like to just prescribe them when in doubt, but that steroids and decongestants would actually be what she recommended.

I myself have had severe allergic reactions to antibiotics before after being treated for strep throat (including angioedema). I have had patients come in with severe rashes for unnecessary antibiotics. I have had a patient with C Diff colitis after antibiotics for strep throat. I have never seen a case of Rheumatic fever (and yes, I know plenty of people who don't get treated with antibiotics for strep). There's nothing else beneficial to antibiotics. I am much more likely to be sued for something caused by antibiotics than something caused by lack of antibiotics in strep throat.

 

[Rendar5]

Again, I'm talking the rational patient where they are there for symptomatic treatment, not the irrational patient (i.e. webmd "doctor" where they have a set idea of what you need to do to treat them and simple explanations of data fall on deaf ear). If the potential harms to my job/sanity outweighs the risks of antibiotics to them, then screw them, give em what they want. Still low risk, low benefit either way.

 

[gman33]

Who are these rational patients people keep talking about?

 

[deleted109597]

http://www.nytimes.com/2015/02/03/u...al&utm_source=twitter.com&utm_campaign=buffer

 

[styphon]

Who are these rational patients people keep talking about?

I also wonder where these magical patients are.

Ex:
"my friend/wife/son got antibiotics"
"I only get bad colds that need antibiotics"
"I don't get viral infections, only bacteria can infect me"
"Doctors always give me antbiotics!"
"I'm a pharmtech/CNA/phone operator and I KNOW medicine and KNOW I need antibiotics"

 

[GeneralVeers]

We don't see too many rational patients in the ED, because these people are likely to stay home. The ED selects for irrational worried people who are often there just to get antibiotics ASAP. No one rational who understood basic concepts about viral infections would go the ED.

 

[Birdstrike]

My take home from this thread and issue, would be this:

"Strep pharyngitis is a bacterial illness. Still, it's usually self-limited. We used to treat all of these with antibiotics. Newer thought is that this is not as important as we used to think, and that sometimes antibiotics can do more hard them good, though some doctors still use antibiotics for this."

In other words, if you do treat it, probably not a big deal. If you don't treat it, or test for it, probably not a big deal. Then patient chooses to either,

A-Demand antibiotic anyways, or

B-Says, "Good. I'm glad it's not as bad as I thought. Thanks, Captain of Reason and Data Analysis, I'll be leaving now with my concoction of OTC meds, I'll gladly power through work tomorrow like a champ, and...hey Doc, how can I make sure this bill gets paid right away like you deserve, you under appreciated hero, and how can I make sure you get a 5 star PG score?"

No, but seriously: it's an ambivalent issue that will vary based on clinical/patient/department/physician factors, influences and preferences. Also, if something goes drastically wrong as a perceived consequence of treating or not treating (which will be rare on this issue) others will use that ambivalence to nitpick what they "would've have done" through their retrospectoscope to suit their view. It's much like anything else we do in Medicine. In other words, Medicine is (still) not an exact science.

It reminds me of an EM abstracts a few years ago when Bukata & Hoffman reviewed the conjunctivitis literature, even the vast majority of the bacterial ones resolve without antibiotics. That's for bacterial, not to mention viral. I remember that lecture because it was surprising since you're taught to worry, "What if I miss bacterial, what if I miss bacterial?" and everyone throws eye antibiotic drops at conjunctivitis, "Just in case..."

Do you use antibiotic drops for bacterial conjunctivitis or any conjunctivitis for that matter, and if so, prove to me you must (or must not)?

 

[gman33]

My main objective with this type of patient is to rule out badness and get them out of the department happy in a short amount of time.
If they really want a rapid strep, they will get it.
If they really want abx, they will get it.
If they really want a work note, they will get it.
If they really want a Percocet, they MAY even get it.

Like many others, the places I work are understaffed and I don't have time to spend arguing with patients who really don't need anything.

Abx drops for conjunctivitis. Usually I give them, unless clearly allergic.

 

[Birdstrike]

My main objective with this type of patient is to rule out badness and get them out of the department happy in a short amount of time.
If they really want a rapid strep, they will get it.
If they really want abx, they will get it.
If they really want a work note, they will get it.
If they really want a Percocet, they MAY even get it.

Like many others, the places I work are understaffed and I don't have time to spend arguing with patients who really don't need anything.

Abx drops for conjunctivitis. Usually I give them, unless clearly allergic.

...so naughty.

 

[Daiphon]

Re: ABx for conjunctivitis - I work nights, so the families I usually see for this need their kids in daycare. FBoFW, kid can't go back per daycare rules unless treated.

Day of lost work/school for parents/caregivers is orders of magnitude more expensive than a $4 tube (or "free" because of the medical card) of emycin.

Kid needs to be in school. Period.

-d

 

[RustedFox]

We don't see too many rational patients in the ED, because these people are likely to stay home. The ED selects for irrational worried people who are often there just to get antibiotics ASAP. No one rational who understood basic concepts about viral infections would go the ED.

QFT.

 

[LabMonster]

So we can agree that nothing is proven to work on anything ever?

Yes, Agreed.

 

[LabMonster]

Every single one of you has caved before. Every single one, has at some point caved to what was not the "ideal in a perfect EBM vacuum" thing to do. You probably do it regularly, more than you think (or admit), not to mention what is "the perfect thing to do" according to some EBM podcast today, may the wrong thing next year, or vice versa.

I'm not buying it. Y'all are irradiating the crap out of people, prescribing antibiotics because "that ear looks a little too red" or admitting people to cover your butt, that could go home, by some "EBM ideal," or doing things you might not do, due to Press-Ganey threats by your admin. And some of those that get admitted get a catheter and a uti, or fall off their hospital bed and get a fracture or get a nosocomial pneumonia. You're pan-scanning traumas that don't always have not a single clinically relevant finding, that could've gotten less. Uh-huh. None of you are "pure of EBM heart." Not one.

It's almost as if the "art" of medicine has degenerated to the "art of CYA." EBM has, in general, shown that not many of our interventions do a damn thing. Opioids get people high so they don't care about their pain, antibiotics seem to help in severe disease and fluid resuscitation is great with the hypotensive patient. But it seems the rest is a quagmire.

I agree with you, everyone caves, no one obeys EBM to the strictest letter - and I don't think we should because the data is definitely not all in. Good EBM data provides data on strictly controlled studies with rigidly controlled populations that can sound like dogma... Like that person s/p chole who can't possibly have a retained stone, but they do. Or that patient who can't possibly have an epidural abscess because the MRI is negative (and MRI is positive days later.)

EBM gives us a solid ground, but we still need to exercise our judgement as physicians. Sometimes, that means treating a virus with antibiotics (with informed consent, of course.)

 

[VA Hopeful Dr]

Re: ABx for conjunctivitis - I work nights, so the families I usually see for this need their kids in daycare. FBoFW, kid can't go back per daycare rules unless treated.

Day of lost work/school for parents/caregivers is orders of magnitude more expensive than a $4 tube (or "free" because of the medical card) of emycin.

Kid needs to be in school. Period.

-d

That's what I do as well.

"This is a viral eye infection, so antibiotics won't do your child any good. However, the school/daycare won't let them come back without being on eye drops so take this Rx. They won't get better any faster, but they will be able to go back to school/daycare".

 

[Birdstrike]

That's what I do as well.

"This is a viral eye infection, so antibiotics won't do your child any good. However, the school/daycare won't let them come back without being on eye drops so take this Rx. They won't get better any faster, but they will be able to go back to school/daycare".

Not,

"Please keep your child out of school/daycare until well, as conjunctivitis, particularly viral is highly contagious and will spread around school/daycare like wildfire while generating many more unnecessary several-hundred-dollar ED visits, more unnecessary antibiotics while fueling the spread of this self-limited yet miser- inducing communicable disease to other families that really don't need it"?

 

[VA Hopeful Dr]

Not,

"Please keep your child out of school/daycare until well, as conjunctivitis, particularly viral is highly contagious and will spread around school/daycare like wildfire while generating many more unnecessary several-hundred-dollar ED visits, more unnecessary antibiotics while fueling the spread of this self-limited yet miser- inducing communicable disease to other families that really don't need it"?

Not that whole spiel, but I do suggest they keep the kid home and wash hands like crazy while the eye is still draining. Rarely works. In retrospect, I should just refuse and then the school will force them to stay home; but, honestly, I'm just tired of getting called in to discuss patient complaints.

Plus, I stay away from the newer antibiotics - polytrim for all!

 

[Birdstrike]

honestly, I'm just tired of getting called in to discuss patient complaints.

I know. Damned if you do, damned if you don't.

 

[VA Hopeful Dr]

I know. Damned if you do, damned if you don't.

I honestly don't know how you ED docs do it. I've only been in Urgent Care for 8 months and I've come to dread the days I have to work, and y'all have it much worse than I do.

 

[GeneralVeers]

I honestly don't know how you ED docs do it. I've only been in Urgent Care for 8 months and I've come to dread the days I have to work, and y'all have it much worse than I do.

It's not easy, though the compensation makes up for it a bit. The hardest part is trying to have a serious conversation with some crazy person who has a mild viral illness and is convinced that they need an extensive workup and treatment, while at the same time taking care of critical septic/cardiac patients who actually deserve your time.

 

[WilcoWorld]

Not,

"Please keep your child out of school/daycare until well, as conjunctivitis, particularly viral is highly contagious and will spread around school/daycare like wildfire while generating many more unnecessary several-hundred-dollar ED visits, more unnecessary antibiotics while fueling the spread of this self-limited yet miser- inducing communicable disease to other families that really don't need it"?

I'm far from our specialty's greatest steward of antibiotics, and I do Rx for conjunctivitis most of the time. But I, admittedly somewhat backhandedly, get around both issues by offering to write a back to school note. In this note, which the parents variably perceive as a favor/service/right, I say something like "Johnny Adenovirus was seen in the ED on 2/4/15. He was prescribed antibiotics and may return to school when he has been fever free for 24 hours and no longer has eye drainage."

 

[WilcoWorld]

I saw a case of rheumatic fever this week. The patient has never left the U.S. In fact, when I asked about travel history he said, "No, but I go to Walmart, and you see all kinds of people there!"

 

[ccfccp]

EBM now clearly shows that Wal-Mart causes Rheumatic Fever.

 

[Birdstrike]

EBM now clearly shows that Wal-Mart causes Rheumatic Fever.

"Have you been harmed by Walmart once again? First a drop of H2O negligently place on the floor tile causing your slip, fall and long term disability. Now, Rheumatic fever."

"Please call 1-800-Walmart-Gave-Me-RF, today! You may be entitled to compensation. Birdstrike Law Firm is here to help."

 

[kratos99]

As a teacher of EBM, I have to say that EBM is not all about the "evidence". There are three pillars to EBM. One, is the clinical data: the history, physical and lab work/imaging tests that we all learned to obtain and interpret as students and residents. Two, is the actual evidence. And three, is patient values. Sometimes patient values override concerns about side effects and I will admit I will give in to giving antibiotics for URIs. However, patient values can't override everything, otherwise we would be giving out narcotics like crazy to drug addicts, and doing all sorts of things that can cause harm.

And yes, there are somethings for which evidence shouldn't or needn't apply; like jumping out of an airplane with a parachute.

 

[GeneralVeers]

As a teacher of EBM, I have to say that EBM is not all about the "evidence". There are three pillars to EBM. One, is the clinical data: the history, physical and lab work/imaging tests that we all learned to obtain and interpret as students and residents. Two, is the actual evidence. And three, is patient values. Sometimes patient values override concerns about side effects and I will admit I will give in to giving antibiotics for URIs. However, patient values can't override everything, otherwise we would be giving out narcotics like crazy to drug addicts, and doing all sorts of things that can cause harm.

And yes, there are somethings for which evidence shouldn't or needn't apply; like jumping out of an airplane with a parachute.

Antibiotics DO cause harm! If they were truly without consequences I'd just give every sore throat/ear pain/cough antibiotics to get them out. If it's clearly a viral URI, then they will not get antibiotics from me. I'll give in to patients with symptoms that *might* have a small chance of being a treatable bacterial illness.