I have an icu pt diagnosed with pneumonia given cipro by an nurse practitioner

[MedicineDoc]

Pt originally was diagnosed as an outpatient started on cipro for pneumonia and later collapsed and went into acute respiratory failure and in the process had a non st elevation mi. He's now hanging out on the vent day # 3. GGGggoooooo Nnursse PPpractitioners!!!!! You Guys. ROCK!!!!!

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[Endolas]

This should end well...

 

[Boba Q Fett]

holy ****ing jesus ****...........WOW

 

[deleted87716]

Darn that pesky pneumococcus...

I've seen Cipro used for CAP by inexperienced docs as well, so it's not necessarily an indictment of nurse practitioners. Anyone relying on "cookbook medicine" will find Cipro listed as a option for CAP in most antibiotic reference guides. Unfortunately, it has rather poor coverage for strep pneumo compared to some of the newer quinolones.

Cheaper isn't always better. This is true of clinicians, as well.

 

[deleted6669]

another common abx mistake made by all types of providers is still using keflex for abscesses...ever heard of mrsa? I had a pt last night on keflex(from his fp md pcp, although non-em pa's and np's do this as well) for a facial abscess. guy was a meth user and didn't make a secret of it...so #1...do the I+D...#2 use an abx with mrsa coverage.....septra ds, doxy, clinda(although some resistance now), rifampin, etc

 

[deleted87716]

^ ER docs do it, too.

Cultures are helpful, as well.

 

[VA Hopeful Dr]

another common abx mistake made by all types of providers is still using keflex for abscesses...ever heard of mrsa? I had a pt last night on keflex(from his fp md pcp, although non-em pa's and np's do this as well) for a facial abscess. guy was a meth user and didn't make a secret of it...so #1...do the I+D...#2 use an abx with mrsa coverage.....septra ds, doxy, clinda(although some resistance now), rifampin, etc

In some areas, MRSA+ outpatient abscesses can be very low. Also, and I don't mean this to be condescending in any way, but how often and with what else are you using rifampin? I know it does have great penetration into damned near anything, but as you can't use it by itself I've never thought it that useful other than for vegetative endocarditis.

 

[deleted6669]

In some areas, MRSA+ outpatient abscesses can be very low. Also, and I don't mean this to be condescending in any way, but how often and with what else are you using rifampin? I know it does have great penetration into damned near anything, but as you can't use it by itself I've never thought it that useful other than for vegetative endocarditis.

those who use rifampin as 1st line for mrsa(and I'm not one of those, I use doxy) use it with septra ds.
our mrsa (culture proven) % is 80% of abscesses and it's a well known stat in our community so using keflex for an abscess doesn't really make sense.

 

[VA Hopeful Dr]

those who use rifampin as 1st line for mrsa(and I'm not one of those, I use doxy) use it with septra ds.
our mrsa (culture proven) % is 80% of abscesses and it's a well known stat in our community so using keflex for an abscess doesn't really make sense.

Fair point. Have you noticed any big differences between doxy/septra alone vs. rifampin+septra?

 

[deleted6669]

Fair point. Have you noticed any big differences between doxy/septra alone vs. rifampin+septra?

NOPE....but some folks are of the belief that mrsa needs to be txd with 2 abx...I'm not convinced.....there is fairly good evidence that I+D alone is adequate as long as there is not a surrounding cellulitis(but by the time I see them in the e.d. most of them have some degree of surrounding cellulitis).

 

[deleted87716]

For CA-MRSA abscesses: I&D + TMP-SMX if cellulitis present + decolonization.

 

[deleted6669]

For CA-MRSA abscesses: I&D + TMP-SMX if cellulitis present + decolonization.

Do you guys double dose your septra ds ( 2 bid)?
our ID folks like that as they are starting to see some resistance here with the lower doses.
agree with decolonization with intranasal bactroban bid x 5 days + hibiclens as shower soap QD x 2 weeks(with care to avoid eyes due to permanent corneal scarring).
I aslo put in a plug for quitting smoking to improve peripheral circulation....

 

[deleted87716]

Do you guys double dose your septra ds ( 2 bid)?
our ID folks like that as they are starting to see some resistance here with the lower doses.

Haven't run across that yet.

 

[JackADeli]

...mrsa? ...use an abx with mrsa coverage.....septra ds, doxy, clinda(although some resistance now), rifampin, etc

Do you use rifampin stand alone or secondary as an adjunct? I was under the impression rifampin was better as an adjunct, particularly to penetrate when prosthetic material might be involved, but as a stand alone resistance develops quickly. Has this changed?

For CA-MRSA abscesses: I&D + TMP-SMX if cellulitis present + decolonization.

That is our most common approach, decompress/I&D, debride, bactrim.... Bactrim is one of the more common used agents, especially in vasculopaths with bad feet.... But, the I&D and debride is really a critical first step.

 

[deleted6669]

I use doxy or septra. my colleagues who use rifampin use it with septra.

 

[JustPlainBill]

OP - I've got that one beat, hands down....

FM Attending on a Family Medicine Inpatient service consulted renal for a patient---why?

well, the patient had a bump in creatinine from 0.8 to 1.42 after two CT w/contrast scans without prophylaxis.....the attending wanted to consult renal to see if there was a reason the creatinine might bump....no, I am not kidding

After the renal fellow chewed out the intern who was told to do the consult, they proceeded to get their temper under control and firmly inform the attending that this was not a reason to consult. The attending tried to insist and eventually won since they are an attending....

After the attending walked off, the renal fellow looked me in the eyes with a look of disgust and just rolled their eyes.....

And they wonder why the FM program is not taken seriously here....

No, I am not kidding...

 

[deleted87716]

 

[MedicineDoc]

Well just plain bill if you are a hammer everything is a nail and if you are a renal fellow everything is a kidney. Maybe the pt needed two ct scans with contrast. The creatinine doesn't bump until there is already a significant decrease in Gfr. The attending most likely wanted input from renal on renally dosing the patients medications which can be complex depending on the meds. Neurologists are about the only ones who are often just consulted for a why answer even though tx is unlikley to matter. Alot of times we consult just for medicolegal rubber stamp reasons as people are successfully sued on bogus suits. We almost always know what our consultants will do in a given sutuation from frequent past encounters with them. In truth fm are some of the most knowledgeable attendings around and best at counteracting the tunnel vision of. Consultants. If the ship is going down it's time to put more flags on it.

 

[deleted87716]

A lot of times we consult just for medicolegal rubber stamp reasons...We almost always know what our consultants will do in a given sutuation from frequent past encounters with them.

Yep.

 

[MedicineDoc]

I'll give you an example this week our Er soca admitted 2 pts to two different fm attendins for nausea, dizziness and both got cts of the head snd one got both a ct and an MRI before the fm doc got there. Both had they gone to the fm clinic would have gone home on some meclizine for benign paroxysmal vertigo instead of getting the label of possible posterIor stroke.

 

[deleted87716]

They should just install the CT scanner at the entrance to the ER. It would speed things up tremendously.

 

[JustPlainBill]

Well just plain bill if you are a hammer everything is a nail and if you are a renal fellow everything is a kidney. Maybe the pt needed two ct scans with contrast. The creatinine doesn't bump until there is already a significant decrease in Gfr. The attending most likely wanted input from renal on renally dosing the patients medications which can be complex depending on the meds. Neurologists are about the only ones who are often just consulted for a why answer even though tx is unlikley to matter. Alot of times we consult just for medicolegal rubber stamp reasons as people are successfully sued on bogus suits. We almost always know what our consultants will do in a given sutuation from frequent past encounters with them. In truth fm are some of the most knowledgeable attendings around and best at counteracting the tunnel vision of. Consultants. If the ship is going down it's time to put more flags on it.

I see your point and agree with most of what you said....this particular attending has done other things that just lead me to believe this person just flat out doesn't know what's going on.....they've got a reputation of being consult heavy and not doing a standard workup before consulting...the upper level almost threw a fit and both interns couldn't believe what they were hearing....it wasn't a 'rubber stamp what I'm doing' it was truly a 'why could this be happening' type of deal....

 

[MedicineDoc]

another common abx mistake made by all types of providers is still using keflex for abscesses...ever heard of mrsa? I had a pt last night on keflex(from his fp md pcp, although non-em pa's and np's do this as well) for a facial abscess. guy was a meth user and didn't make a secret of it...so #1...do the I+D...#2 use an abx with mrsa coverage.....septra ds, doxy, clinda(although some resistance now), rifampin, etc

Actually dental related abscesses ie meth user are more likely anaerobes and if you had to cover it empirically overnight prior to an I and d by an ent the next morning clinda would be one of the first line drugs. If you were concerned about possible serious gram positive such as mrsa vanc would be a first choice to add to clinda ( which would be for anerobes ). You might add vanc if you were worried about airway closure or sepsis and couldn't risk not covering mrsa adequately especially if ent wouldn't be seeing the pt til morning. You could take off the vanc and leave on clinda and observe after I and d.

 

[deleted6669]

Actually dental related abscesses ie meth user are more likely anaerobes and if you had to cover it empirically overnight prior to an I and d by an ent the next morning clinda would be one of the first line drugs. If you were concerned about possible serious gram positive such as mrsa vanc would be a first choice to add to clinda ( which would be for anerobes ). You might add vanc if you were worried about airway closure or sepsis and couldn't risk not covering mrsa adequately especially if ent wouldn't be seeing the pt til morning. You could take off the vanc and leave on clinda and observe after I and d.

agree with above if dental. this was FACIAL as in he picked his face and got an external skin structure infection. guy also had a prior documented hx of mrsa in our system. we are fortunate to have OMF access in addition to ent and they handle most of the truly "dental" issues.

 

[Hamhock]

another common abx mistake made by all types of providers is still using keflex for abscesses...ever heard of mrsa? I had a pt last night on keflex(from his fp md pcp, although non-em pa's and np's do this as well) for a facial abscess. guy was a meth user and didn't make a secret of it...so #1...do the I+D...#2 use an abx with mrsa coverage.....septra ds, doxy, clinda(although some resistance now), rifampin, etc

easy...
there's a fair bit of evidence developing that abscess - including all MRSA abscess - requires no abx
NONE (as long as there is no cellulitis)
it was previously "well-known" that abscess only required I+D and no abx, but "what about MRSA?" people screamed...well, abx are still not required (unless you are trying to decrease repeat abscess occurence - and that's debateable)

[[and please don't get me going about the comments regarding the ED using the CT too much...especially regarding potential posterior infarct in old and dizzy...that's even easier]]

HH

 

[deleted6669]

easy...
there's a fair bit of evidence developing that abscess - including all MRSA abscess - requires no abx
NONE (as long as there is no cellulitis)
it was previously "well-known" that abscess only required I+D and no abx, but "what about MRSA?" people screamed...well, abx are still not required (unless you are trying to decrease repeat abscess occurence - and that's debateable)
HH

Agree- see my comments in post 10 of this thread.

 

[jackieMD2007]

They should just install the CT scanner at the entrance to the ER. It would speed things up tremendously.

But then people would protest that we were just trying to "look at their junk" with the "fancy x-ray machine" and "request a pat-down" from the doctor.

 

[lowbudget]

After the attending walked off, the renal fellow looked me in the eyes with a look of disgust and just rolled their eyes.....

Your renal fellow is a lazy sissy.

And? How did the case end? Did the hypothesis of contrast-induced ARF ended up being what happened or was there something else going on?

 

[MOHS_01]

lb,

Off topic -- but that supercell thunderstorm pic is one of the wickedest looking things I have ever seen.

 

[lowbudget]

lb,

Off topic -- but that supercell thunderstorm pic is one of the wickedest looking things I have ever seen.

Dude, check out National Geographics 2010 Photography Contest.
http://www.boston.com/bigpicture/2010/11/national_geographics_photograp.html

I thought a flying Great White Shark was sweet, but this storm is frickin' fierce. LOL!

 

[notinkansas]

Alot of times we consult just for medicolegal rubber stamp reasons as people are successfully sued on bogus suits. We almost always know what our consultants will do in a given sutuation from frequent past encounters with them. In truth fm are some of the most knowledgeable attendings around and best at counteracting the tunnel vision of. Consultants. If the ship is going down it's time to put more flags on it.

Ah, yes. The "bogus consult". My favorite back when I was a general surgery resident. Usually wasn't called until 5pm, either.

 

[MedicineDoc]

Ah, yes. The "bogus consult". My favorite back when I was a general surgery resident. Usually wasn't called until 5pm, either.

Almost as good as the consult fm for hypertension on the patient with optimal bp and currently on their home meds and the have the fm resident admit the possible appendicitis at 2 am and I will see them in the morning.