CDC and Antibiotics Guide

[JustPlainBill]

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Did anyone else see the chart posted by the CDC attempting to educate parents on when antibiotics are appropriate -- I almost spit DP through my nose at that one -- just try explaining to a Google, M.D. Mom that's sitting in your office that "knows" how strep starts in her child with a negative strep, pharyngitis x 1 day with erythematous nasal mucosa and slight mucoid PND that it's likely viral and to use OTC medications for symptom relief -- that you're not giving them a script for Mom-approved therapy -- we want Omnicef since Amoxcillin never works ---

Accoridng to the CDC chart, Whooping Cough, Strep and UTIs are the only indications for antibiotics (no, really?!!!) ---

Actually had a colleague get beat on by management when she told a mom the pharyngitis was likely viral (after doing a rapid strep and CBC to prove it) and mom accused her of refusing to treat -- the UC company wound up refunding the entire visit and calling in the script the Mom was demanding ---

 

[VA Hopeful Dr]

Did anyone else see the chart posted by the CDC attempting to educate parents on when antibiotics are appropriate -- I almost spit DP through my nose at that one -- just try explaining to a Google, M.D. Mom that's sitting in your office that "knows" how strep starts in her child with a negative strep, pharyngitis x 1 day with erythematous nasal mucosa and slight mucoid PND that it's likely viral and to use OTC medications for symptom relief -- that you're not giving them a script for Mom-approved therapy -- we want Omnicef since Amoxcillin never works ---

Accoridng to the CDC chart, Whooping Cough, Strep and UTIs are the only indications for antibiotics (no, really?!!!) ---

Actually had a colleague get beat on by management when she told a mom the pharyngitis was likely viral (after doing a rapid strep and CBC to prove it) and mom accused her of refusing to treat -- the UC company wound up refunding the entire visit and calling in the script the Mom was demanding ---

Welcome to the **** hole that is urgent care (and even some primary care). It sometimes feels like I'm the only MD in this whole damned city that doesn't just act as an antibiotic vending machine...

For strep, when in doubt do a culture. You can even explain (with some truth) that insurance is now refusing to pay if strep is diagnosed without +rapid or culture. I will often offer decadron for 2-3 days in the mean time, has some decent evidence behind it.

 

[JustPlainBill]

Welcome to the **** hole that is urgent care (and even some primary care). It sometimes feels like I'm the only MD in this whole damned city that doesn't just act as an antibiotic vending machine...

For strep, when in doubt do a culture. You can even explain (with some truth) that insurance is now refusing to pay if strep is diagnosed without +rapid or culture. I will often offer decadron for 2-3 days in the mean time, has some decent evidence behind it.

Yep --- but most don't want to wait 7 days turnaround -- actually had one SWF college student call the day after presenting with acute onset pharyngitis (that morning) with a rapid strep negative (and believe me, we got a good sample) that I had dx'd as likely viral pharyngitis -- stating that she was in so much pain and warm, salt water gargles weren't working and neither was Magic Mouthwash -- told her to give it some time --- called back later in the day demanding alternate therapy -- called in my favorite "anti-viral" -- Z pack -- after 2 days of that (total time now 4 days of sx) called back stating Abx not working, what else could I do -- informed that she needed to present for further eval or wait it out for at least 7 to 10 days unless worsening --- pissed and called the complaint line....

People in this society get a little snarky when I tell them virals can last up to 7 to 14 days --- and I think CabinBuilder reported in conversation that a case of flu lasted a month ----

now I'm beginning to see why 4 and 40 is so popular ---

 

[VA Hopeful Dr]

Yep --- but most don't want to wait 7 days turnaround -- actually had one SWF college student call the day after presenting with acute onset pharyngitis (that morning) with a rapid strep negative (and believe me, we got a good sample) that I had dx'd as likely viral pharyngitis -- stating that she was in so much pain and warm, salt water gargles weren't working and neither was Magic Mouthwash -- told her to give it some time --- called back later in the day demanding alternate therapy -- called in my favorite "anti-viral" -- Z pack -- after 2 days of that (total time now 4 days of sx) called back stating Abx not working, what else could I do -- informed that she needed to present for further eval or wait it out for at least 7 to 10 days unless worsening --- pissed and called the complaint line....

People in this society get a little snarky when I tell them virals can last up to 7 to 14 days --- and I think CabinBuilder reported in conversation that a case of flu lasted a month ----

now I'm beginning to see why 4 and 40 is so popular ---

If your strep cultures take 7 days, your lab is doing it wrong. From plate to read should be 24 hours. That suggests to me that your shop is ordering a full throat culture with sensitivities instead of just a group A strep culture.

Seriously, give decadron a shot. A few days in an otherwise healthy person won't hurt anything, patient gets a script, and it actually does seem to help.

Alternatively, my standard sore throat cocktail is OTC advil 800mg TID, chloraseptic spray, and lots of ice cream/milk shakes.

My cut off is usually 8-10 days. People get really pissed off (and I have a hard time blaming them) if after a solid week they still aren't feeling any better. Plus, even the IDSA says that after 10 days treating with antibiotics is OK.

 

[styphon]

If your strep cultures take 7 days, your lab is doing it wrong. From plate to read should be 24 hours. That suggests to me that your shop is ordering a full throat culture with sensitivities instead of just a group A strep culture.

Seriously, give decadron a shot. A few days in an otherwise healthy person won't hurt anything, patient gets a script, and it actually does seem to help.

Alternatively, my standard sore throat cocktail is OTC advil 800mg TID, chloraseptic spray, and lots of ice cream/milk shakes.

My cut off is usually 8-10 days. People get really pissed off (and I have a hard time blaming them) if after a solid week they still aren't feeling any better. Plus, even the IDSA says that after 10 days treating with antibiotics is OK.

I prefer doing the throat cx as opposed to GAS cx, but I still get the result in 48-72hrs. I often do throat cx if the pt insists, or the tonsils/symptoms point to a bacterial infection.

Before I would explain the centor criteria, the % chance of them having strept, and symptomatic OTC treatment, by doing such I had complaints at least ever week re: treatment. So now I give dexamethasone to make people feel like "they came in for something" and that "I did something" and will also offer to write a script for motrin 800 "prescription strength!" Doing such has greatly decreased the amount and frequency of my complaints

 

[JustPlainBill]

I had an attending once tell me as a MS3 that the older Vietnamese population in his patient panel never considered the visit over until they had received a shot -- had to do with the French and US SF teams that would bring injectable PCN with them and most of the children/adults got either vaccines or PCN thus leading to the belief that each physician visit had to have some form of injection or the office visit wasn't done.... makes me wonder.

 

[VA Hopeful Dr]

I had an attending once tell me as a MS3 that the older Vietnamese population in his patient panel never considered the visit over until they had received a shot -- had to do with the French and US SF teams that would bring injectable PCN with them and most of the children/adults got either vaccines or PCN thus leading to the belief that each physician visit had to have some form of injection or the office visit wasn't done.... makes me wonder.

Oh yeah, I love doing IM decadron and bicillin, but most folks nowadays don't want shots.

 

[VA Hopeful Dr]

I prefer doing the throat cx as opposed to GAS cx, but I still get the result in 48-72hrs. I often do throat cx if the pt insists, or the tonsils/symptoms point to a bacterial infection.

Before I would explain the centor criteria, the % chance of them having strept, and symptomatic OTC treatment, by doing such I had complaints at least ever week re: treatment. So now I give dexamethasone to make people feel like "they came in for something" and that "I did something" and will also offer to write a script for motrin 800 "prescription strength!" Doing such has greatly decreased the amount and frequency of my complaints

I think this best demonstrates the biggest thing I had to learn leaving residency - managing patient expectations.

 

[cabinbuilder]

and I think CabinBuilder reported in conversation that a case of flu lasted a month ----

QUOTE]


Yes!!!! I love when the patient comes in with "the ZPak hasn't worked" and "I'm still coughing". Yes you have viral brochitis and expect to cough 4-8 weeks. What????? I can't wait that long.
I also love when patient's come in with "stomach flu" and state, "but I had a flu shot". Sigh...

 

[JustPlainBill]

If your strep cultures take 7 days, your lab is doing it wrong. From plate to read should be 24 hours. That suggests to me that your shop is ordering a full throat culture with sensitivities instead of just a group A strep culture.

Seriously, give decadron a shot. A few days in an otherwise healthy person won't hurt anything, patient gets a script, and it actually does seem to help.

Alternatively, my standard sore throat cocktail is OTC advil 800mg TID, chloraseptic spray, and lots of ice cream/milk shakes.

My cut off is usually 8-10 days. People get really pissed off (and I have a hard time blaming them) if after a solid week they still aren't feeling any better. Plus, even the IDSA says that after 10 days treating with antibiotics is OK.

This was a send out to LabCorp/Quest from an UC site -- Most of what I run into is the "McDonald's" mentality -- patient has "researched" it (i.e. google search) and "knows" that they need an antibiotic after diagnosing themselves based on web Si/Sx --

I've probably ranted this before -- sometimes, I treat them like a colleague -- and slip into full academic institution attending mode and begin quoting Centor criteria, sensitivity/specificity, NNT, NNH figures of recent studies and then the various specifics re: pharyngitis causing organisms and ask them which study from the literature they had read since I wanted to refer to this and possibly change my practice. Usually, I get the "well, I just did a google search" ---

So, on a serious note: What sorts of OTC meds do people prescribe for pharyngitis/URI that actually work? and that are ok in the standard HTN/DM patient? I always tell them (thank you cabinbuilder) to go to the pharmacy, look down the aisle, reference their symptoms with the offerings and make a selection.....

 

[cabinbuilder]

This was a send out to LabCorp/Quest from an UC site -- Most of what I run into is the "McDonald's" mentality -- patient has "researched" it (i.e. google search) and "knows" that they need an antibiotic after diagnosing themselves based on web Si/Sx --

I've probably ranted this before -- sometimes, I treat them like a colleague -- and slip into full academic institution attending mode and begin quoting Centor criteria, sensitivity/specificity, NNT, NNH figures of recent studies and then the various specifics re: pharyngitis causing organisms and ask them which study from the literature they had read since I wanted to refer to this and possibly change my practice. Usually, I get the "well, I just did a google search" ---

So, on a serious note: What sorts of OTC meds do people prescribe for pharyngitis/URI that actually work? and that are ok in the standard HTN/DM patient? I always tell them (thank you cabinbuilder) to go to the pharmacy, look down the aisle, reference their symptoms with the offerings and make a selection.....

YW. I also throw in my "take 2 tsp vinegar straight weekly and go get some Chinese BBQ pork with HOT MUSTARD". Kills most viral pharyngitis and opens the sinuses pretty well.

 

[VA Hopeful Dr]

This was a send out to LabCorp/Quest from an UC site -- Most of what I run into is the "McDonald's" mentality -- patient has "researched" it (i.e. google search) and "knows" that they need an antibiotic after diagnosing themselves based on web Si/Sx --

I've probably ranted this before -- sometimes, I treat them like a colleague -- and slip into full academic institution attending mode and begin quoting Centor criteria, sensitivity/specificity, NNT, NNH figures of recent studies and then the various specifics re: pharyngitis causing organisms and ask them which study from the literature they had read since I wanted to refer to this and possibly change my practice. Usually, I get the "well, I just did a google search" ---

So, on a serious note: What sorts of OTC meds do people prescribe for pharyngitis/URI that actually work? and that are ok in the standard HTN/DM patient? I always tell them (thank you cabinbuilder) to go to the pharmacy, look down the aisle, reference their symptoms with the offerings and make a selection.....

Mucinex DM, Sudafed (the 12-hour kind you have to sign a contract for saying you won't make meth), and my previously mentioned sore throat cocktail.

Sudafed is fine short term in someone with well controlled HTN. If they aren't controlled, they get Afrin and a lecture to f/u with PCP for blood pressure management.

 

[cabinbuilder]

Today's quote:
ME "I'm going to send you home with a Z-Pak and some Codeine cough syrup".
PT: "Ok, but the only thing that cleared me up last time was antibiotics."
ME: "Well Z-Pak is antibiotics"
PT: "Oh, I never heard of that before".

Sigh........

 

[styphon]

Mucinex DM, Sudafed (the 12-hour kind you have to sign a contract for saying you won't make meth), and my previously mentioned sore throat cocktail.

Sudafed is fine short term in someone with well controlled HTN. If they aren't controlled, they get Afrin and a lecture to f/u with PCP for blood pressure management.

The treatments mentioned by us will, at most, improve symptoms and do nothing for the duration/length of infection. So your question above "what really works for sore throat?" is time, but no one wants to hear that.

Overlooking that key fact and instead focusing on making patients happy, I like to use Coricidin HBP is great for people with HTN as it will have no effect on BP. Robitussin also makes a low sugar brand of their cough syrup, which is good for diabetics. I will also use "tessalon perles" to help improve peoples satisfaction.

If they are "I don't take pills (yet usually demand abx)" you can recommend honey, tea, cough drops...

 

[VA Hopeful Dr]

The treatments mentioned by us will, at most, improve symptoms and do nothing for the duration/length of infection. So your question above "what really works for sore throat?" is time, but no one wants to hear that.

Overlooking that key fact and instead focusing on making patients happy, I like to use Coricidin HBP is great for people with HTN as it will have no effect on BP. Robitussin also makes a low sugar brand of their cough syrup, which is good for diabetics. I will also use "tessalon perles" to help improve peoples satisfaction.

If they are "I don't take pills (yet usually demand abx)" you can recommend honey, tea, cough drops...

I have found that there are 2 camps of patients with regards to tessalon, since by now most people have had them at least once. Its either a miracle drug or worthless, no real in between.

I love the honey, tea, cough drop trifecta - as I sit here with all 3 trying to stay at work despite this hacking cough.

I keep a jar of my mother's recipe for hot tea in the office with a print out of how to make it. I've had great response to that since I have patients try it before they leave, and wish the urgent care I worked at had a Keurig so I could do that there as well.

 

[JustPlainBill]

I have found that there are 2 camps of patients with regards to tessalon, since by now most people have had them at least once. Its either a miracle drug or worthless, no real in between.

I love the honey, tea, cough drop trifecta - as I sit here with all 3 trying to stay at work despite this hacking cough.

I keep a jar of my mother's recipe for hot tea in the office with a print out of how to make it. I've had great response to that since I have patients try it before they leave, and wish the urgent care I worked at had a Keurig so I could do that there as well.

I'm hesitant to give them my mother's recipe for hot tea guaranteed to cure cough ( or at least make you stop caring about it) --

From the northernmost part of Northern Germany in the days when PCN was in it's infancy -- the cure:

3/4 cup of hot tea
1/4 cup of a stiff shot of the best rum you can find.

drink 1 -2 cups of tea, get into bed and pile on the covers and sweat it out --

As I said, you either get "cured" or you don't care -- either way, win-win situation.

she also used to make me drink raw eggs with sugar (held off on the red wine that was also part of my Oma's elixir for sickness) whenever I was sick as a kid and feeling puny --

And then there was the nutbag Air Force pediatrician in Libya who recommended 1/2 bourbon, 1/2 coke syrup mixed in equal parts and given a teaspoon at a time to his patient's as a cough syrup --- My Dad spent a lot of time making sure the mixture was just right -- I'm now realizing why he had his smoking jacket on with a cigar in his hand while doing it, usually singing his favorite songs with a big smile on his face....

Again -- this is not medical advice and given as a historical hilarious footnote -- no warranties expressed or implied, your mileage may vary, all disclaimers apply.

 

[JustPlainBill]

Today's quote:
ME "I'm going to send you home with a Z-Pak and some Codeine cough syrup".
PT: "Ok, but the only thing that cleared me up last time was antibiotics."
ME: "Well Z-Pak is antibiotics"
PT: "Oh, I never heard of that before".

Sigh........

Dang it, Cabinbuilder -- you missed your opportunity -- I thought I trained you better --- should have told them it was the latest/greatest medical therapeutic release made from bat guano of the African fruit bat and had also been found to tighten facial wrinkles but only if taken in the moonlight, scantily clad while barking like a dog on all fours ---

 

[VA Hopeful Dr]

I'm hesitant to give them my mother's recipe for hot tea guaranteed to cure cough ( or at least make you stop caring about it) --

From the northernmost part of Northern Germany in the days when PCN was in it's infancy -- the cure:

3/4 cup of hot tea
1/4 cup of a stiff shot of the best rum you can find.

drink 1 -2 cups of tea, get into bed and pile on the covers and sweat it out --

As I said, you either get "cured" or you don't care -- either way, win-win situation.

she also used to make me drink raw eggs with sugar (held off on the red wine that was also part of my Oma's elixir for sickness) whenever I was sick as a kid and feeling puny --

And then there was the nutbag Air Force pediatrician in Libya who recommended 1/2 bourbon, 1/2 coke syrup mixed in equal parts and given a teaspoon at a time to his patient's as a cough syrup --- My Dad spent a lot of time making sure the mixture was just right -- I'm now realizing why he had his smoking jacket on with a cigar in his hand while doing it, usually singing his favorite songs with a big smile on his face....

Again -- this is not medical advice and given as a historical hilarious footnote -- no warranties expressed or implied, your mileage may vary, all disclaimers apply.

I absolutely swear by the Hot Toddy, but you can't tell patients to do that. Same way my wife's colic was cured by dipping her pacifier in a bottle of peach snappes - took 2 doses over 2 days, never had problems again - but can't tell parents to do that either.

 

[JustPlainBill]

I absolutely swear by the Hot Toddy, but you can't tell patients to do that. Same way my wife's colic was cured by dipping her pacifier in a bottle of peach snappes - took 2 doses over 2 days, never had problems again - but can't tell parents to do that either.

Throw in some Heino singing Rosamunde (Youtube it) and a raucous crowd of other revelers and you really won't care about anything else -- you're cured ----

 

[cabinbuilder]

Dang it, Cabinbuilder -- you missed your opportunity -- I thought I trained you better --- should have told them it was the latest/greatest medical therapeutic release made from bat guano of the African fruit bat and had also been found to tighten facial wrinkles but only if taken in the moonlight, scantily clad while barking like a dog on all fours ---

Sigh... Sorry I'm such a failure. I will try to do better next time. 🙂

 

[TorMed]

I'm hesitant to give them my mother's recipe for hot tea guaranteed to cure cough ( or at least make you stop caring about it) --

From the northernmost part of Northern Germany in the days when PCN was in it's infancy -- the cure:

3/4 cup of hot tea
1/4 cup of a stiff shot of the best rum you can find.

drink 1 -2 cups of tea, get into bed and pile on the covers and sweat it out --

As I said, you either get "cured" or you don't care -- either way, win-win situation.

she also used to make me drink raw eggs with sugar (held off on the red wine that was also part of my Oma's elixir for sickness) whenever I was sick as a kid and feeling puny --

And then there was the nutbag Air Force pediatrician in Libya who recommended 1/2 bourbon, 1/2 coke syrup mixed in equal parts and given a teaspoon at a time to his patient's as a cough syrup --- My Dad spent a lot of time making sure the mixture was just right -- I'm now realizing why he had his smoking jacket on with a cigar in his hand while doing it, usually singing his favorite songs with a big smile on his face....

Again -- this is not medical advice and given as a historical hilarious footnote -- no warranties expressed or implied, your mileage may vary, all disclaimers apply.

Eastern Austria:

Tea with brandy, honey, raw egg and something that tasted like nutmeg. In a tall glass brought to you in bed.