Combating antibiotic resistance

Discussion in 'Emergency Medicine' started by WilcoWorld, 09.20.14.

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  1. WilcoWorld

    WilcoWorld Senior Member 10+ Year Member

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    The White House has released a plan to combat antibiotic resistance. Frontline details it here. I am happy to see increased funding for research and incentives for new antibiotic R&D. However I am as angry as I am unsurprised to see that they are happy to put the screws to docs while being essentially hands-off with Agriculture. Yes, doctors should be stewards of antibiotics, but to claim that and to be ramping-up government focus on patient satisfaction is to speak out of both sides of your mouth. Furthermore, there is evidence that livestock use of antibiotics is a greater source of resistance than healthcare-related uses. But of course, Washington doesn't want to step on Big Agriculture's toes.

    Maybe I should write my senator, maybe I should write the president, but all I really wanna do is [face palm].
     
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  3. WilcoWorld

    WilcoWorld Senior Member 10+ Year Member

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    From the above-linked article:
    • Incentivize the health care industry to use antibiotics more carefully. Hospitals have become reservoirs of resistant bacteria and the science advisers suggest that the government could make a big difference by using federal reimbursement for Medicare and Medicaid to force better stewardship of antibiotics. This means making sure that doctors curb overuse of antibiotics, a leading cause of resistance.
    • Antibiotics are also widely used in American agriculture and more needs to be done to curb their use in raising farm animals. The science advisers suggest that the government seek “substantial changes” in the use of antibiotics on the farm. However, they don’t suggest changes beyond the measures already announcedby the Food and Drug Administration, which has asked pharmaceutical companies to voluntarily phase out the use of the antibiotics for promoting growth in farm animals over three years and put antibiotics under the supervision of a veterinarian. The drugs would still be permitted to be added routinely to feed for cattle, swine and poultry for the purpose of disease prevention, which critics have said is still at low doses that would likely drive resistance.
    Translation: we can tell doctors what to do, but we can only ask corporations to try to phase out their plasmid farms.
     
  4. EMIM2011

    EMIM2011 5+ Year Member

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    We know what THAT means...
     
  5. Spinach Dip

    Spinach Dip Delicious with nachos 2+ Year Member

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    Translation: One of our bean-counters thought we could save some money by decreasing how much medicare/medicaid/etc pay for antibiotics. Of course, we are doing this because it is for the good of the people and not because we are $17T in debt and engaged in an elaborate game of 3-card monte. To prove how concerned we truly are for the good of the people, we will be increasing funding for R&D into new antibiotics (and we are already planning on phasing that out in 2 years, fyi).



    :bang:
     
  6. Birdstrike

    Birdstrike 5+ Year Member

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    It's politics 101. If you pay attention to politics you'll see this repeated ad nauseum:

    Get elected to fix problem. Create solution which worsens problem. Run for re-election to "fix" problem which was made worse by "solution" to original problem. New solution again worsens original problem. Next election: repeat cycle of promising solutions, which worsen problem, which creates perfect issue for next campaign cycle of promised "fixes."

    Don't ever vote for politicians that promise to ever "fix" anything. You're just voting for them to worsen the situation with the unwritten agreement that you'll again vote for them in the next election cycle to fix their "solution."
     
    Last edited: 09.21.14
  7. GeneralVeers

    GeneralVeers Globus Hystericus 10+ Year Member

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    Even better we are caught in a Catch-22. The government will not reimburse us if we give anbiotics for certain conditions, however if we don't give antibiotics our patient satisfaction scores will be low and the government won't reimburse us for "quality" reasons.

    Welcome to centrally-planned health care
     
  8. Arcan57

    Arcan57 Junior Member 10+ Year Member

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    No abx =/ low satisfaction scores. It just means it's harder to do (ie takes longer) which means we won't see as many patients during a shift which means less productivity which means generating fewer bills to the government. See, no need to be hyperbolic.
     
  9. Evisju7

    Evisju7

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    Disregarding the last two points for now, the other points are decent.
    Improving research and encouraging new antibiotics to be created? Sounds good.
    Forcing docs to do anything, via government? Awful.
    Those does anyone disagree that antibiotics are often overprescribed?
     
  10. Evisju7

    Evisju7

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    *though
     
  11. GeneralVeers

    GeneralVeers Globus Hystericus 10+ Year Member

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    Probably 75% of antibiotics are prescribed inappropriately. Either they are given for things which largely do not benefit (Strep throat, otitis media, rhinitis, sinusitis), or the incorrect antibiotic is prescribed (Keflex for skin infections).
     
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  12. styphon

    styphon Senior Member 10+ Year Member

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    -Remove satisfication surveys
    -Tort reform

    I bet abx use drops 50% for outpt/ER visits that don't require admission.
     
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  13. Evisju7

    Evisju7

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    Yes. You make an excellent point
     
  14. styphon

    styphon Senior Member 10+ Year Member

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    I would disagree, instead- I see coworkers, ER reports, other facilities prescribe antibiotics for COLDS, confirmed VIRAL pharyngitis, sinusitis that lasts 1-2 days, bronchitis in a healthy adult, etc.

    Also abx in strept pharyngitis reduce the incidence of rheumatic heart disease.
     
  15. Birdstrike

    Birdstrike 5+ Year Member

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    Medicine is being replaced by consumerism. "Patient Centered" Care = "The customer is always right" = Maximal dollars for the Government-Hospital-Insurance Industrial Complex

    I predict a day when a patient will have the legal "right" to choose their diagnosis, and appeal or override one they don't agree with. Ultimately, the patient will choose the diagnosis based on their research, Google algorithms or other whims, then the physician will be obligated to sign off on it, with the burden of proof on him to overrule their "inalienable right" to choose their own diagnosis and treatment, as a consumer. Are we that far off from this now?
     
    Last edited: 09.29.14
  16. MSmentor018

    MSmentor018 Hooah! SDN Advisor 7+ Year Member

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    not at all...once the makers of webmd streamline their keyboard to diagnosis time to less than 1 min then patients in triage can start ordering off a menu on what they want and when they want it done, then wait for the results while having a smoke and a big mac for lunch across the street
     
  17. Arcan57

    Arcan57 Junior Member 10+ Year Member

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    I think you mean don't reduce?
     
  18. styphon

    styphon Senior Member 10+ Year Member

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    no, i meant as I said - treatment of strept throat lowers the change of rheumatic heart disease - which has been proven in the 50s:

    The role of the streptococcus in the pathogenesis of rheumatic fever.
    CATANZARO FJ, STETSON CA, MORRIS AJ, CHAMOVITZ R, RAMMELKAMP CH Jr, STOLZER BL, PERRY WD
    Am J Med. 1954;17(6):749.
    Prevention of rheumatic fever; treatment of the preceding streptococcic infection.
    DENNY FW, WANNAMAKER LW, BRINK WR, RAMMELKAMP CH Jr, CUSTER EA
    J Am Med Assoc. 1950;143(2):151.

    You may be confusing treatment causing no change in disease incidince with PSGN or PANDAS.
     
  19. Arcan57

    Arcan57 Junior Member 10+ Year Member

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    Ok, that paper was good evidence that antibiotics decrease the incidence of RF in patients with strep throat that lived in the 1950s. There has been at least one much larger cohort study since that showed that rheumatic fever isn't really a thing anymore, at least in developed nations. The WHO's map of disease incidence from 1990 onward shows a big blank spot over the US and pretty much everywhere on the continent except Nicaragua and Cuba. So if you want to give abx to prevent a disease that doesn't exist in our country, that's fine. But if you think you're benefiting the patient then you'd be incorrect.
     
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  20. Apollyon

    Apollyon Screw the GST Lifetime Donor 10+ Year Member

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    I just had a patient 2 days ago whose sibling developed rheumatic fever, here in the US, less than 2 years ago. Per Mom, it was because of misdiagnosis x2 in our (before I was there) rural ED. However, for this child, Mom didn't demand abx (or anything else) - she just asked if we could test for strep, which I did gladly.
     
  21. Apollyon

    Apollyon Screw the GST Lifetime Donor 10+ Year Member

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    Educate me on that. I asked an ortho hand fellow about that (and I said, "A guy online says that Keflex doesn't work for skin infections"), and the fellow told me that it does, and that they use it frequently. Thank you.
     
  22. WilcoWorld

    WilcoWorld Senior Member 10+ Year Member

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    Me: "What do you use to treat wound infections?"
    The best Orthopedist I know: "An ID consult."
     
  23. VA Hopeful Dr

    VA Hopeful Dr Senior Member 10+ Year Member

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    Its fantastic, so long as you're pretty sure its not MRSA (obvious run of the mill cellulitis or for culture proven MSSA abscess). What I've taken to doing for cellulitis is both keflex and bactrim - bactrim in case of MRSA and keflex because its far better at strep and MSSA than bactrim.
     
  24. VA Hopeful Dr

    VA Hopeful Dr Senior Member 10+ Year Member

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    Didn't I read somewhere that the NHS in the UK is about to stop treating strep pharyngitis because of this second study? If so, great opportunity to see whether or not the first world needs to treat it.
     
  25. Birdstrike

    Birdstrike 5+ Year Member

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    You know why the disease doesn't exist? Because all you have to do to get a antibiotic in this country for anything is to fart. Or think about farting. Or just.....breathe. Or just show up and demand one for your....anything. Everyone with strep gets their abx (plus 20,000,000 people that don't need them). Maybe we shouldn't vaccinated against childhood rubella, mumps, and Hib meningitis, because those are rare?

    Oh, wait... They're rare because we do vaccinate against them.
     
    Last edited: 09.29.14
  26. alpinism

    alpinism Give Em' the Jet Fuel Bronze Donor 5+ Year Member

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    Abx in Strep throat absolutely does more harm than good.

    There really is no excuse to use them in any patient unless they're immigrants or you're in the middle of an ongoing rheumatic fever epidemic.

    Looking at the numbers:

    About 14 million per year sore throat visits in the US.

    About 80-85% of these are viral pharyngitis.

    Nothing new or exciting. Yet.

    Now, Streptococcal pharyngitis constitutes the remainder of cases = about 15% of total sore throat visits.

    Thus, about 2 million strep throat visits per year in the US.

    So, on to acute rheumatic fever (ARF):

    Incidence from the CDC in 1992: 0.1/100,000 or 1 in 1,000,000

    Why 1992 do you ask?

    Because they stopped tracking it in 1992 because it stopped being a public heath threat

    And by the way, the incidence of ARF here in the US has been decreasing since the 1800s, long before we started using Abx.

    So, if the incidence still 1/100,000,000 then thats about 300 cases/year of ARF

    But, only 30% of ARF patients go to the doctor, thus we only see about 100/year

    Thus, 2 million strep throat visits per year / 100 ARF visits per year = 1 in 20,000 strep throat cases go on to become ARF

    Now remember, Abx don’t prevent ARF, they only reduce your risk by 50%.

    Thus, with a relative risk reduction (RRR) of 50%, your Number Needed to Treat (NNT) for ARF is now 40,000

    Or in layman’s terms, you need to treat 40,000 cases of strep throat to prevent 1 case of ARF.

    Now lets compare that to some adverse effects of Abx for strep throat:

    about 1 in 5 patients get diarrhea = Number Needed to Harm (NNH) of 5

    about 1 in 20 patients get a rash = NNH of 20

    about 1 in 10,000 patients have a fatal anaphylactic reaction = NNH of 10,000

    And this one most people don’t know about:

    Because you don’t adequately develop protective antibodies when treated with Abx compared to placebo, patients treated with Abx have an 18% absolute higher risk of getting another strep throat. Not Relative, Absolute. Thus, patients treated with Abx now have a 1 in 6 chance of getting another strep throat which of course also increases your chances of getting ARF = NNH of 6


    Now, taking all those above numbers into account,

    For every 1 ARF you prevent, you cause:

    8,000 diarrheas

    7,000 strep throats

    2,000 rashes

    and kill 4 people from anaphylactic reactions



    ...Stay thirsty my friends.

    Sources:
    1. http://smartem.org/podcasts/treatment-acute-pharyngitis
    2. https://www.emrap.org/episode/2013/february/penicillinin
    3. http://www.epmonthly.com/department...antibiotics-for-strep-do-more-harm-than-good/
    4. http://www.epmonthly.com/department...iotics-for-strep-addressing-readers-concerns/
     
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  27. Birdstrike

    Birdstrike 5+ Year Member

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    Jedi, the force is strong within you. Pure of heart you are.
     
    Last edited: 09.29.14
  28. Arcan57

    Arcan57 Junior Member 10+ Year Member

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    Boss.
     
  29. TooMuchResearch

    TooMuchResearch i'm goin' to Kathmandu... Lifetime Donor 7+ Year Member

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    Great, now I'll have to use SDN as a reference when my attending asks why I don't want to treat strep. "What, podcasts aren't hip enough anymore? You're referencing online message boards?"

    You know the problem though, right? People expect antibiotics. Other doctors expect antibiotics. And when you get that 1/1000000 case, bam, plaintiff's attorney expects antibiotics.

    Just like they expect you to admit the patient with very high BP and a non-concerning headache.

    Just like they expect you to...
     
  30. GeneralVeers

    GeneralVeers Globus Hystericus 10+ Year Member

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    Would I harm 2,000 patients with antibiotics just to keep my job and lifestyle? Yes.
     
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  31. styphon

    styphon Senior Member 10+ Year Member

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    Now this is useful..

    My problem is, I have such difficulty over the 85% with viral pharnygitis (I have +20 complaints regarding not giving abx to viral pharnygitis this year alone) that I cannot begin to focus on not treating strept.
     
  32. Arcan57

    Arcan57 Junior Member 10+ Year Member

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    As I'm sure you're aware, your analogy that wide spread antibiotic use for mild, self-limited disease = vaccines doesn't quite hold up. Unless you're referencing the smallpox vaccine, which was too dangerous to give to the general population given the baseline incidence of the disease compared to side-effects but unless I'm mistaken still had a better safety profile then antibiotics.

    If you're getting that many complaints, you may want to look at your scripting for how you describe the illness and why you're not giving antibiotics. I set-up the non-antibiotic use up as I'm doing my physical exam. I talk about the things I'm not seeing (I don't say throat looks red, I tell them I don't see a strep throat, I don't hear a pneumonia, etc) and then I launch into the "playing the odds this is a virus" speech, that we look for signs of a bacterial infection that would be helped with antibiotics and haven't found them, that they don't need to worry about the fever height as long as kid looks good, is well-hydrated, and isn't having increased WOB, and that it' usually going to last ~10days. Combining that with instructions to delay filling an amox Rx for otitis media for 2 days and giving an auralgan Rx has netted me exactly zero complaints regarding antibiotic non-use in the last two years. Now if you want to argue I'm chickening out by giving them the delayed abx Rx at all? Yes, yes I am.
     
  33. WilcoWorld

    WilcoWorld Senior Member 10+ Year Member

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    This is my biggest peeve - I see the patient in the ED, go through things much as Arcan describes above, and a couple days later the Peds/FM/UC clinic sees the now afebrile kid with a negative strep test in follow up and Rx's Augmentin for otitis media...
     
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  34. Birdstrike

    Birdstrike 5+ Year Member

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    Yes. Then they're the hero for diagnosing what the ER doctor "missed" which allowed them to get worse, only to be saved by their top notch PCP who "knows them better than anyone else" and that a z-pak/levaquin/amox/______(insert fave placebo) is what "I always need to get better." Then the comment comes from PCP hero, about how the ER always throws "useless antibiotics" at everyone without carefully making a diagnosis. It's classic. You can't win.
     
    Last edited: 09.30.14
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  35. styphon

    styphon Senior Member 10+ Year Member

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    I do a similar approach for delayed abx for mild-mod otitis media, which most of the time has gotten me less angry patients - although once someone did throw a script at me and storm out because of this tactic.

    But I have tried setting up pt's during the physical exam "tonsils are normal size, no redness, no discharge" "I don't feel any lymphadenopathy" then I started adding a speech about how strept can be predicted by using history and physical findings, and that they are close to 0% of having strept, and they have a virus and abx won't be helpful and possibily dangerous b/c side effects, we also have posters in every room "ANTIBIOTICS DO NOT WORK AGAINST VIRUSES" - yet I still get complaints. These are not kids/parents - these are usually people 25 y/o or older white middle upperclass/upperclass adults, it was actually much easier in the inner city to deny abx without a violent response.

    There are so many other things I would like to change to make my practicing more evidence based - but these people with viral pharyngitis just suck the life out of me, get me poor satisfaction scores, and bog down my day.
     
  36. GeneralVeers

    GeneralVeers Globus Hystericus 10+ Year Member

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    The problem is that hospital admins and medical directors are required to take every B.S. complaint seriously. We could fix the problem by simply ripping up and ignoring every complaint by a patient who wants an inappropriate test/treatment.
     
  37. RustedFox

    RustedFox We're all stars now. In the GOAT RODEO. 7+ Year Member

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    1.) Location: New York... there's half of your problem, right there. (Former denizen of New Jersey)

    2.) The real deal here is 'giving' the apes 'something' to 'help' the sore throat.... it is that gesture that specifically will "satisfy" them. Try steroids, try oral lidocaine, try.. whatever.
     
  38. TooMuchResearch

    TooMuchResearch i'm goin' to Kathmandu... Lifetime Donor 7+ Year Member

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    Parenteral steroids and a good conversation for the win?
     
  39. EMIM2011

    EMIM2011 5+ Year Member

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    I tell them antibiotics will hurt them, because they kill the "good" bacteria and put Little Johnnie at risk for a bad super bug. Works 100%
     
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  40. Arcan57

    Arcan57 Junior Member 10+ Year Member

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    For non-toilet trained kids, the specter of diarrhea is usually also effective. Having to change 20+ diapers a day is horrific, especially if it's a toddler.
     
  41. VA Hopeful Dr

    VA Hopeful Dr Senior Member 10+ Year Member

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    "Your in-office strep test was negative. The test isn't perfect, so we're sending to the hospital lab for confirmation. If it turns out to be strep, we'll treat it. If not, here is what I do when I get sore throats <vicks chloroseptic and milkshakes>".

    I didn't used to do cultures at all when I was in a regular FP office, but at urgent care I find I do more of them since the patients don't seem to really trust me.
     

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