So my attending is WAY wrong in managing this patient

[cleverwebb]

Hey everyone,

So I have a problem with my attending being super-nice yet rather stubborn. He's completely mismanaging a culture-negative subacute infective endocarditis case; he's basically WHIMSICALLY prescribing the guy antibiotics which at one point HAPPENED to follow the AHA guidelines, but it's become a ludicrous cocktail of various "cins" at this point. It's frustrating. The team keeps questioning his approach, but, big shock that nothing happens. All this is taking place at this public hospital we have to rotate in for a month. SO I just had a nice long "unofficial" conversation with an ID attending at the university hospital, and she COMPLETELY disagrees with our current approach. Incidentally, I completely agree with her, and I'm sure my team will too when I tell them about this tomorrow.

What should I do? The attending's wildly experimental regimens aren't even working.

Ideas, anyone?

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[VA Hopeful Dr]

Hey everyone,

So I have a problem with my attending being super-nice yet rather stubborn. He's completely mismanaging a culture-negative subacute infective endocarditis case; he's basically WHIMSICALLY prescribing the guy antibiotics which at one point HAPPENED to follow the AHA guidelines, but it's become a ludicrous cocktail of various "cins" at this point. It's frustrating. The team keeps questioning his approach, but, big shock that nothing happens. All this is taking place at this public hospital we have to rotate in for a month. SO I just had a nice long "unofficial" conversation with an ID attending at the university hospital, and she COMPLETELY disagrees with our current approach. Incidentally, I completely agree with her, and I'm sure my team will too when I tell them about this tomorrow.

What should I do? The attending's wildly experimental regimens aren't even working.

Ideas, anyone?

Talk to your residents. Find the current guidelines for the exact problem the patient has, print them out, and give them to your residents when you talk about your discussion with the ID attending. Let them use what you're gathered to try and change the patient's management.

 

[SLUser11]

Hey everyone,

So I have a problem with my attending being super-nice yet rather stubborn. He's completely mismanaging a culture-negative subacute infective endocarditis case; he's basically WHIMSICALLY prescribing the guy antibiotics which at one point HAPPENED to follow the AHA guidelines, but it's become a ludicrous cocktail of various "cins" at this point. It's frustrating. The team keeps questioning his approach, but, big shock that nothing happens. All this is taking place at this public hospital we have to rotate in for a month. SO I just had a nice long "unofficial" conversation with an ID attending at the university hospital, and she COMPLETELY disagrees with our current approach. Incidentally, I completely agree with her, and I'm sure my team will too when I tell them about this tomorrow.

What should I do? The attending's wildly experimental regimens aren't even working.

Ideas, anyone?

My suggestion is to know your role.

Once you get actual experience to go with your confidence, you'll find that most of what doctors do is not evidence-based, or is based on level 3 or 4 evidence at best. The actual practice of community medicine is a lot different than hypothetical textbook medicine.

Do I wish this weren't the case? Of course. But it's hard to teach old dogs new tricks, and I don't think you should risk your neck unless the doctor's approach is going to seriously harm the patient.

You feel like a super-smart hero, but you're going to accidentally look like an @ss if you do what you are planning to do. Choose your battles. Trust me.

 

[silas2642]

I would be really careful about this one. I think that approaching one of your more experienced residents and asking very tactfully, "I was reading the other night about pt. x, and it seems to be accepted that in this case we would usually use x, y, and z antibiotics. I was wondering why Dr. So and so chose a different regimen?"

You may even be able to ask the attending this, assuming he is open to discussion of the logic behind his decisions. You may really learn something new or you may actually be right, and if you are at least you've said your peace.

 

[MattD]

Hey everyone,

So I have a problem with my attending being super-nice yet rather stubborn. He's completely mismanaging a culture-negative subacute infective endocarditis case. The team keeps questioning his approach.

What should I do? The attending's wildly experimental regimens aren't even working.

Ideas, anyone?

I highlighted the important part for you. It is entirely possible that you are right about this case. However, from what you have said it sounds like the residents on your team also disagree with the attending, and have said so. This fight is over for you. If the residents cannot convince the attending, you sure as hell won't be able to. While I commend your desire to stand up for your patient, as SLU said, you have to pick your battles. At this point I wouldn't even ask the attending 'to explain the logic of x vs. y treatment', as another poster mentioned doing. You've become emotionally involved in the argument and will almost certainly make an ass of yourself. You are lowest on the totem pole, if you speak out of turn you WILL at some point get hurt. If you simply MUST risk your fledgling career this way, you should at least do so in a situation where you can actually make a difference in a patient's life

 

[ZagDoc]

Agree with the responses. Ultimately, nothing you can do as a medical student but present evidence and tactfully offer suggestions. Ultimately, he's the one legally responsible for the care delivered. This is one of those battles you just don't pick.

But you take the lesson with you when you go on to practice yourself.

 

[thechad]

Ummm, what is the treatment for culture neg endocarditis? HACEK rx is ampicillin + aminoglycoside, and doxycycline for the other organisms, right? I couldn't find the new AHA guidelines you were talking about, do you have a link so I can read them? Thanks!

 

[Knicks]

ooops, n/m

 

[TANSTAAFL]

Is this the Cocktail you refer to? I've yet to start med school, but interested nonetheless.

(Circulation. 2005;111:e394-e434.)
© 2005 American Heart Association, Inc.
AHA Scientific Statement

Infective Endocarditis

Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: Endorsed by the Infectious Diseases Society of America

TABLE 14. Therapy for Culture-Negative Endocarditis Including Bartonella Endocarditis

Native valve:
Ampicillin
Gentamicin sulfate
Vancomycin
Ciprofloxacin

Pediatric dose: ampicillin-sulbactam 300 mg/kg per 24 h IV in 4–6 equally divided doses; gentamicin 3 mg/kg per 24 h IV/IM in 3 equally divided doses; vancomycin 40 mg/kg per 24 h in 2 or 3 equally divided doses; ciprofloxacin 20–30 mg/kg per 24 h IV/PO in 2 equally divided doses

 

[Maybeknot]

would be really careful about this one. I think that approaching one of your more experienced residents and asking very tactfully, "I was reading the other night about pt. x, and it seems to be accepted that in this case we would usually use x, y, and z antibiotics. I was wondering why Dr. So and so chose a different regimen?"

This is excellent advice. Another suggestion would be to -- TACTFULLY -- offer to present something on the latest literature regarding the treatment of this condition. Search pubmed (or use UpToDate as a starting point) and photocopy the best studies and hand them out to everyone on rounds.

You can hopefully do this in a way that makes it sound like you're very interested in the *topic* but not in a way that's making you imply that the attending is mistreating the patient. A fine line, to be sure.

Best of luck.

 

[cpants]

Be careful, because the most likely scenario is that you are wrong and the attending is right (or at least has a science-based argument for his approach). Remember, the guy has been doing this for a long time and has probably treated this condition several times before. Do you really think he is just picking drugs at random? It's possible, but not likely. If you really think he is wrong, I would just simply ask him how he selected the antibiotics you are using to treat the patient.

Maybe there are factors you are not considering. I can think of lots of scenarios where the guidelines might not be followed (allergies, he is using different guidelines, availability of medications, pt's insurance coverage, pt's preference, status of pt's other organs, previous culture results, local susceptibility data, suspicion of other diagnoses on the differential, many other reasons).

 

[cleverwebb]

I highlighted the important part for you. It is entirely possible that you are right about this case. However, from what you have said it sounds like the residents on your team also disagree with the attending, and have said so. This fight is over for you. If the residents cannot convince the attending, you sure as hell won't be able to. While I commend your desire to stand up for your patient, as SLU said, you have to pick your battles. At this point I wouldn't even ask the attending 'to explain the logic of x vs. y treatment', as another poster mentioned doing. You've become emotionally involved in the argument and will almost certainly make an ass of yourself. You are lowest on the totem pole, if you speak out of turn you WILL at some point get hurt. If you simply MUST risk your fledgling career this way, you should at least do so in a situation where you can actually make a difference in a patient's life

Yup, my interns and residents don't agree with him at all. When I suggested that I check with one of the attendings at the university hospital, they loved the idea. And our attending KNOWS about the guidelines--see, as soon as I was assigned to the case, I printed out the AHA stuff; I discussed them with the team, then we all discussed them with the attending. He even LOOKED at them, acknowledged that the patient was currently taking an approved regimen (vanco + cipro + genta, even though, sidebar, the patient was started on this BEFORE trying ampli/genta first, and he has no b-lactam allergy), and STILL insisted on changing the regimen to something of his own creation. Twas a fruitless talk.

...which is when I spoke to the other doc. I reported my findings back to my chief and interns. The chief said that she'll suggest the other attending's opinion to him herself when she meets with him tomorrow, WITHOUT letting him know where we got our intel from. She said she'll talk it out with him in a very academic "hey, so i was reading up on this, what do you think" kind of way.

Hopefully, if the patient's fever doesn't break on ampicillin, the doctor'll give and try something to cover atypicals.

 

[cpants]

Yup, my interns and residents don't agree with him at all. When I suggested that I check with one of the attendings at the university hospital, they loved the idea. And our attending KNOWS about the guidelines--see, as soon as I was assigned to the case, I printed out the AHA stuff; I discussed them with the team, then we all discussed them with the attending. He even LOOKED at them, acknowledged that the patient was currently taking an approved regimen (vanco + cipro + genta, even though, sidebar, the patient was started on this BEFORE trying ampli/genta first, and he has no b-lactam allergy), and STILL insisted on changing the regimen to something of his own creation. Twas a fruitless talk.

...which is when I spoke to the other doc. I reported my findings back to my chief and interns. The chief said that she'll suggest the other attending's opinion to him herself when she meets with him tomorrow, WITHOUT letting him know where we got our intel from. She said she'll talk it out with him in a very academic "hey, so i was reading up on this, what do you think" kind of way.

Hopefully, if the patient's fever doesn't break on ampicillin, the doctor'll give and try something to cover atypicals.

What antibiotics is the patient on now? Changed from what? How is the patient doing?

 

[cleverwebb]

Ummm, what is the treatment for culture neg endocarditis? HACEK rx is ampicillin + aminoglycoside, and doxycycline for the other organisms, right? I couldn't find the new AHA guidelines you were talking about, do you have a link so I can read them? Thanks!

Sure. TANSTAAFL posted the Cx -ve ones, but here's the link. If you can't open it, try searching for infective endocarditis via bestpractice (if your school has that database) and go to the guidelines through there.

http://circ.ahajournals.org/cgi/content/full/111/23/3167

 

[Rendar5]

Be very very very very very careful questioning your attendings. You do not know the local resistance patterns, you do not know the attending's experience withother medications, you have not treated this as many times as the attending, and I don't know that you have any evidence that his cocktail is less effective than "standard of care" nor any evidence that this cocktail is more detrimental to the patient's well-being.

There are 7 ways to do anything in medicine and 6 of them are correct, as a very wise attending once told me.

Unless you are sure that this is the one incorrect method that is going to kill the patient, I suggest you take heed stop working yourself into a frenzy of second-guessing. While you might not get burned this time, you WILL get burned with this behavior in the future.

 

[cleverwebb]

What antibiotics is the patient on now? Changed from what? How is the patient doing?

He's on ampi/sulbactam + vanco + genta, changed from vanco + cipro + genta 2 days ago. The patient is still febrile, but is otherwise doing fine. I scheduled a repeat TEE for him for tomorrow to check on the vegetation (we couldn't see it on a TTE, and they had extensive fights with the attending to get him to let us do the TEE the first time because he didn't think it would be "high yield." It showed aortic valve vegetations, 0.8 cm in size).

Anyway, his reasoning is that ampi/sulbactam will cover anaerobes, as the patient has a dental abscess...but anaerobes are NOT a cause of SBE. And keeping on vanco is really unwise and useless at this point--it's something you'd only use for empiric rx if you suspect your patient is at a high risk for MRSA. Plus, to TREAT culture negative endocarditis, you don't START with vanco/cipro unless the patient is allergic to b-lactams. I posted the AHA link in my prev post, if you're interested.

It really may just be my overzealous third-yearness, but it feels like he's messing up and won't admit to it.

I know I know next to nothing at this point in my career, but it's not like I ever planned on SCOLDING the guy outright. If the other attending I spoke to agreed with his approach, we'd have all probably dropped it. But she didn't--she shared our opinion (and I'd only given her the facts very, VERY objectively so as not to sway her judgement one way or the other).

Seriously now, I HOPE my chief has a break through with him tomorrow while coyly suggesting something else.

 

[Rendar5]

He's on ampi/sulbactam + vanco + genta, changed from vanco + cipro + genta 2 days ago. The patient is still febrile, but is otherwise doing fine. I scheduled a repeat TEE for him for tomorrow to check on the vegetation (we couldn't see it on a TTE, and they had extensive fights with the attending to get him to let us do the TEE the first time because he didn't think it would be "high yield." It showed aortic valve vegetations, 0.8 cm in size).

Anyway, his reasoning is that ampi/sulbactam will cover anaerobes, as the patient has a dental abscess...but anaerobes are NOT a cause of SBE. And keeping on vanco is really unwise and useless at this point--it's something you'd only use for empiric rx if you suspect your patient is at a high risk for MRSA. Plus, to TREAT culture negative endocarditis, you don't START with vanco/cipro unless the patient is allergic to b-lactams. I posted the AHA link in my prev post, if you're interested.

It really may just be my overzealous third-yearness, but it feels like he's messing up and won't admit to it.

I know I know next to nothing at this point in my career, but it's not like I ever planned on SCOLDING the guy outright. If the other attending I spoke to agreed with his approach, we'd have all probably dropped it. But she didn't--she shared our opinion (and I'd only given her the facts very, VERY objectively so as not to sway her judgement one way or the other).

Seriously now, I HOPE my chief has a break through with him tomorrow while coyly suggesting something else.

So he started with a regimen suggested for patients with a viable back-up regimen. Is this going to have a major outcome difference? Right now it sounds like you're getting worked up because this attending isn't doing things based on AHA guidelines, which is not the only way of going about things.

In addition he's changing the regimen to take into account a second infection that the patient is known to have. There are many different different ways to handle dental abscesses, this is one.

Neither is a method I would've chosen, but there's more than one way to skin a cat. The only question you need to answer when dealing with someone treating a patient completely differently from how you would treat them is: is his approach going to cause death or disability for the patient whereas mine will not. If your answer is "I'm not sure as I don't have information showing a difference in rates of death or disability but I think it's wrong still", then move on.

 

[cpants]

He's on ampi/sulbactam + vanco + genta, changed from vanco + cipro + genta 2 days ago. The patient is still febrile, but is otherwise doing fine. I scheduled a repeat TEE for him for tomorrow to check on the vegetation (we couldn't see it on a TTE, and they had extensive fights with the attending to get him to let us do the TEE the first time because he didn't think it would be "high yield." It showed aortic valve vegetations, 0.8 cm in size).

Anyway, his reasoning is that ampi/sulbactam will cover anaerobes, as the patient has a dental abscess...but anaerobes are NOT a cause of SBE. And keeping on vanco is really unwise and useless at this point--it's something you'd only use for empiric rx if you suspect your patient is at a high risk for MRSA. Plus, to TREAT culture negative endocarditis, you don't START with vanco/cipro unless the patient is allergic to b-lactams. I posted the AHA link in my prev post, if you're interested.

It really may just be my overzealous third-yearness, but it feels like he's messing up and won't admit to it.

I know I know next to nothing at this point in my career, but it's not like I ever planned on SCOLDING the guy outright. If the other attending I spoke to agreed with his approach, we'd have all probably dropped it. But she didn't--she shared our opinion (and I'd only given her the facts very, VERY objectively so as not to sway her judgement one way or the other).

Seriously now, I HOPE my chief has a break through with him tomorrow while coyly suggesting something else.

What is the guy's culture history, and did he receive ABX prior to culture?

 

[cpants]

So he started with a regimen suggested for patients with a viable back-up regimen. Is this going to have a major outcome difference? Right now it sounds like you're getting worked up because this attending isn't doing things based on AHA guidelines, which is not the only way of going about things.

In addition he's changing the regimen to take into account a second infection that the patient is known to have. There are many different different ways to handle dental abscesses, this is one.

Neither is a method I would've chosen, but there's more than one way to skin a cat. The only question you need to answer when dealing with someone treating a patient completely differently from how you would treat them is: is his approach going to cause death or disability for the patient whereas mine will not. If your answer is "I'm not sure as I don't have information showing a difference in rates of death or disability but I think it's wrong still", then move on.

I have to agree with you. The regimen isn't really unreasonable. By the OP's insistence on intervening I was expecting him to have prescribed PO penicillin or something.

 

[cpants]

Patients should be classified into 1 of 2 groups (provided the reason for negative blood cultures is determined not to be inadequate laboratory techniques) when choice of empirical therapy is considered. One group includes patients who received antibiotic therapy before collection of blood cultures. For those with acute clinical presentations of native valve infection, coverage for S aureus should be provided as outlined in the section on the treatment of proven staphylococcal disease. For patients with a subacute presentation, coverage of S aureus, viridans group streptococci, and enterococci should be given. Therapy for the HACEK group of organisms also should be considered. One treatment option could include 3 g IV ampicillin-sulbactam every 6 hours combined with gentamicin 1 mg/kg IV or intramuscularly every 8 hours.

From the AHA guidelines you posted above under the Culture-negative heading. With the amp/sulbactam and genta the guy is covering all of the most likely organisms for this patient. He most likely wants to cover MRSA as well, because he has suspicion, he knows the guy had antibiotics prior to cx or because he just wants to be safe.

 

[JimmyShakerDay]

Anyway, his reasoning is that ampi/sulbactam will cover anaerobes, as the patient has a dental abscess...but anaerobes are NOT a cause of SBE.

False. Anaerobes do cause endocarditis. What are you making that claim based off of? Propionibacterium acnes and Bacteroides fragilis have been known to cause endocarditis. Here let me provide you with a review on it:

http://www.ncbi.nlm.nih.gov/pubmed/12373039

Switching from Cipro to Unasyn really doesn't gain too much. Resistance is rising in both groups, especially in gram negative rods to Unasyn. If anything, using Unasyn provides slightly better coverage against Streps than Cipro and it provides better anaerobic coverage. Is he breaking a magical rule? No. You're got a culture-negative endocarditis, who so far (I assume its been several days he's been on treatment) has yet to respond (afebrile for 24 hours).

And keeping on vanco is really unwise and useless at this point--it's something you'd only use for empiric rx if you suspect your patient is at a high risk for MRSA.

1)Do you realize the AHA guidelines you've posted suggest vanco as a first line option for empiric coverage? The coverage against culture-negative is an "OR" situation, you can use either treatment (by their recommendations), either the one with Unasyn or the other with Vanco.

2)You do realize there are other recommendations out there correct? I sure hope so. Both the British Cardiac Society and European Society of Cardiology recommend Vanco as being the antibiotic of choice (combined with Gent).

3)I don't think you quite understand WHY Vanco is recommended. It is not just coverage against MRSA. It is also coverage against ALL Staph (coagulase positive/negative) which tend to all have high resistance to the anti-Staph penicillins (Oxacillin). In addition, Pneumococcus has increasing rates of penicillin and cephalosporin resistance, hence why you see basically every meningitis case at a major hospital covered with both Ceftiaxone and Vanco (many smaller hospitals don't have significant resistant Pneumococcal... yet). Surprisingly enough, the resistant Pneumococcus tend to be only involved in the uncommon, invasive infections, so meningitis you're more likely to find resistance, whereas in a pneumonia, you are less likely. You're also covering against Enterococci, there are only rare case reports of VRE being the definitive organism of endocarditis, so it has pretty good coverage, especially synergistically with Gent.

Don't assume Vanco is only for MRSA infections or to just avoid allergies. It isn't. Its a workhorse against gram-positives that is going to be ridden hard by physicians up until VRSA penetrates the community. If anything in the ideal hospital world, the rule is to try to start broad, and narrow your spectrum based on cultures. You don't start narrow, and then broaden based on response/cultures (unless you're outpatient... then you play that game).

Plus, to TREAT culture negative endocarditis, you don't START with vanco/cipro unless the patient is allergic to b-lactams. I posted the AHA link in my prev post, if you're interested.

Not according to your link. Plus other organizations don't even recommend Unasyn as first line.

It really may just be my overzealous third-yearness, but it feels like he's messing up and won't admit to it.

I still don't see how the treatment consists of "a ludicrous cocktail of various 'cins.'" He started treatment with Vanco/Gent/Cipro, which is a recommended course. There is nothing within the AHA guidelines that state that the Vanco/Gent/Cipro can't be used unless there is a beta-lactam allergy. Heck, the Europeans recommend jumping directly to it and dropping the Cipro. His current treatment with Cipro swapped out for Unasyn isn't radically different, its hardly breaking some magical "antibiotic rule." I think you're missing the forest from the trees.

How many cultures have been taken? You guys have a culture pre-any antibiotics correct? I do agree, if its been like 3 or 4 days and there hasn't been a clear response, then you're really going to have to dig for the rare atypicals.

 

[SLUser11]

It really may just be my overzealous third-yearness, but it feels like he's messing up and won't admit to it.

You nailed it. We all have lots of questions for you to help clarify the story, but I have one that should clear it all up: How many patients have you personally treated with endocarditis?

I could be wrong, but it seems that you're masquerading as an expert on a topic that you have very little true experience with. We can all read uptodate or bestpractice and feel like we know how to treat a disease, but very few of us would use this limited knowledge to condemn the experienced doctor's approach to the disease.

Seriously, I would not push this topic any further with your attending. It is common practice for residents to bad mouth the staff behind their back and talk about their incompetence, etc. It is a bad idea to emulate this behavior.

 

[cleverwebb]

False. Anaerobes do cause endocarditis. What are you making that claim based off of? Propionibacterium acnes and Bacteroides fragilis have been known to cause endocarditis. Here let me provide you with a review on it:

http://www.ncbi.nlm.nih.gov/pubmed/12373039

Switching from Cipro to Unasyn really doesn't gain too much. Resistance is rising in both groups, especially in gram negative rods to Unasyn. If anything, using Unasyn provides slightly better coverage against Streps than Cipro and it provides better anaerobic coverage. Is he breaking a magical rule? No. You're got a culture-negative endocarditis, who so far (I assume its been several days he's been on treatment) has yet to respond (afebrile for 24 hours).



1)Do you realize the AHA guidelines you've posted suggest vanco as a first line option for empiric coverage? The coverage against culture-negative is an "OR" situation, you can use either treatment (by their recommendations), either the one with Unasyn or the other with Vanco.

2)You do realize there are other recommendations out there correct? I sure hope so. Both the British Cardiac Society and European Society of Cardiology recommend Vanco as being the antibiotic of choice (combined with Gent).

3)I don't think you quite understand WHY Vanco is recommended. It is not just coverage against MRSA. It is also coverage against ALL Staph (coagulase positive/negative) which tend to all have high resistance to the anti-Staph penicillins (Oxacillin). In addition, Pneumococcus has increasing rates of penicillin and cephalosporin resistance, hence why you see basically every meningitis case at a major hospital covered with both Ceftiaxone and Vanco (many smaller hospitals don't have significant resistant Pneumococcal... yet). Surprisingly enough, the resistant Pneumococcus tend to be only involved in the uncommon, invasive infections, so meningitis you're more likely to find resistance, whereas in a pneumonia, you are less likely. You're also covering against Enterococci, there are only rare case reports of VRE being the definitive organism of endocarditis, so it has pretty good coverage, especially synergistically with Gent.

Don't assume Vanco is only for MRSA infections or to just avoid allergies. It isn't. Its a workhorse against gram-positives that is going to be ridden hard by physicians up until VRSA penetrates the community. If anything in the ideal hospital world, the rule is to try to start broad, and narrow your spectrum based on cultures. You don't start narrow, and then broaden based on response/cultures (unless you're outpatient... then you play that game).



Not according to your link. Plus other organizations don't even recommend Unasyn as first line.



I still don't see how the treatment consists of "a ludicrous cocktail of various 'cins.'" He started treatment with Vanco/Gent/Cipro, which is a recommended course. There is nothing within the AHA guidelines that state that the Vanco/Gent/Cipro can't be used unless there is a beta-lactam allergy. Heck, the Europeans recommend jumping directly to it and dropping the Cipro. His current treatment with Cipro swapped out for Unasyn isn't radically different, its hardly breaking some magical "antibiotic rule." I think you're missing the forest from the trees.

How many cultures have been taken? You guys have a culture pre-any antibiotics correct? I do agree, if its been like 3 or 4 days and there hasn't been a clear response, then you're really going to have to dig for the rare atypicals.

When he first presented and was worked up for FUO, we cultured before initiating therapy, obviously. I wasn't rotating at that hospital yet, but I remember his chart saying that they took 4 separate tubes, two for aerobes, two for anaerobes. He had not taken any antibiotics before. He was EMPRICALLY started on ceftriaxone + genta and did not respond. Vanco was added...then cef was discontinued, and cipro was added instead. The lab then reported that cultures were completely negative--the micrococcus they grew was a contaminant.

Three days ago, the patient was on vanco (day 12), cipro (day 7), genta (day 7), and was STILL febrile. Cipro was discontinued, and Unasyn was added. Today, >48 hours later, he was still febrile. My chief suggested using doxy instead of vanco (as vanco isn't really showing any benefit at this point) to cover the atypicals, and the attending agreed.

The guy was never at high risk for MRSA--no recurrent hospitalizations, no previous MRSA infection, and he is not an IV drug user. From what I've read, vanco is actually inferior in efficacy against non-MRSA staph. And yes, I'm fully aware of vanco's efficacy against MRS in general, but that doesn't change the fact that the guy isn't responding. My natural reflex was to think "so...why keep him on it?"

My link DOES say that unasyn + sulbactam is first line for CULTURE NEGATIVE endo. I'm not talking about empiric rx right now, I'm talking about actual culture NEGATIVE *native* valve SBE. Check page 3180 of the AHA guidelines.

I'm not being obnoxious in my questioning of his reasoning. I just don't agree with it based on what I've read, and he hasn't really given me a tremendously convincing explanation. that's it. he hasn't given me a reason to believe him. i understand my place in the hierarchy--heavens forefend i should actively change his orders behind everyone's backs, but that doesn't mean I won't be intractable in my opinions when the evidence before me calls for a certain intractability and i have no compelling reason to think otherwise! from what i've read, Unasyn + vanco doesn't seem that much different from vanco + cipro. I could be wrong, clearly, but he did not EXPLAIN it to me properly even though i BADGERED him for some semblance of meaning re: what he was doing, and the books haven't told me any different. It seemed to me like he was playing around with drug regimens that were all basically permutations of the same coverage and avoiding giving something to target all the atypicals (except legionella, which isn't covered by doxy).

And I need to clarify something: my little rampage may have started out as a guidelines crusade, but I'm not that obstinate. I understand about flexibility. My precious guidelines (page 3180) say nothing about doxycycline for culture negative native valve SBE, and yet I support its use because it makes SENSE. What *DOESN'T* is, for example, a move from cipro/vanco to vanco/unasyn. That approach, like I've been saying, is a bit redundant, based on their respective coverages.

I hope my patient doesn't have his traditional morning febrile spike tomorrow now that he's on doxy + unasyn + genta. And i hope that his TEE doesn't show an abscess.

One last thing, in case anyone here wants to suggest it, we all considered the possibility of this being IE that has now turned into drug fever, but we aren't looking into that at this point.

 

[BobBarker]

You are acting a little crazy..

 

[sideways]

Seems like you're dead set on screwing yourself over.

 

[Gastrapathy]

While you wander the hospital undermining your attending, inappropriately curbsiding consultants and demanding better explanations, under whose medical license and hospital credentials are you practicing?

This isn't about knowing your role. You don't have a role. Back down or prepare to be crushed.

 

[cpants]

When he first presented and was worked up for FUO, we cultured before initiating therapy, obviously. I wasn't rotating at that hospital yet, but I remember his chart saying that they took 4 separate tubes, two for aerobes, two for anaerobes. He had not taken any antibiotics before. He was EMPRICALLY started on ceftriaxone + genta and did not respond. Vanco was added...then cef was discontinued, and cipro was added instead. The lab then reported that cultures were completely negative--the micrococcus they grew was a contaminant.

Three days ago, the patient was on vanco (day 12), cipro (day 7), genta (day 7), and was STILL febrile. Cipro was discontinued, and Unasyn was added. Today, >48 hours later, he was still febrile. My chief suggested using doxy instead of vanco (as vanco isn't really showing any benefit at this point) to cover the atypicals, and the attending agreed.

The guy was never at high risk for MRSA--no recurrent hospitalizations, no previous MRSA infection, and he is not an IV drug user. From what I've read, vanco is actually inferior in efficacy against non-MRSA staph. And yes, I'm fully aware of vanco's efficacy against MRS in general, but that doesn't change the fact that the guy isn't responding. My natural reflex was to think "so...why keep him on it?"

My link DOES say that unasyn + sulbactam is first line for CULTURE NEGATIVE endo. I'm not talking about empiric rx right now, I'm talking about actual culture NEGATIVE *native* valve SBE. Check page 3180 of the AHA guidelines.

I'm not being obnoxious in my questioning of his reasoning. I just don't agree with it based on what I've read, and he hasn't really given me a tremendously convincing explanation. that's it. he hasn't given me a reason to believe him. i understand my place in the hierarchy--heavens forefend i should actively change his orders behind everyone's backs, but that doesn't mean I won't be intractable in my opinions when the evidence before me calls for a certain intractability and i have no compelling reason to think otherwise! from what i've read, Unasyn + vanco doesn't seem that much different from vanco + cipro. I could be wrong, clearly, but he did not EXPLAIN it to me properly even though i BADGERED him for some semblance of meaning re: what he was doing, and the books haven't told me any different. It seemed to me like he was playing around with drug regimens that were all basically permutations of the same coverage and avoiding giving something to target all the atypicals (except legionella, which isn't covered by doxy).

And I need to clarify something: my little rampage may have started out as a guidelines crusade, but I'm not that obstinate. I understand about flexibility. My precious guidelines (page 3180) say nothing about doxycycline for culture negative native valve SBE, and yet I support its use because it makes SENSE. What *DOESN'T* is, for example, a move from cipro/vanco to vanco/unasyn. That approach, like I've been saying, is a bit redundant, based on their respective coverages.

I hope my patient doesn't have his traditional morning febrile spike tomorrow now that he's on doxy + unasyn + genta. And i hope that his TEE doesn't show an abscess.

One last thing, in case anyone here wants to suggest it, we all considered the possibility of this being IE that has now turned into drug fever, but we aren't looking into that at this point.

First of all, therapy for culture negative endocarditis will by definition be empiric until you culture an organism.

Now, your mindset is way off base here. This attending doesn't owe you any explanation for his antibiotic choice. He basically followed the recommendations for culture neg endocarditis (Unasyn + Gent is first line), with some double coverage of gram positives, which are the most likely organisms. What's the big deal? It's certainly not a "ludicrous cocktail of various 'cins'" as you stated in your original post. Guidelines are just that, something to guide you. They don't dictate the only appropriate treatment regimen. Your attending made a clinical judgment, which perhaps you and your residents don't agree with, but his judgment is informed by a lot more experience than yours.

I'm trying to figure out what you are so worked up about. Despite your title, the attending certainly isn't WAY wrong in managing the patient. The only mismanagement I am seeing is not having ID on board to give input on the case. Any patient with IE should have an ID consult.

 

[JimmyShakerDay]

LOL, I guess now I understand why third year medical students don't give signouts to the cross-cover team or a fellow/attending. Its great how each time the story is told that more and more essential information is revealed (oh, I forgot, the patient also has a dental abscess!).

OP- calm down. Get off that horse you think you're on. I've been there. There's been situations as a medical student where I thought I understood things so well that I thought the treatment plan was wrong. But what I learned is that perspective and knowledge are impossible to meet as a third year student. Its become abundantly clear that you don't quite understand the treatment.

You've been complaining about Vancomycin. The treatment makes even MORE sense now. The patient came in, probably got the standard CBC, CXR, cultures, UA/culture, and of course, a good history and physical exam. He's started on a reasonable antibiotic regimen of Ceftri/gent. At some point, an echo is completed, with vegetations visible, either before/after the abx have been started. Likely endocarditis as the source. Treatment is continued. The patient fails to defervesce. Cultures still cooking.

Vanco is added. Uhhh, the Vanco wasn't added just willing-nilly. He failed to respond to a cephalosporin. That's all the more reason why to start vanco, it completely raises the pre-test probability of a penicillin/cephalosporin resistant bug to a level that you cannot ignore. This isn't about a "beta-lactam allergy." An endocarditis patient that fails to respond to a good cephalosporin means either two things, its resistant and you need vanco or something else like linezolid, or its not a gram-positive. He made the correct call. You don't seem to understand the course of treatment, probably since you weren't there, and are now playing Monday Morning Quarterback.

I assume then the cultures come back negative at 5 days, minus a "contaminant." I still don't understand your "dates" since he apparently was on gent since the start, but its only apparently "day 7." Sounds like 5 days after the vanco was added, cipro was added, meeting the recommended antibiotic guidelines for culture negative. And you still get upset, because the patient fails to respond after a week. Considering the reasonable treatments the attending opted for, this isn't an everyday endocarditis, if this is endocarditis, and its rare.

You're a zebra hunter. I was too. But 9 times out of 10, if you're looking for the zebras first, you'll be wrong. 3rd years are like that. This is the one time where looking for the zebra would have worked out. But that doesn't justify being wrong the other 9 times. I would have lended you credence to your complaints if you were justified in your statements, but you clearly are not. Especially when you make claims like:

-he's basically WHIMSICALLY prescribing the guy antibiotics
-anaerobes are NOT a cause of SBE
-to TREAT culture negative endocarditis, you don't START with vanco/cipro unless the patient is allergic to b-lactams.
-a move from cipro/vanco to vanco/unasyn. That approach, like I've been saying, is a bit redundant, based on their respective coverages.

If anything, you're recommendation to switch to doxy, and drop vanco is weak. If one should drop vanco since it is not working, why continue throw gentamicin and unasyn at him? Weak argument. If anything, this guy possible needs a CT surgery consult, an antifungal, or a pan-scan looking for septic emboli that have now populated distant sites, like a splenic abscess.

 

[Depakote]

Seems like you're dead set on screwing yourself over.

I agree. You've been advised to drop the issue, but you're convinced you're right.

Now is as good of a time as any to go full throttle, tell your attending he's doing things wrong and see how that turns out for you. It's a lesson you'll need to learn at some point in your career.

 

[cpants]

I agree. You've been advised to drop the issue, but you're convinced you're right.

Now is as good of a time as any to go full throttle, tell your attending he's doing things wrong and see how that turns out for you. It's a lesson you'll need to learn at some point in your career so now's as good a time as any.

Yeah, I agree. Better yet, go above the attending's head. I would email the head of the department, and while you're at it, let the patient know about how incompetent the attending is and that he is on the wrong antibiotics. You can't let mismanagement this severe go unchallanged.

 

[JimmyShakerDay]

Plus he's not an "university" doctor, so he must be incompetent, and must be taught a lesson.

 

[njbmd]

Hey everyone,

So I have a problem with my attending being super-nice yet rather stubborn. He's completely mismanaging a culture-negative subacute infective endocarditis case; he's basically WHIMSICALLY prescribing the guy antibiotics which at one point HAPPENED to follow the AHA guidelines, but it's become a ludicrous cocktail of various "cins" at this point. It's frustrating. The team keeps questioning his approach, but, big shock that nothing happens. All this is taking place at this public hospital we have to rotate in for a month. SO I just had a nice long "unofficial" conversation with an ID attending at the university hospital, and she COMPLETELY disagrees with our current approach. Incidentally, I completely agree with her, and I'm sure my team will too when I tell them about this tomorrow.
What should I do? The attending's wildly experimental regimens aren't even working.

Ideas, anyone?

This ID attending physician is NOT your friend or confident. This move showed very poor judgment on your part since you don't have a license to practice medicine yet. If you have a question about patient management, the attending who prescribed the therapy is the person to ask. This you CAN do as a medical student but to go to another attending to even discuss a patient is a bad move. That attending may have a wonderful discussion with your preceptor that won't make you look good.

When you get to the attending level, think about how you would handle a medical student who did this on your service because it's going to happen. As an attending, if a student came to me with this kind of behavior my first piece of advice would be for them to discuss this matter with their attending physician or chief resident.

Be careful, because the most likely scenario is that you are wrong and the attending is right (or at least has a science-based argument for his approach). Remember, the guy has been doing this for a long time and has probably treated this condition several times before. Do you really think he is just picking drugs at random? It's possible, but not likely. If you really think he is wrong, I would just simply ask him how he selected the antibiotics you are using to treat the patient.

Maybe there are factors you are not considering. I can think of lots of scenarios where the guidelines might not be followed (allergies, he is using different guidelines, availability of medications, pt's insurance coverage, pt's preference, status of pt's other organs, previous culture results, local susceptibility data, suspicion of other diagnoses on the differential, many other reasons).

Good advice here too.

Yup, my interns and residents don't agree with him at all. When I suggested that I check with one of the attendings at the university hospital, they loved the idea. And our attending KNOWS about the guidelines--see, as soon as I was assigned to the case, I printed out the AHA stuff; I discussed them with the team, then we all discussed them with the attending. He even LOOKED at them, acknowledged that the patient was currently taking an approved regimen (vanco + cipro + genta, even though, sidebar, the patient was started on this BEFORE trying ampli/genta first, and he has no b-lactam allergy), and STILL insisted on changing the regimen to something of his own creation. Twas a fruitless talk.

...which is when I spoke to the other doc. I reported my findings back to my chief and interns. The chief said that she'll suggest the other attending's opinion to him herself when she meets with him tomorrow, WITHOUT letting him know where we got our intel from. She said she'll talk it out with him in a very academic "hey, so i was reading up on this, what do you think" kind of way.

Hopefully, if the patient's fever doesn't break on ampicillin, the doctor'll give and try something to cover atypicals.

If the ID attending discusses this with your attending, you and the resident will have invited scrutiny that neither of you needs at this level. As others have stated, you are in a learning position that only comes around one time. Don't screw yourself and your team with this type of behavior. Medicine is very unforgiving of these types of incidents.

Your attending physician is a licensed physician and assumes all liability for the decisions that they make concerning patient care. Sure, this may be a good time to discuss antibiotic regimens but it's never a good time to second-guess someone with far more experience than yourself regardless of what you read or learn from another physician. Your attending physician could be totally wrong but it's not for you (a medical student) to call them out on this or get another physician involved in the case. This could wind up "biting you" where you don't want to have a wound.

 

[J1515]

Yeah, I agree. Better yet, go above the attending's head. I would email the head of the department, and while you're at it, let the patient know about how incompetent the attending is and that he is on the wrong antibiotics. You can't let mismanagement this severe go unchallanged.

Also make sure to cc your email to your school's clinical ed dept and the dean, and perhaps the CDC.

 

[cleverwebb]

First of all, therapy for culture negative endocarditis will by definition be empiric until you culture an organism.

Erm, no. Empiric = before cultures are out. Culture-negative = cultures aren't out after days of incubation. It's an entire entity on its own.

LOL, I guess now I understand why third year medical students don't give signouts to the cross-cover team or a fellow/attending. Its great how each time the story is told that more and more essential information is revealed (oh, I forgot, the patient also has a dental abscess!).

OP- calm down. Get off that horse you think you're on. I've been there. There's been situations as a medical student where I thought I understood things so well that I thought the treatment plan was wrong. But what I learned is that perspective and knowledge are impossible to meet as a third year student. Its become abundantly clear that you don't quite understand the treatment.

You've been complaining about Vancomycin. The treatment makes even MORE sense now. The patient came in, probably got the standard CBC, CXR, cultures, UA/culture, and of course, a good history and physical exam. He's started on a reasonable antibiotic regimen of Ceftri/gent. At some point, an echo is completed, with vegetations visible, either before/after the abx have been started. Likely endocarditis as the source. Treatment is continued. The patient fails to defervesce. Cultures still cooking.

Vanco is added. Uhhh, the Vanco wasn't added just willing-nilly. He failed to respond to a cephalosporin. That's all the more reason why to start vanco, it completely raises the pre-test probability of a penicillin/cephalosporin resistant bug to a level that you cannot ignore. This isn't about a "beta-lactam allergy." An endocarditis patient that fails to respond to a good cephalosporin means either two things, its resistant and you need vanco or something else like linezolid, or its not a gram-positive. He made the correct call. You don't seem to understand the course of treatment, probably since you weren't there, and are now playing Monday Morning Quarterback.

I assume then the cultures come back negative at 5 days, minus a "contaminant." I still don't understand your "dates" since he apparently was on gent since the start, but its only apparently "day 7." Sounds like 5 days after the vanco was added, cipro was added, meeting the recommended antibiotic guidelines for culture negative. And you still get upset, because the patient fails to respond after a week. Considering the reasonable treatments the attending opted for, this isn't an everyday endocarditis, if this is endocarditis, and its rare.

You're a zebra hunter. I was too. But 9 times out of 10, if you're looking for the zebras first, you'll be wrong. 3rd years are like that. This is the one time where looking for the zebra would have worked out. But that doesn't justify being wrong the other 9 times. I would have lended you credence to your complaints if you were justified in your statements, but you clearly are not. Especially when you make claims like:

-he's basically WHIMSICALLY prescribing the guy antibiotics
-anaerobes are NOT a cause of SBE
-to TREAT culture negative endocarditis, you don't START with vanco/cipro unless the patient is allergic to b-lactams.
-a move from cipro/vanco to vanco/unasyn. That approach, like I've been saying, is a bit redundant, based on their respective coverages.

If anything, you're recommendation to switch to doxy, and drop vanco is weak. If one should drop vanco since it is not working, why continue throw gentamicin and unasyn at him? Weak argument. If anything, this guy possible needs a CT surgery consult, an antifungal, or a pan-scan looking for septic emboli that have now populated distant sites, like a splenic abscess.

Ah see, we agree,re: something I haven't stated yet regarding my own personal reasoning. I already connected the dots about him switching the guy from a b-lactam (ceph) to vanco; it occurred to me that he just assumed that b-lactams aren't working at all, so what would be the point of adding unasyn. Let's do vanco. Fine. Great. So the patient was on vanco + cipro + genta, which goes with the AHA guidelines. The hang-up I have about this is that I assume he switched to vanco to cover for MRSA...which, as far as I know, ARE culturable and highly unlikely considering the patient's nonsuspicious history for MRSA colonization etc. I should've been more specific about this--I'd spoken about the unlikelihood of his being infected by MRSA in a previous post. Plus, if his reasoning was "vanco to cover the MRSAs that ceftriaxone missed," why add unasyn then d/c vanco days later upon my chief's suggestion of doxy? (more on this later)

I *COMPLETELY* get that I sound like a total douche. I do. And I *do* know my place--I do. With the perspective that comes with 5 days s/p initial post, my rampage has died down. But the history my team has with this attending is muddy at best--as I've already said, he did not want to get a TEE done, which is a test that, despite my lack of experience and clumsy clinical sense [etc], seemed like a COMPLETELY reasonable option because of his otherwise negative work-up and in spite of his negative TTE. The interns had a little argument with him, and he gave.

His last update is that he still wasn't defervescing after 48 hours on unasyn + vanco + genta. Vanco was d/cd, and doxy was added. 48 hours later, he had his first ever fever-free day. There's no self-righteous smirking going on here, honest, cuz, you see:
a) in all likelihood, the unasyn could've done this
b) if anything, THIS regimen here sounds like a "cocktail of various 'cins," which goes against my initial dictum.

 

[cleverwebb]

While you wander the hospital undermining your attending, inappropriately curbsiding consultants and demanding better explanations, under whose medical license and hospital credentials are you practicing?

This isn't about knowing your role. You don't have a role. Back down or prepare to be crushed.

Maybe I should just sit in my chair and be good, what with my passive lack of a role. Great way to learn.

Third year students aren't there to be yelled at, aren't there to sit in a conference room all day and write progress notes. You might roll your eyes at this, and you'll probably dismiss this entire rant as pseudo-rebellious, over-enthused, pompous idiocy, but I DO have a role, and I did NOT cross a line. My consult was unofficial--"hey, other doc, what do you think of this?" The residents supported it out of an academic state of mind, especially since they were starting to feel like we were running out of ideas. I did NOT go to my attending with this, I did NOT casually let it slip into my daily round with the patient and his wife that *I* think things aren't going great because a) THAT would've bit me in the ass, and b) who the hell am *I* to go PROCLAIMING my students' opinion to anyone OTHER than my direct team?

 

[cleverwebb]

This ID attending physician is NOT your friend or confident. This move showed very poor judgment on your part since you don't have a license to practice medicine yet. If you have a question about patient management, the attending who prescribed the therapy is the person to ask. This you CAN do as a medical student but to go to another attending to even discuss a patient is a bad move. That attending may have a wonderful discussion with your preceptor that won't make you look good.

When you get to the attending level, think about how you would handle a medical student who did this on your service because it's going to happen. As an attending, if a student came to me with this kind of behavior my first piece of advice would be for them to discuss this matter with their attending physician or chief resident.

My attending WOULDN'T explain anything, as I've made abundantly clear. Maybe he REALLY has no obligation to, so I sought someone else's point of view, and now I've DEFINITELY learned more about antibiotic problem-solving than I would've otherwise.

I always consider what it would be like to have a bunch of cocky third-years undermining me in the future. It would be....irritating to say the least. I've promised myself that I would prophylaxis this by trying to teach better than I'm being taught.

 

[cheech10]

You're missing an important point: the sensitivity of blood cultures is not 100%, closer to 90%, and less if he got any antibiotics prior to cultures being drawn. So your patient is on Amp+Gent, appropriately, for endocarditis, and Vanco in case MRSA or Enterococcus faecium was missed with the initial cultures. Seems reasonable to me.

If he wasn't very ill on presentation (no hypotension or heart failure) I probably would have held off antibiotics until at least 3, and preferably 4 or 5, sets of blood cultures (2 bottles per set, 1 aerobic and 1 anaerobic) had been drawn, with at least 1 set cultured for 21 days to grow more fastidious organisms. To call it culture-negative with only 2 sets of cultures drawn might be premature.

 

[MCYan]

what else can you do? perhaps you are right, but he/she is the attending. Medicine is not all about what they teach you - do whatever is the best for the patient.

 

[group_theory]

cleverwebb - i admire your passion and the fact that you're trying to look out for the patient's best interest.

But in this case, it seems you are arguing about the color of the leaves and forgetting about the trees and the forest. The fact that you have the backing of a university ID physician means nothing - you were the one presenting your view (one-sided by default) to the ID physician, hence you were only presenting what you thought was relevant to the ID doc - hence why the ID doc agreed with you.

I also find the gaps in your medical knowledge a bit concerning (some of the gaps were pointed out in thread such as not knowing the indication of vancomycin usage, or insisting that anaerobes cannot cause endocarditis). Also, just FYI, having 2 negative sets of blood cultures (as you described it, 2 aerobic and 2 anaerobic vials) only have a sensitivity of 80%. And if you only have 2 negative cultures, you can't call it culture-negative just yet.

It's also important to realize that medicine is an art as much as it is a science. A TEE have its own associated risk (along with sedation risk). Sometimes with a negative TTE but strong suspicion for endocarditis, it might make sense to wait a few days before repeating a TTE or proceeding with a TEE.

But what concerns me the most is the fact that while you are free to question or disagree with the attending, how you dealt with this disagreement was a little over-the-top. You complained about it to your residents (which is fine), but you went to the chief, and also to another doctor at another hospital to get an unofficial "second opinion" or consult. You were so indignant about it that you started a SDN post titled "my attending is WAY wrong in managing this patient" (it turns out his approach was quite reasonable and you just didn't appreciate the finer details of treatment).

If I were the resident evaluating you, basing the evaluation purely on this thread (since I don't know you in person and how you interact as a team), I would have given you a Pass in medicine with the following comment - "trust issues - would be hesistant to have as an intern".

But since i'm not grading you, my comments are not worth anything official, so it really doesn't matter . Just realize that if you come across like this in real life, other residents who are evaluating you may pick up on the same issues.

 

[cpants]

Erm, no. Empiric = before cultures are out. Culture-negative = cultures aren't out after days of incubation. It's an entire entity on its own.

Negative cultures may change your suspicion for different organisms and thus change your antibiotic choices, but it is still empiric therapy. You provide broad coverage for the most likely organisms based on the data you have. If that's not empiric, what would you call it?

 

[smq123]

Yup, my interns and residents don't agree with him at all. When I suggested that I check with one of the attendings at the university hospital, they loved the idea.

But what concerns me the most is the fact that while you are free to question or disagree with the attending, how you dealt with this disagreement was a little over-the-top. You complained about it to your residents (which is fine), but you went to the chief, and also to another doctor at another hospital to get an unofficial "second opinion" or consult. You were so indignant about it that you started a SDN post titled "my attending is WAY wrong in managing this patient" (it turns out his approach was quite reasonable and you just didn't appreciate the finer details of treatment).

If I were the resident evaluating you, basing the evaluation purely on this thread (since I don't know you in person and how you interact as a team), I would have given you a Pass in medicine with the following comment - "trust issues - would be hesistant to have as an intern".

To be fair, the OP may be getting very very very bad advice from his residents on his team. There's no reason that they should have encouraged him to curbside an ID attending at another hospital, who has absolutely nothing to do with this patient's care. The fact that they "loved" the idea when it was mentioned to them is kind of concerning too.

 

[CHR]

Question your attending is a good thing. But you must also trust and listen to your attending.

Sometime treatment response can be slower in some patients. There are other signs of response other than fever, and clinical well being is one of them.

The patient is doing better, so the organism is most likely partially susceptible. Sometimes you can't do better than a partially effective therapy and prolong the treatment. IE takes time to treat.

Dental abscess is an anaerobe prone infection and I see that he's shooting for stronger anaerobic regimen. Ciprofloxacin is not very forefront in term of effectiveness against anaerobe. Unasyn is. Doxycyclin is. I, myself, use Metronidazole instead of Doxycyclin but... the patients puke pretty much the same either way.

The elimination of vancomycin is very understandable. I believe he thinks that the patient is not prone to drug resistance. The reason why some start Vancomycin in the early stage is that they fear an acute rapidly progressive IE that is drug resistant. They start Vancomycin first in order to be on the safe side and then de-escalate according to the sensitivity. Since the culture is negative and the patient does not progress rapidly, the rationale is probably an anaerobic infection with or without simple G +ve infection. Unasyn is fine.

Dental caries is most likely the source and anaerobe +/- simple G+ve are the organisms. I would prefer my resident to think about other than the most obvious site and the most obvious organism, are there any other possible pathogens? Could it be marantic - does the patient have underlying autoimmune disease? Could it be tuberculous - is his CXR really clear esp at RUL, does he have TB contact? Could it be fungal - does he have any prosthesis or cardiac Sx? All of these are very far-fetched and very unlikely but, as a Med Student, you should spend your time focusing on being thorough and think broadly about the differential diagnosis and etiology.

Did you get rid of the source of infection? When is the dentist appointment?

 

[cleverwebb]

I also find the gaps in your medical knowledge a bit concerning (some of the gaps were pointed out in thread such as not knowing the indication of vancomycin usage, or insisting that anaerobes cannot cause endocarditis). Also, just FYI, having 2 negative sets of blood cultures (as you described it, 2 aerobic and 2 anaerobic vials) only have a sensitivity of 80%. And if you only have 2 negative cultures, you can't call it culture-negative just yet.

It's also important to realize that medicine is an art as much as it is a science. A TEE have its own associated risk (along with sedation risk). Sometimes with a negative TTE but strong suspicion for endocarditis, it might make sense to wait a few days before repeating a TTE or proceeding with a TEE.

But what concerns me the most is the fact that while you are free to question or disagree with the attending, how you dealt with this disagreement was a little over-the-top. You complained about it to your residents (which is fine), but you went to the chief, and also to another doctor at another hospital to get an unofficial "second opinion" or consult. You were so indignant about it that you started a SDN post titled "my attending is WAY wrong in managing this patient" (it turns out his approach was quite reasonable and you just didn't appreciate the finer details of treatment).

If I were the resident evaluating you, basing the evaluation purely on this thread (since I don't know you in person and how you interact as a team), I would have given you a Pass in medicine with the following comment - "trust issues - would be hesistant to have as an intern".

But since i'm not grading you, my comments are not worth anything official, so it really doesn't matter . Just realize that if you come across like this in real life, other residents who are evaluating you may pick up on the same issues.

No, see, it didn't "GO" to my chief an WHINE. My chief was right there in the conference room, we were all expressing our doubts and concerns and trying to understand the rationale behind every antibiotic change; when I suggested that we go to someone else with this, see what's the what, they--chief INCLUDED--told me to definitely go for it. Otherwise, I'd have dropped it. Completely.

No knowledge gaps--like I said, I get the vanco indications; I did my homework. My OCPD won't let me behave otherwise. Sigh. We were just splitting hairs about MRS vs MRSA. An re: anaerobes--I admit, that was rash of me. I'll give you that. I reread the guidelines, and there are one or two more obscure organisms out there that ARE anaerobes and that DO cause IE.

Not that it matters now, anyway--the guy had his repeat TEE today, and there it was: a nice periaortic abscess, a tiny perf in one of the cusps of the AV with mild regurg (not audible by cardiac auscultation), and a vegetation that's grown from 0.8 cm to 1.1 cm. Which explains his INTRACTABLE fever. His one afebrile day was probably just a crazy random happenstance.

[sidebar...this repeat TEE was something that we as a team had to (once again) fight for--the attending was opting to keep waiting for him to defervesce on his own . so my apprehension wasn't ENTIRELY unfounded].

I do, however, need to cool it.

 

[cleverwebb]

Question your attending is a good thing. But you must also trust and listen to your attending.

Sometime treatment response can be slower in some patients. There are other signs of response other than fever, and clinical well being is one of them.

The patient is doing better, so the organism is most likely partially susceptible. Sometimes you can't do better than a partially effective therapy and prolong the treatment. IE takes time to treat.

Dental abscess is an anaerobe prone infection and I see that he's shooting for stronger anaerobic regimen. Ciprofloxacin is not very forefront in term of effectiveness against anaerobe. Unasyn is. Doxycyclin is. I, myself, use Metronidazole instead of Doxycyclin but... the patients puke pretty much the same either way.

The elimination of vancomycin is very understandable. I believe he thinks that the patient is not prone to drug resistance. The reason why some start Vancomycin in the early stage is that they fear an acute rapidly progressive IE that is drug resistant. They start Vancomycin first in order to be on the safe side and then de-escalate according to the sensitivity. Since the culture is negative and the patient does not progress rapidly, the rationale is probably an anaerobic infection with or without simple G +ve infection. Unasyn is fine.

Dental caries is most likely the source and anaerobe +/- simple G+ve are the organisms. I would prefer my resident to think about other than the most obvious site and the most obvious organism, are there any other possible pathogens? Could it be marantic - does the patient have underlying autoimmune disease? Could it be tuberculous - is his CXR really clear esp at RUL, does he have TB contact? Could it be fungal - does he have any prosthesis or cardiac Sx? All of these are very far-fetched and very unlikely but, as a Med Student, you should spend your time focusing on being thorough and think broadly about the differential diagnosis and etiology.

Did you get rid of the source of infection? When is the dentist appointment?

Dentist appointment pending valve replacement.

And yes everything on the differential that you mentioned, I/we went through. CTs were negative for malignancy, PPD and CXR were negative, rheumatologic workup was negative, viral serologies were negative, and fungal was very unlikely--no prosthesis, not debilitated--etc. All the patient had was fever for 21 days prior to presentation and a h/o recent dental work. Great case, but poor, unlucky guy.

I'm optimistic about his prognosis though, as he's nowhere near CHF, and from what I've read, that's the only factor that's been shown to have any effect on surgical outcome in IE.

 

[JustPlainBill]

This is really NOMFB but since you started the post.....

An approach I've always found useful, which requires
swallowing some pride but I've learned a helluva lot
this way....

Me: Sir, may I ask a question? - Quickly establishes the
pecking order and that I have respect for the attending
and their position.

Attending: Sure.

Me: If you wouldn't mind, please correct my understanding about....

Attending: -> usually will begin teaching me based on my question
and I get some insight as to how they think and deliver patient care.
That's the key learning experience. I could give a rats ***** less about
the medicine part...that'll change. What I want to know is how they
think and what the considerations are....I realize you can write what I know about medicine in the back of a matchbook with a large grease pencil and most of my attendings have forgotten more and take more for granted that is contained in the first two years of medical school but I WANT to know how they think.....so I can start looking at patients from their paradigm.....

By using the 'please correct my understanding', I'm giving them the option of reviewing their Tx modality mentally before explaining it and I've had a few make subtle changes. More often, I've gotten a real education on the subtleties of a particular patient and realized why the hell I was wrong in my thinking.....

You have to swallow a lot of pride but you learn a lot more that way.

One thing: attendings talk, so lose the backdoor curbside behavior. Also, if I really want to determine someone's behavior and character to see if I can really trust them, I'll make a comment that could be interpreted either way and see which way they take it. Most people will gladly shoot their mouth off if you just stand there and smile and give them gentle verbal prodding like 'oh, really?!'......and then you know what you're dealing with.....

Don't screw yourself this early.....

 

[Gastrapathy]

To be fair, the OP may be getting very very very bad advice from his residents on his team. There's no reason that they should have encouraged him to curbside an ID attending at another hospital, who has absolutely nothing to do with this patient's care. The fact that they "loved" the idea when it was mentioned to them is kind of concerning too.

Can't you picture how that went down? I would love to have seen their smirks when he went off to find the ID attending. Bet they couldn't wipe them off their faces all day.

Some people need to learn through pain.

 

[cpants]

Any updates OP? By now I would imagine that the patient is long dead and the state medical board has stripped your attending of his license pending the outcome of his criminal trial.

 

[Nellyakgo]

Also, if I really want to determine someone's behavior and character to see if I can really trust them, I'll make a comment that could be interpreted either way and see which way they take it. Most people will gladly shoot their mouth off if you just stand there and smile and give them gentle verbal prodding like 'oh, really?!'......and then you know what you're dealing with.....

.....

I'm very bad at judging character. Please educate me more on the above. What do you mean/how? I didn't quite get it.

 

[DarknightX]

So he's WAY wrong because he switched from cipro/vanc/gent to unasyn/vanc/gent? What organism do you think could be causing his fever that isn't being covered?

And you're right...you do have a role. Your role is to STFU and learn. You have absolutely zero role in patient care. Even the nurses and the janitors are more important than medical students. You see, they have a real job, and they get paid to provide a service. As a medical student, we're just guests who are observing. The sooner you accept that, the easier your third year will be. Trust me, the residents don't care about your ideas. There is nothing that you can think of that they haven't already thought about. You should be happy that they are even humoring you.

When you're an attending, you can give whatever antibiotic combinations you like, but this is your attending's patient, it's his call and his responsibility. If the patient was to take a turn for the worst, or even die, are you going to go break the news to his family?

You're seriously giving us medical students a bad name here. Go study for your shelf. It's a much better use of your time than playing doctor.

 

[MattD]

The residents weren't agreeing with their superiors opinion and asked me to "secretly" give them a bottle of the drug which I did because I agreed with them.

WHAT? I hope you realize, looking back, that these residents were NOT your friends and completely used you as a scapegoat. This to me is unconscionable. If a resident feels strongly enough to do something behind the attendings back, he/she should do it himself, not send the medical student who doesn't even have a career yet for the attending to ruin. I don't want to think what would have happened if the attending caught a frackin medical student administering pit to a patient the attending expressly said not to induce. I can't see the residents jumping to the student's defense either. Just wow.