5 day Z Pak vs 3 day Tri Pak - efficacy?

[winterallsummer]

Does anyone use the 3 day Tri Pak over the traditional Z Pak for either CAP, sinusitis or other bacterial indication?  I admittedly don't remember even being taught about the Tri Pak in PA school and have yet to see it used on a rotation.

 

I am trying to find any data supporting one over the other but reviews seem mixed or to state they are generally equivalent.  Given this information, can the Tri Pak be recommended over the Z Pak for sinusitis or CAP (and in CAP both as monotherapy or in duel therapy with beta lactam), given the improved compliance and easier dosing regimen?  Note that the Tri Pak is 500 mg for all 3 days.

 

UpToDate recommends either for uncomplicated CAP for monotherapy.

 

http://www.ncbi.nlm.nih.gov/pubmed/15909262

http://link.springer.com/article/10.1007%2FBF01975847

http://aac.asm.org/content/47/9/2770.long

http://www.ersj.org.uk/content/8/3/398.short

[primadonna22274]

Z-paks are useless for sinusitis regardless of 3 or 5 day course. They weren't useless 15 years ago but they sure are now.

Look up IDSA guidelines for any infection you're treating.

I only use azithro for atypical pneumonia as it's still effective against mycoplasma and pertussis. If I suspect a strep or other cause, I use at least a 2nd-gen cephalosporin if I can and if not, consider a broader-spectrum longer-course macrolide. Also a big fan of Clindamycin for mouth organisms and true sinusitis.

Save the fluoroquinolones for AECB exacerbations and true pneumonia that has failed other therapies. We don't have much left beyond FQs that isn't parenteral.

 

[winterallsummer]

Prima, thanks for the reply.  Macrolide and beta lactam therapy is widely advocated for CAP (the other mainstray being resp FQ).  What macrolide are you using in place of zitrhomax?  The ISDA guideline also does recommend macrolide monotherapy (including zithro but not specifying 3 vs 5d) and addition of a beta lactam for duel therapy (or a FQ) in complicated CAP (eg COPD, lung CA, etc).

 

In cases that you DO use zithromax, are you using the 5 or 3 day pak?

[primadonna22274]

Prima, thanks for the reply. Macrolide and beta lactam therapy is widely advocated for CAP (the other mainstray being resp FQ). What macrolide are you using in place of zitrhomax? The ISDA guideline also does recommend macrolide monotherapy (including zithro but not specifying 3 vs 5d) and addition of a beta lactam for duel therapy (or a FQ) in complicated CAP (eg COPD, lung CA, etc).

 

In cases that you DO use zithromax, are you using the 5 or 3 day pak?

I will say I use azithro (typically 5 days by convention although data is strong for 3 days at high dose and I might prefer that if I didn't have to build a new rx in our hopeless EMR!) plus ceftriaxone IM x 1. I almost never use it by itself.

[primadonna22274]

Oops, forgot to answer your other macrolide q: clarithro but rarely as the side effects are too much for most folks to take. Plain EES is generally easy and cheap but not as effective for atypicals--then I really prefer doxy or tetracycline.

[GetMeOuttaThisMess]

Any abx for "sinusitis" is worthless in >90% of cases. Check out abx criteria for questionable sinusitis as to when to use (rec tx is Augmentin x7days). Most sinusitis is not actual sinusitis.

 

You'll get patient to forget URI sx due to diarrhea from Augmentin at recommended dosing.

[primadonna22274]

Having just finished a month of ENT, this fact has been beaten into my consciousness--sinusitis needs irrigation, decongestants, nasal steroids, maybe systemic steroids, maybe a mucolytic, and RARELY antibiotics.

The ENT guys favor Augmentin x 2 wk, a broad-spectrum cephalosporin, maybe doxy, and finally FQs if the patient fails all that (and documented abnormal CT plus frank pus on nasal endoscopy...obviously not what most of us in the trenches have access to). They will also use a compounded Clindamycin-betadine-saline rinse both nostrils BID x 8 wk for refractory sinusitis. That take a dedicated patient but it sure does work--and prevents surgery about 2/3 of the time.

[GetMeOuttaThisMess]

^^^, one of man's greatest, but most underrated inventions; the Neti pot. Oh, BTW. Don't forget not to mix macrolides with one of America's recommended polypill components (ASA, benzo, statin, and ACEI) with that being the statin. Raises risk of rhabdo.

[ventana]

DON'T use Z-pak, TriPak or any macrolide any more for teh "uri" complaints..... worthless

 

 

I must admitt it was a great marketing idea to make it four letters and one dash to prescribe an Abx -  we sure did write a lot of it - (to the point that now it is worthless)

 

Search new guidelines on URI txt

[mdebord]

I mostly use Zpaks now for the people I do not believe have an infxn but won't take no for an answer - sometimes in the form of a written Rx accompanied by "I really think it's just a virus, but if you don't improve over the weekend with the conservative therapy we discussed, you may start this."    I recall reading a European study that found this was well-received and did cut back on some overuse.  For true sinusitis, Augmentin.  For the allergic, Omnicef (although I am aware the new guidelines call for dual therapy).  For CAP, azithro 500 x 5 days plus or minus a Rocephin shot.  

[KMD16]

acute rhino-sinusitis tx = symptomatically. Rarely rx abx. Except if sx > 10d or the pt has other comorbidity.

[KMD16]

I mostly use Zpaks now for the people I do not believe have an infxn but won't take no for an answer - sometimes in the form of a written Rx accompanied by "I really think it's just a virus, but if you don't improve over the weekend with the conservative therapy we discussed, you may start this." I recall reading a European study that found this was well-received and did cut back on some overuse. For true sinusitis, Augmentin. For the allergic, Omnicef (although I am aware the new guidelines call for dual therapy). For CAP, azithro 500 x 5 days plus or minus a Rocephin shot.

Why rx an abx if you know it's viral etiology?

[mdebord]

Some of them somewhat meet the criteria (it's been almost ten days, they tell me they had fever last night, tenderness to percussion) but I'm suspicious.  But sometimes it boils down to the fact that I have neither the time nor energy to have this argument ten times a day.  And don't get me wrong - I am very thorough in explaining why I don't think they need Abx and also in my recs for OTC tx - but they are just not having it.  It's an uphill battle.

[rev ronin]

Why rx an abx if you know it's viral etiology?

Like he said... for people who won't take "no" for an answer.  Like it or not, we're employees of customer-driven organizations, and when the customer needs "something done", and we don't "do something" (learned and appropriate evaluation not being anything, of course) we will lose business.  If it was all about the biological processes, rx nothing.  But biology doesn't exist in a vacuum, and patient satisfaction and economic rewards are another two big parts of the equation.

[Guest JMPA]

^^^, one of man's greatest, but most underrated inventions; the Neti pot. Oh, BTW. Don't forget not to mix macrolides with one of America's recommended polypill components (ASA, benzo, statin, and ACEI) with that being the statin. Raises risk of rhabdo.

also one of the most misused inventions causing morbidity and mortality. Neti introduces bacterior into the sinuses and can cause brain infections and abcess. just say no to Neti

[primadonna22274]

The ENT guys I just rotated with never recommended Neti pot--because it's difficult to use. The "spray bottle" type Neil Med sinus rinse is what they recommend to everyone. The caveat: ALWAYS use distilled or boiled water. NEVER tap water. Unless you want a Naegleria fowlerii infection (you don't!!)

[GetMeOuttaThisMess]

^^ (JMPA), grossly overstated IMO. Anything, if abused, can be detrimental. Benefit>risk IMO for most individuals. Agree that distilled/sterile saline is indicated as opposed to tap (2 cases reported of encephalitis that I'm aware of attributed to aemobic infection from municipal water supply). Local ENT dept of med school encourages nasal saline irrigation, as do the most recent rhino-sinusitis guidelines that I saw ('10 as I recall).

 

Prima, what did they find difficult with usage?

[KMD16]

Like he said... for people who won't take "no" for an answer. Like it or not, we're employees of customer-driven organizations, and when the customer needs "something done", and we don't "do something" (learned and appropriate evaluation not being anything, of course) we will lose business. If it was all about the biological processes, rx nothing. But biology doesn't exist in a vacuum, and patient satisfaction and economic rewards are another two big parts of the equation.

Treating a viral infx with abx is bad medicine. These pts bounced back. They comes back c/o how ineffective the abx was/asking for different agent/abx class or c/o abx side effect = more HA = low pt satisfaction score.

[EMEDPA]

Oops, forgot to answer your other macrolide q: clarithro but rarely as the side effects are too much for most folks to take. Plain EES is generally easy and cheap but not as effective for atypicals--then I really prefer doxy or tetracycline.

I think tetracycline is now off the market if I am not mistaken...

[cinntsp]

There was a doc that worked at a clinic I rotated through(but a different location primarily) that was a total academic and would not prescribe outside of guidelines/criteria for anything.  Most patients didn't like her(of course) despite her being very nice and humble, because they didn't get their abx and decadron shot for every little sniffle, so they would come to our location from then on.  I really respected her approach and it's unfortunate that so much of healthcare is driven by patient satisfaction metrics.

[rev ronin]

Treating a viral infx with abx is bad medicine. These pts bounced back. They comes back c/o how ineffective the abx was/asking for different agent/abx class or c/o abx side effect = more HA = low pt satisfaction score.

We're not (in this hypothetical case) treating the viral infection at all.  It'll get better on its own, or with the symptomatic care treatments also prescribed.  It's how the cycle always worked: about the time the viral infection was getting better on its own, the patient got antibiotics, and is now *certain* that they're a special case, where antibiotics always work, when in fact they never did, but never caused significant enough harm (diarrhea, allergic reaction, etc.) to dissuade the patient from seeking antibiotics again, either.  If they do come back with an "antibiotic failure", you ask them if they did all the other stuff (irrigation, etc.) you told them to do, too, and if they didn't, you have a very good conversation about why the antibiotics didn't work... or they're simply too ignorant to be taught.

 

Patient autonomy means letting them pick "wrong", when that wrong is not specifically harmful.  On a macro level, yes, I want to give out antibiotics only for every infection that they will actually treat, but on a global scale that means little to combat antibiotic resistance when many countries have antibiotics as OTCs.

[ventana]

I mostly use Zpaks now for the people I do not believe have an infxn but won't take no for an answer - sometimes in the form of a written Rx accompanied by "I really think it's just a virus, but if you don't improve over the weekend with the conservative therapy we discussed, you may start this."    I recall reading a European study that found this was well-received and did cut back on some overuse.  For true sinusitis, Augmentin.  For the allergic, Omnicef (although I am aware the new guidelines call for dual therapy).  For CAP, azithro 500 x 5 days plus or minus a Rocephin shot.  

 

What a horrible idea!!!

 

I get that sometimes you have to treat but why on earth go with a broad spectrum?

Do the old fashion basic abx like Amox instead of going to the big guns

 

 

 

 

another thing that bugs me (pun intended)  PCPs writing a FQ for a simple URI   --- WTH???  talk about horrible prescribing!

 

 

simple conservative measures first, if they 'insist' on treatment go over the entire conservative treatment realm (and i had a nice handout that I would give as well)  

If they continue to insist and they have a viral etiology - just tell them NO - it is okay -  would you give a patient dig just because they asked for it?  What about Morphine?  

 

remember all drugs are poisons some of which have good side effects.

 

 

As for other issues with ABX   anyone been following stool transplantation?  This whole field seems to be driven by the past over use of Abx.......

[KMD16]

We're not (in this hypothetical case) treating the viral infection at all. It'll get better on its own, or with the symptomatic care treatments also prescribed. It's how the cycle always worked: about the time the viral infection was getting better on its own, the patient got antibiotics, and is now *certain* that they're a special case, where antibiotics always work, when in fact they never did, but never caused significant enough harm (diarrhea, allergic reaction, etc.) to dissuade the patient from seeking antibiotics again, either. If they do come back with an "antibiotic failure", you ask them if they did all the other stuff (irrigation, etc.) you told them to do, too, and if they didn't, you have a very good conversation about why the antibiotics didn't work... or they're simply too ignorant to be taught.

 

Patient autonomy means letting them pick "wrong", when that wrong is not specifically harmful. On a macro level, yes, I want to give out antibiotics only for every infection that they will actually treat, but on a global scale that means little to combat antibiotic resistance when many countries have antibiotics as OTCs.

This is not about writing a lengthy and pointless responses. Medicine is evidence base. # of years in practice also a plus. I have being doing this longer than you. You should be willing to listen to those who had being in the field longer. When a pt request for an antibiotic. If i see no indication for initiating an abx I simply would not write them one. I would sit down and go over conservative measures or would rx regime for symptomatic relief. For instance, I would rx flonase to pt with a viral rhinosinusitis with recom that they return to their PCP, or come back if their sx became worse let say in 5 or 6 days (supposing the pt was only 4d into their illness at the time of their visit). Whenever a pt push for abx, I usually would counsel them of the side effect ( diarrhea, resistant, interaction with their meds, the possibility it could worsen their illness etc).

[KMD16]

What a horrible idea!!!

 

I get that sometimes you have to treat but why on earth go with a broad spectrum?

Do the old fashion basic abx like Amox instead of going to the big guns

 

 

 

 

another thing that bugs me (pun intended) PCPs writing a FQ for a simple URI --- WTH??? talk about horrible prescribing!

 

 

simple conservative measures first, if they 'insist' on treatment go over the entire conservative treatment realm (and i had a nice handout that I would give as well)

If they continue to insist and they have a viral etiology - just tell them NO - it is okay - would you give a patient dig just because they asked for it? What about Morphine?

 

remember all drugs are poisons some of which have good side effects.

 

 

As for other issues with ABX anyone been following stool transplantation? This whole field seems to be driven by the past over use of Abx.......

I agreed with you v. That's exactly what I was saying. When pt comes in requesting or expecting an abx. If you see no need for an abx do not start them on one.

[GetMeOuttaThisMess]

For some of us, we've been out since the stone-age and remember how actual sinusitis was a medical problem. Then the surgeons stole it because they needed to make home/car payments. They within the past decade gave it back to medicine once they realized that after a year post-op the same pt. was back in their office with the same sx. and there wasn't anything to operate on again.