primadonna22274 Posted February 10, 2014 Share Posted February 10, 2014 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.Truly an interesting experience for me to see the ENT surgeons admitting SINUS SURGERY DOES NOT WORK...unless the person has a significant structural problem, obstructing polyps or a bone-destroying mucocele. So these guys preach daily irrigation, helping the nose work better, nasal steroids and allergy control.To the person who asked why not the Neti pot: many of the older folks have arthritis that makes it too difficult to contort the head and neck effectively to use it. The straight-up sinus rinse is much easier and works very well. 1 Quote Link to comment Share on other sites More sharing options...
cbrsmurf Posted February 10, 2014 Share Posted February 10, 2014 I know the OP was asking tx for CAP, but take a look at this for macrolide resistance: http://www.cddep.org/ResistanceMap/bug-drug/SP-ML#.UvkQomJdVKI I've read a couple studies on patients developing resistance of around 50% after the first use of a macrolide. Can't find them right now though... Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted February 10, 2014 Moderator Share Posted February 10, 2014 I know the OP was asking tx for CAP, but take a look at this for macrolide resistance: http://www.cddep.org/ResistanceMap/bug-drug/SP-ML#.UvkQomJdVKI I've read a couple studies on patients developing resistance of around 50% after the first use of a macrolide. Can't find them right now though... that's why Doxy is your friend if they are pcn allergic and have a real infection..... Quote Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted February 11, 2014 Administrator Share Posted February 11, 2014 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). Oh don't misunderstand me--I'm absolutely willing to listen, and I DO manage to talk patients out of inappropriate antibiotics in the vast majority of cases, using most of those same tactics. The only issue of difference is what to do when the patient won't listen to good advice. There are plenty of things I won't do no matter what, and most of those I can avoid, but giving antibiotics I can't. I've got hills I'm willing to die on, but that's simply not one of them. For all any of us know, patients who want antibiotics too early MIGHT have a bacterial infection--not likely, of course, but still possible. I work in a large system driven by metrics, and patient satisfaction is a big part of whether I will have a job in the future. It's not a matter of me and my SP having a chat about antibiotic use, it's about patients who fill out anonymous 'patient satisfaction' cards which are only circled numbers that I will never see or get a chance to respond to. In that sort of a context, I'm sure you'll agree that my constraints might be different than others'. 1 Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted February 11, 2014 Moderator Share Posted February 11, 2014 I work in a large system driven by metrics, and patient satisfaction is a big part of whether I will have a job in the future. It's not a matter of me and my SP having a chat about antibiotic use, it's about patients who fill out anonymous 'patient satisfaction' cards which are only circled numbers that I will never see or get a chance to respond to. In that sort of a context, I'm sure you'll agree that my constraints might be different than others'. in 2014 we all have to deal with this crap unfortunately..... Quote Link to comment Share on other sites More sharing options...
bradtPA Posted February 11, 2014 Share Posted February 11, 2014 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. The current narcotic epidemic has me scared to use clarithro; afraid of causing an overdose in someone that won't admit to me they are on methadone or heroin.... Quote Link to comment Share on other sites More sharing options...
sk732 Posted March 16, 2014 Share Posted March 16, 2014 I'm known where I work as an "ABx Nazi"...I have I don't know how many people at this time of year that come wandering in at day 3 of their cold passively/aggressively demanding ABx. As a not so avid sufferer of sinus disease over the years, I've become great friends with my Neil Med wash, and encourage many to use that or Hydrasense. I will go through the long spiel of why's and wherefore's, since I'm paid by the hour and really don't care about metrics at this point in time - the fact I'm still employed I think speaks for itself. One thing I did learn many years ago though - write something out on a piece of paper of how to manage the problem and people generally leave a little happier than when they came in, even if it's for an OTC treatment. The CDC used to make little "Viral Illness" Rx pads that went a long way in helping in this regard - now they're a downloadable, 8.5 x 11" form that you simply fill in the blanks for and hand it over to the patient. Patients are a lot more satisfied if they leave with something in their hand that looks remotely like an Rx - they don't feel like they've wasted their time (even if in reality, they have), but the optics are different then. As for choice of drug, I think I've pretty much ditched Azithro from my brain - I left an area of high resistance because of over use - and use it only for Chlamydia now. There has been the odd study showing part of the resistance issue is it sticking around at sub-therapeutic levels for a long time, giving partially eradicated bacteria a good look at it. Regardless, if they're a true treatment failure with an actual good effort with the steroids and rinses and an appropriate amount of time has past, I usually go with a 2 week course of Doxy or Amoxil. The doxy is in theory easier to take at bid dosing, though it is a bugger if you're a big dairy consumer and does cause a lot of heartburn. As for the numpties that use third line agents like Avelox for a CAP, I'm willing to bet that if they gave their heads a shake, they'd hear the rocks rattling around. I gave a CME lecture for the CAPA conference one year on just this sort of thing, and under the list of "baddies" we were up against besides the various bacteria themselves, I listed "our Rx pads". The excuse I always got was this - "it makes them better faster"...unfortunately, the pharmaceutical companies aren't lining up to pound out newer ABx because they don't make as much money off of them as they do from their chronic care/cancer care drugs. Being ex-military, I always remember this saying from leadership school - "administrators/managers do the right thing, whereas leaders do what's right". We're supposed to act as leaders when caring for people, so do what's right, not what's easy/convenient...believe it or not, the patients will (though sometimes grudgingly and eventually) usually respect you more for it. I know it's hard at the last patient of the day and you're running over or there's a full waiting room, but I still take the time if it will keep the blossoming issue of amtimicrobial resistance in my little community and my personal care home to a dull roar. My (inflated) $0.02. SK 4 Quote Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted March 16, 2014 Share Posted March 16, 2014 Preach it! Actually, if you were to follow the last guidelines that I am aware of that were released you'd be giving them diarrhea from the high dose Augmentin. I used to bang my head against the wall with them as well but it was worth it. As I told them, "there's a reason why I spent the time and money that I did in school". Surprisingly, most of them just nodded and went about their business (free care to the employees so they at least got away from work for a few minutes). Aside from chlamydia, it's all voodoo treatment anyway. Resistance reportedly for up to six months for just about all abx's after therapy, so those that are smarter than I say. Quote Link to comment Share on other sites More sharing options...
Febrifuge Posted March 17, 2014 Share Posted March 17, 2014 732, would you happen to have a link to that CDC viral illness handout? It sounds very useful. Quote Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted March 17, 2014 Share Posted March 17, 2014 CDC Search under provided title: http://www.cdc.gov/getsmart/campaign-materials/print-materials/ViralRxPad.html I like the end where it states to call the CDC for any questions (I know, or at least presume, that it implies that if the provider has any questions to call) 2 a.m., "Hello? CDC? My throat still hurts." Quote Link to comment Share on other sites More sharing options...
Febrifuge Posted March 17, 2014 Share Posted March 17, 2014 Your Google-fu is mightier than mine. I found 4 or 5 wrong pages at CDC and gave up. Thanks. Quote Link to comment Share on other sites More sharing options...
CodyPhrmD Posted May 19, 2021 Share Posted May 19, 2021 On 2/9/2014 at 8:51 PM, Guest JMPA said: 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 This is untrue. Neti (the squeeze bottle) is an amazing tool to help reduce or eliminate the viral/bacterial load in the nasal cavities. Ultimately, it will not fix the issue and abx will be required if bacterial, but mechanically removing the overwhelmingly large amount of v/b from the sinus cavity will greatly decrease the severity of the disease state. In a nutshell, it will reduce sxs to the point that the pt will not feel as sick, even to the point they do not get the inflamed tonsils. I use it, and I highly recommend it, even though the price tag is well overpriced. But, the pt MUST UNDERSTAND to use only distilled water and clean the Neti regularly or they could get a brain eating amoeba and die. (as a note, that actually happened in my area. And then I sold a Neti after a lengthy discussion, to the boss of the lady who died from Netipot.... it worked for him so well that he came back in and thanked me for being so persistent. That's a real story.) Quote Link to comment Share on other sites More sharing options...
sas5814 Posted May 19, 2021 Share Posted May 19, 2021 I have used and advocated for the Neti (used properly) for many years. How did this subject come back from 2014? You been in prison Cody? Quote Link to comment Share on other sites More sharing options...
CodyPhrmD Posted May 19, 2021 Share Posted May 19, 2021 On 3/16/2014 at 5:14 PM, sk732 said: I'm known where I work as an "ABx Nazi"...I have I don't know how many people at this time of year that come wandering in at day 3 of their cold passively/aggressively demanding ABx. As a not so avid sufferer of sinus disease over the years, I've become great friends with my Neil Med wash, and encourage many to use that or Hydrasense. I will go through the long spiel of why's and wherefore's, since I'm paid by the hour and really don't care about metrics at this point in time - the fact I'm still employed I think speaks for itself. One thing I did learn many years ago though - write something out on a piece of paper of how to manage the problem and people generally leave a little happier than when they came in, even if it's for an OTC treatment. The CDC used to make little "Viral Illness" Rx pads that went a long way in helping in this regard - now they're a downloadable, 8.5 x 11" form that you simply fill in the blanks for and hand it over to the patient. Patients are a lot more satisfied if they leave with something in their hand that looks remotely like an Rx - they don't feel like they've wasted their time (even if in reality, they have), but the optics are different then. As for choice of drug, I think I've pretty much ditched Azithro from my brain - I left an area of high resistance because of over use - and use it only for Chlamydia now. There has been the odd study showing part of the resistance issue is it sticking around at sub-therapeutic levels for a long time, giving partially eradicated bacteria a good look at it. Regardless, if they're a true treatment failure with an actual good effort with the steroids and rinses and an appropriate amount of time has past, I usually go with a 2 week course of Doxy or Amoxil. The doxy is in theory easier to take at bid dosing, though it is a bugger if you're a big dairy consumer and does cause a lot of heartburn. As for the numpties that use third line agents like Avelox for a CAP, I'm willing to bet that if they gave their heads a shake, they'd hear the rocks rattling around. I gave a CME lecture for the CAPA conference one year on just this sort of thing, and under the list of "baddies" we were up against besides the various bacteria themselves, I listed "our Rx pads". The excuse I always got was this - "it makes them better faster"...unfortunately, the pharmaceutical companies aren't lining up to pound out newer ABx because they don't make as much money off of them as they do from their chronic care/cancer care drugs. Being ex-military, I always remember this saying from leadership school - "administrators/managers do the right thing, whereas leaders do what's right". We're supposed to act as leaders when caring for people, so do what's right, not what's easy/convenient...believe it or not, the patients will (though sometimes grudgingly and eventually) usually respect you more for it. I know it's hard at the last patient of the day and you're running over or there's a full waiting room, but I still take the time if it will keep the blossoming issue of amtimicrobial resistance in my little community and my personal care home to a dull roar. My (inflated) $0.02. SK Brother from military, great $0.02 (adjusted for GPD 2021 post COVID-SARS2-19) Quote Link to comment Share on other sites More sharing options...
CodyPhrmD Posted May 19, 2021 Share Posted May 19, 2021 2 hours ago, sas5814 said: I have used and advocated for the Neti (used properly) for many years. How did this subject come back from 2014? You been in prison Cody? Well Mr. The Duke, a goggle search turned up this thread... then I went and commented post prison break. Quote Link to comment Share on other sites More sharing options...
Recommended Posts
Join the conversation
You can post now and register later. If you have an account, sign in now to post with your account.