Just want to vent on abx overuse

[sk732]

One of the funniest things I had a patients mom tell me when I said “well the good news is your kiddo doesn’t have a fever” and she was dead serious “I don’t care what your thermometer tells me, my mommy thermometer (hand on forehead) tells me it’s a fever”

Ask her when it was last calibrated?

SK


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[Gordon, PA-C]

One good way to get around this problem is to do viral swab PCRs on everybody with congestion.  You can get the results back anywhere from 4 to 24 hours (if I send it out in the AM it usually comes back by 2 PM) and the costs are fairly cheap and range from $0 to $30.

When moonlighting at a primary care clinic I've used those swabs and successfully got a lot of antibiotic seekers to hold off on antibiotics until the viral swab comes back, and when it comes back positive for rhinovirus I can tell them that is proof that antibiotics won't work.

I have found that if you have objective data like a viral PCR they are much much less likely to get angry and argue with you.  It sucks that you have to drive up healthcare costs with PCR tests but I think it's better than the alternative of just throwing antibiotics at everyone.

[jlumsden]

I'm noticing that not only are these urgent care facilities liberal with antibiotics -- they give the wrong antibiotics.  People are getting azithromycin for their sinus infections.   Men are getting nitrofurantoin for their urinary tract infections.  Fluoroquinolones are being used as first line options.  The patient comes to me thinking his illness is getting worse, when often, he is dealing with the side effects of the antibiotics.

 

[GetMeOuttaThisMess]

While it isn’t a first line choice, one can use macrolides for sinusitis in the rare event it’s one of the 4% of bacterial sinusitis cases.

Depends on if you’re treating the unicorn scenario of bacterial sinusitis and bacterial bronchitis.

 

[sk732]

Just now, GetMeOuttaThisMess said:

While it isn’t a first line choice, one can use macrolides for sinusitis in the rare event it’s one of the 4% of bacterial sinusitis cases.

Kinda like using a JDAM in lieu of a hand grenade isn't it?

Just signed off a UTI C&S with multidrug resistant K.pneumoniae...thankfully not carbapenemaze producing.  Not looking forward to seeing that anytime soon.  I had one lady so overtreated for UTI's that the all but panresistant E.coli she was growing was sent to the national microbiology lab for genetic testing...nitro only that would work, and she got mad when I prescribed it so I showed her the report with all the "R"'s and only one solitary "S".  She stopped seeing me...

SK

 

[GetMeOuttaThisMess]

1 hour ago, sk732 said:

Kinda like using a JDAM in lieu of a hand grenade isn't it?

Just signed off a UTI C&S with multidrug resistant K.pneumoniae...thankfully not carbapenemaze producing.  Not looking forward to seeing that anytime soon.  I had one lady so overtreated for UTI's that the all but panresistant E.coli she was growing was sent to the national microbiology lab for genetic testing...nitro only that would work, and she got mad when I prescribed it so I showed her the report with all the "R"'s and only one solitary "S".  She stopped seeing me...

SK

 

What do you want to give a pt. with a hx of anaphylaxis with PCN?  Doxy, clinda, FQ?  TMP/ SMX no longer recommended as a first line.  Can’t use ceph due to anaphylaxis hx with PCN.  Issues with each of those as well.  In reality, it’s typically a moot point because they aren’t bacterial.  This is why it’s important to know what are the s/s that increase likelihood of a bacterial sinusitis.

[MCHAD]

On 12/2/2017 at 6:30 PM, EMEDPA said:

"amoxicillin doesn't work for me anymore so I list it as an allergy...."

I heard a variant of this a couple weeks ago “my body is immune to amoxicillin so it doesn’t work anymore” I also like “it usually takes 2 rounds of Zithromax to make my sinus infections go away” to that one I’ve actually started saying “it’s because you likely had a cold that would’ve started to improve by day 7 anyways, the antibiotics didn’t do anything and in fact that antibiotic isn’t really recommended for sinus infections anymore anyways” 

[sk732]

14 minutes ago, GetMeOuttaThisMess said:

What do you want to give a pt. with a hx of anaphylaxis with PCN?  Doxy, clinda, FQ?  TMP/ SMX no longer recommended as a first line.  Can’t use ceph due to anaphylaxis hx with PCN.  Issues with each of those as well.  In reality, it’s typically a moot point because they aren’t bacterial.  This is why it’s important to know what are the s/s that increase likelihood of a bacterial sinusitis.

Well, IF I'm going to give something, it won't be a quinolone.  If they have an allergy to penicillin, and IF I'm going to give something, I'd usually go with doxycycline.  I've given cephalosporins to people with PCN allergies and only caused a problem maybe 3 times in past 20 odd years.  The other good thing is I actually get periodically issued an antibiogram for my region, so I have an idea what's working on the common things that are usually implicated, and part of a redistribution of my job description has me signing off a lot of the microbiology studies, so I get a decent idea of resistance patterns.  

SK

 

[GetMeOuttaThisMess]

Non-anaphylaxis allergy to PCN and a cephalosporin trial is now acceptable with cross-sensitivity felt to be <4% (anaphylaxis with ceph used to be felt to be ~10% back in late 70's/early 80's).  IF however the PCN allergy was true anaphylaxis and one gives a cephalosporin with secondary anaphylaxis, then a period in timeout before the legal authorities probably awaits if someone picks up on what was done (at least here in the U.S.).

The reason that I asked is that for those who may not have a lot of skins on the wall just yet, they need to be aware of these changes in thought process over the years.  They also need to be aware that antibiotic choice, regardless of likelihood of its benefit, needs to be able to incorporate all those anatomical regions, if possible, that are impacted.  Thus, the statement regarding the unicorn bacterial sinusitis and bacterial bronchitis.

[sk732]

Lit I'd seen over the years indicated up to 25% crossover, decreasing with time and testing to the 4-5% quoted - and highly unlikely if using 3rd or higher generation ones, as the biochemical structures changed.  Like anything, it's a risk/benefit analysis - if the best drug to use is Keflex and the person has an actual or alleged penicillin allergy and other agents aren't great to use (ie a pile of IV only ones), you need to do the analysis of (a) odds of it replicating, (b) your experience in this actually happening, (c) size and hardness of your gonads and (d) size and hardness of your SP's gonads in backing you up.

1 hour ago, GetMeOuttaThisMess said:

The reason that I asked is that for those who may not have a lot of skins on the wall just yet, they need to be aware of these changes in thought process over the years.  They also need to be aware that antibiotic choice, regardless of likelihood of its benefit, needs to be able to incorporate all those anatomical regions, if possible, that are impacted.  Thus, the statement regarding the unicorn bacterial sinusitis and bacterial bronchitis.

Gotcha...see (c) and (d) above :-D...except make sure that if (c) is good, that (d) won't be your rate limiting step because they're small and lack lustre and worried about patient satisfaction scores instead of real medicine.

SK

[sas5814]

Anything I was going to add to this thread has been said. I have the never ending argument, mostly because of FP NPs, who give steroids and antibiotics to everyone with a drippy nose. Had one woman go from my exam in the UC strait to her best buddy the NP in the back of the building and get dx with "severe sinus infection" and get steroids and a Zpack...which has become the punch line in a joke.

It never ends.

[GetMeOuttaThisMess]

Anything I was going to add to this thread has been said. I have the never ending argument, mostly because of FP NPs, who give steroids and antibiotics to everyone with a drippy nose. Had one woman go from my exam in the UC strait to her best buddy the NP in the back of the building and get dx with "severe sinus infection" and get steroids and a Zpack...which has become the punch line in a joke.
It never ends.

To be a little more specific, you’re referencing oral steroids and not nasal.

[sk732]

5 hours ago, sas5814 said:

Anything I was going to add to this thread has been said. I have the never ending argument, mostly because of FP NPs, who give steroids and antibiotics to everyone with a drippy nose. Had one woman go from my exam in the UC strait to her best buddy the NP in the back of the building and get dx with "severe sinus infection" and get steroids and a Zpack...which has become the punch line in a joke.

It never ends.

 

[d2305]

Just think of all the chlamydia you've cured with z paks.

[BruceBanner]

On 12/3/2017 at 9:37 PM, jlumsden said:

I'm noticing that not only are these urgent care facilities liberal with antibiotics -- they give the wrong antibiotics.  People are getting azithromycin for their sinus infections.   Men are getting nitrofurantoin for their urinary tract infections.  Fluoroquinolones are being used as first line options.  The patient comes to me thinking his illness is getting worse, when often, he is dealing with the side effects of the antibiotics.

 

YES. No offense to anyone who works in urgent care but I see some of the worst decision-making come out of these places.

Z-packs are the answer to all things URI, Augmentin for any hint of a cutaneous infection, hack-job suturing, patients coming in to see me saying an exam wasnt even done...list goes on.

[PAMEDIC]

On 12/3/2017 at 8:34 PM, MCHAD said:

... and in fact that antibiotic isn’t really recommended for sinus infections anymore anyways” 

I usually just follow the standard in 5-minute Clinical Consult:

"Antibiotics should be reserved for symptoms that persist > 10 days, onset with severe symptoms (high fever, purulent nasal discharge, facial pain) for at least 3 to 4 consecutive days, or worsening signs/symptoms that were initially improving."
 

I have no problem prescribing Augmentin if these standards are met.  I encourage and promote supportive care as well, but I have worked with some PAs who wouldn't prescribe antibiotics unless the patient was about the be admitted, at which point I'd say some are being too militant.

Maybe in a few years, my opinion will change.

[rknowle]

New grad here in FM at a practice with an inhouse lab. Any "rules of thumb" that you use for when to order a CBC? Abnormal vital signs, co-morbidities, etc.? Some of the other providers seem to order one on everyone with the sniffles and inevitably they will have a "bacterial shift". Speaking of which, is there any clinical data on "shifts". What cutoff do you use? Some providers use greater than 60 grans, others use greater than 65. Thanks for your input. 

[lkth487]

I can only speak for pediatrics - you pretty much never need to order a CBC in an outpatient setting for a fever unless you're worried about Kawasaki or a non infectious process (oncological, rheum, etc).  The white count especially - it's not helpful in pneumonia, bronchiolitis, URIs, ear infection, etc etc.  Unless they are under 2 months of age, or something like that.

[sas5814]

On 12/1/2017 at 2:45 AM, rev ronin said:

Or maybe some obecalp would be in order?

We had 4 colors of obecalp and #4 red was THE MOST POWERFUL SO BE CAREFUL! Then some whiney butt in admin decided it wasn't ethical despite my argument that if a placebo made someone better were were doing the very best for the patient with no risk.

[TheDude]

I work UC aside from my main specialty (CVT Surgery).  The clinic I work at is fairly busy this time of year with the usual coughs colds and FLU stuff. 

 

A couple of weeks ago a young lady and her whole family show up for her UTI.  I get the usual UA and HcG and off I go.  The UA is completely clean, I mean its probably cleaner than mine.  I go in to talk to the patient and get an exam on her.  As I am talking the mom pipes in and says "just give us our ABX so we can get out of here to go eat, she always has these UTI's and that's what we always get."  I acknowledge her and give her the results of the UA and that I need to do a good exam to make sure I am not missing something.  She is febrile, has LLQ ABD pain that started peri-umbilical, then moved left, pain has been going on for about 2-3 hours.  N/V/D, and pain on exam.  I make the comment and suggestion that this is something that needs to be further looked at in depth in the ER and could possibly be her appendix or her female reproductive organs.  The mom stands up and starts berating me on how I am stupid and that she always gets these "UTI's" and that I just need to give them their f'ing ABX now.  The "boyfriend" in his wife-beater gets between me and the patient and says "You want it in here or outside?"  I play dumb knowing that he's about to threaten me.  So of course I say "what?" He then proceeds to say he's going to beat my ass one way or another.  So I open the door and say "this visit is over, I have offered suggestions to which your daughter may have and that we do not have the ability to treat here and that she needs to be seen in the ER."  The all get up, daughter can barely get off the table, The mom making a scene saying she will have my license blah blah blah and throws the doors open and walks out.

They go to the local ER.  The girl had a ruptured appy, the ER attending calls me to get the story.  He gives me a similar picture that they waltzed in with the same complaints and then bam, she has a bad appy, he told me "the idiot down the street said she a bad belly, but we know its a UTI and we want to see another doc."  So the ER had another ER attending and the General Surgeon see her, they still wanted to take her AMA but finally came to their small senses.  They still filed a complaint on me with the UC and a complaint with the ER.  I never heard anything else.  Looking back on the EMR, this gal comes in about 2 times a month for variable Uro or Gyn issues and is always given ABX's and then I see they will call saying she's not better.  I am assuming she doesn't take the full doses and has developed resistances and all.

I'd rather deal with a narc seeker than this crap.  This sucked and is becoming just as prevalent as narc seekers.

 

 

[sas5814]

On 12/5/2017 at 0:50 PM, GetMeOuttaThisMess said:

 

To be a little more specific, you’re referencing oral steroids and not nasal.

 

yes. The ever popular crowd pleasing medrol dose pack.

[anewconvert]

8 hours ago, sas5814 said:

yes. The ever popular crowd pleasing medrol dose pack.

Everyone needs a prize when they come to the UC ;)

[EMEDPA]

1 hour ago, anewconvert said:

Everyone needs a prize when they come to the UC ;)

aka the "lovely parting gift". perhaps you will feel better about your $500 bill when you realize you got Sudafed and tessalon for it....or not....

[sk732]

Everyone needs a prize when they come to the UC ;)

That’s just it isn’t it - they seem to think they deserve something for darkening our doorways...

SK


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[sas5814]

I just saw a kid for a drug reaction. She saw a NP for a spot of impetigo on her nose and a sore throat. No testing was done on the throat but "she thought it could be strep" and prescribed a 10 day supply of clindamycin. The kid isn't allergic to penicillin.

I am afraid my game face slipped off. Mom said "we didn't see her regular doctor. We saw a PA" and I very emphatically said "NO YOU DID NOT. You saw a nurse practitioner. There is a big difference." *cough*

There are so many facets to antibiotic abuse...