Just want to vent on abx overuse

[sk732]

This episode of "DUH" is brought to you by the letters "C" and "S"...

SK

 

[GetMeOuttaThisMess]

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...

 

 

Two things. One, maybe she has drank the Kool-aid like myself and doesn’t care to trust a RST, especially when it excludes other bacterial sources. Two, maybe she was trying to get even with Mom for bringing the kid in by offering a liquid GI cocktail with clindamycin. In all seriousness, maybe she didn’t recognize it as clearly being impetigo and wanted to cover her arse for strep/MRSA with clinda. Augmentin and clinda ARE the great GI equalizer. So what was the drug reaction? A rash?

 

 

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[sas5814]

yup...fairly classic drug rash. Things dermatology are not my strong suit but this looked like it came out of a text book.

I had access to the chart. She called it impetigo. It was a spot about 1/3 the size of a dime. Killing a fly with a sledgehammer IMHO.

[sk732]

2 minutes ago, GetMeOuttaThisMess said:

 

 ...maybe she was trying to get even with Mom for bringing the kid in by offering a liquid GI cocktail with clindamycin.

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I did entertain that idea for a second...does this NP have a Hx of psychopathy?

SK

[GetMeOuttaThisMess]

I did entertain that idea for a second...does this NP have a Hx of psychopathy?
SK

I swear that I sometimes think we’re of a same parent.


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[sk732]

lol

[DizzyJ]

On ‎12‎/‎9‎/‎2017 at 11:18 AM, TheDude said:

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.

 

 

Excellent example of what is becoming more and more prevalent.  Antibiotic demanders and their tag line "So, I came here for nothing basically?".  That is correct if you value my medical opinion as "nothing".  Cough/cold patients are not happy with a viral diagnosis and then on the other end we have patients unhappy because we think they have something more serious requiring an ER visit. 

[sk732]

Need another T-Shirt - "People like you are why antibiotics are prescription drugs".

SK

 

[DizzyJ]

Had an older adult patient present with a white film on tongue as well as some white sore patches on the mucosa. 

Patient says:  "I was with a friend, who is a doctor, and he took a look at it and gave me a prescription for a Z-pack"

Me: "Well, this looks pretty classic for thrush and not a bacterial infection.  What kind of doctor is your friend?"

Patient: "A dentist"

 

[sk732]

13 minutes ago, DizzyJ said:

Had an older adult patient present with a white film on tongue as well as some white sore patches on the mucosa. 

Patient says:  "I was with a friend, who is a doctor, and he took a look at it and gave me a prescription for a Z-pack"

Me: "Well, this looks pretty classic for thrush and not a bacterial infection.  What kind of doctor is your friend?"

Patient: "A dentist"

 

An alleged expert in oral pathology...and people wonder why I hate tooth faeries.

SK

[CAdamsPAC]

On 12/9/2017 at 11:18 AM, TheDude said:

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.

 

 

Been there seen that! Try being a solo provider in rural Alaska dealing with the "know it all, town drunk and leader of the pack".

[GetMeOuttaThisMess]

14 hours ago, CAdamsPAC said:

Been there seen that! Try being a solo provider in rural Alaska dealing with the "know it all, town drunk and leader of the pack".

Simple, "Go chew on that tree bark over there and then go rinse your mouth in the river water.  All done."  That's what I learned from watching "Life Below Zero".  If the bark doesn't work that can also chew on fresh moose kill and floss with bear fur.

[thinkertdm]

On 12/2/2017 at 10:20 PM, MCHAD said:

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”

I get this a lot- I have "claims a 'fever' but no objective measurement of their temperature has been taken" as a smart phrase, it saves time during the history.  Two others I get a lot drive me bananas, I want to scream- the people with lower "normal" temps and 98f is a fever, and the history of... history of bronchitis, ear infections, strep that only shows up on culture...but get snarky when I ask about history of recent travel, bed rest, surgery.

And the exposed to's?  I literally get exposed to multiple things a day, I don't walk in to see my self.

I could go on and on   what really broke the camel's back was the fellow who had chest pain the night before, midsternal, bad enough he had to leave work for...lasted a few hours, when he took aspirin- aspirin? Not ibuprofen?  Yep, aspirin.  Bp was 180/110, no chest pain, and refused to go to the Ed, but his cc was the sore throat he's had for two days.  His girlfriend was there for similar symptoms, with their 6 month old.  He was 24, but 300 pounds, and our shop isn't even an urgent care, so no EKG, just a long line of antibiotic seekers.  

The administrators states people want walk in medicine, but this isn't medicine, it's baloney.  I loved the VA where I was practicing real medicine and helping people. My brain (and heart) dies when a 76 yo "walks in" with a cold, and the nurses notes says cough x 3 weeks, dyspnea, he's gained 20 pounds since his last visit a year ago- with Ortho? Wtf?  And last PCP visit was three years ago? This isn't a five minute visit, this is a g*ddamn break down of the system.  Why?  Ideally, PCP gets called, an rn (not lpn or ma) talks to him, and because he has a therapeutic relationship with a provider, and a decision can be made- er, office visit today, few days.  But now, a poorly trained robot casts them to the wind.  We know this is wrong, and do what we can.

[lkth487]

When I discharge newborns from the nursery, I have a smart-phrase about fevers and what temperature actually constitutes a fever and how to take it in babies.   It's literally bolded, underlined, and in a 20 font....

"he has a fever to 99F" might literally be the single most important reason I chose not to do a pediatric EM fellowship.

[LT_Oneal_PAC]

3 hours ago, lkth487 said:

When I discharge newborns from the nursery, I have a smart-phrase about fevers and what temperature actually constitutes and fever and how to take it in babies.   It's literally bolded, underlined, and in a 20 font....

"he has a fever to 99F" might literally be the single more important reason I chose not to do a pediatric EM fellowship.

I have a nice, easily understood, large font handout on fevers.

”he’s normally low so 99 is a fever for him.” It’s really hard to not change my expression with this phrase that causes me physical pain

[sk732]

If I had a penny for every snowflake out there that claims they're normal temp is 36-36.5Deg C (what I call normal variability), I wouldn't need my job...

On a personal note, I finally relented to allow my boss at work to prescribe me some doxy and a puffer - I got some SARS -like plague from a patient about a month ago, thought it was influenza at first (yes got my shot) but swabs were negative...2 weeksish of fever and rigoring, some sinus issues that I dealt with using my NeilMed, ongoing cough x 3 weeks but been having drenching night sweats for a lot that time.  RN's at work freaked out one day because I looked worse than a couple sepsis patients they had on the go - the charge wouldn't let me work if you can believe that...I've actually had to take more sick time this past month than I've used in the past 15 years combined.  Anyway, 2/7 in on the Doxy and no more night sweats, puffer is helping the cough a bit.  

#jumpedoverfinelinebetweenhardandstupid

SK

[CAdamsPAC]

8 minutes ago, sk732 said:

If I had a penny for every snowflake out there that claims they're normal temp is 36-36.5Deg C (what I call normal variability), I wouldn't need my job...

On a personal note, I finally relented to allow my boss at work to prescribe me some doxy and a puffer - I got some SARS -like plague from a patient about a month ago, thought it was influenza at first (yes got my shot) but swabs were negative...2 weeksish of fever and rigoring, some sinus issues that I dealt with using my NeilMed, ongoing cough x 3 weeks but been having drenching night sweats for a lot that time.  RN's at work freaked out one day because I looked worse than a couple sepsis patients they had on the go - the charge wouldn't let me work if you can believe that...I've actually had to take more sick time this past month than I've used in the past 15 years combined.  Anyway, 2/7 in on the Doxy and no more night sweats, puffer is helping the cough a bit.  

#jumpedoverfinelinebetweenhardandstupid

SK

Doxy 100mg bid x 10 days with  Azithro 500mg bid x 5 days brought me back from the edge bilobar pna

!

[sk732]

I'm honestly interested in WTF I had/have - the patient I saw that had exactly the same initial presentation ended up in ICU with ARDS 2ry to either a viral or weird bacterial pneumonitis...was acting like influenza or atypical like mycoplasma or chlamydia (fever, horrible sore throat, energy sucked away, cough).

 

SK

[cbrsmurf]

Having worked in ENT a few years now, some things in this thread I noticed:

If a patient is getting 6 sinus or sinus-like infections a year, it maybe reasonable to get allergy testing, imaging, and/or a referral to ENT.

Cross-reactivity between penicillins and cephalosporins is overstated (around 1% or less, not 10%).

Macrolides can be used for sinusitis.  However, development of drug-resistance to macrolides is very high, compared to other classes of antibiotics.

It is reasonable in many patients to place them on a 3 week course of antibiotics or sinusitis.

There is evidence adding 2-3 drops of baby shampoo to saline rinses may reduce the time of sinus infections.

[GetMeOuttaThisMess]

2 hours ago, cbrsmurf said:

There is evidence adding 2-3 drops of baby shampoo to saline rinses may reduce the time of sinus infections.

Now THIS is news to me.  "Don't worry about buying a bottle ma'am.  You can use the leftover with a makeup sponge on your funk eye (conjunctivitis) that all females tend to develop over the years".

[Miaow]

On ‎12‎/‎2‎/‎2017 at 8:20 PM, MCHAD said:

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”

I legit had a parent come in with her young teen daughter claiming the girl had chlamydia (all tests negative x 2). The mom insisted that she needed antibiotics because in their family "bacteria likes to hide in their bodies." It runs in their family. Who can possibly argue with that logic? Azith 1 gram PO x 1 dose coming right up! 

Also, with all the talk of URI's here I would like to offer up the "UTI" as the most over-Rx'ed-for-unnecessary-antibiotics condition in recorded history. 75% (conservative estimate) of my patients leave the Urgent Care or ED with a "UTI" with no growth on culture in 48 hours. This isn't to say that I blame UC or ED, oftentimes these patients are exceptionally hard to deal with (mystery pelvic pain, etc.) and demand some kind of "diagnosis" and "cure" in order to feel satisfied. Then they come in to see me for "follow up on recurrent UTI" at which point I have to break it to them, they did not have a UTI x 10 times in the past year. 

[MCHAD]

3 minutes ago, Miaow said:

 Then they come in to see me for "follow up on recurrent UTI" at which point I have to break it to them, they did not have a UTI x 10 times in the past year. 

And if they did why aren’t they seeing a urologist!?

[Miaow]

4 minutes ago, MCHAD said:

And if they did why aren’t they seeing a urologist!?

There is so much overlap between Urology and OB/GYN that I have AT LEAST a patient a week in for some kind of urologic complaint that would almost certainly benefit from Urology consult. However, due to conditions like a large cystocele they may need a pessary to help them void more effectively and urology wants nothing to do with pessaries! 

I had a patient last Friday (Christmas Eve) at 5pm (of course) who was "allergic" to PCN, Sulfa, Nitrofurantoin, Ciprofloxacin and all macrolides with an E.coli resistant to everything but Amikacin, Gentamicin and Nitrofurantoin. Thankfully, after running down her list of allergies, her allergy to Macrobid was that it makes her vomit so ... Macrobid plus PR Phenergan to save the day! 

[PAMEDIC]

22 hours ago, Miaow said:

Also, with all the talk of URI's here I would like to offer up the "UTI" as the most over-Rx'ed-for-unnecessary-antibiotics condition in recorded history. 75% (conservative estimate) of my patients leave the Urgent Care or ED with a "UTI" with no growth on culture in 48 hours. This isn't to say that I blame UC or ED, oftentimes these patients are exceptionally hard to deal with (mystery pelvic pain, etc.) and demand some kind of "diagnosis" and "cure" in order to feel satisfied. Then they come in to see me for "follow up on recurrent UTI" at which point I have to break it to them, they did not have a UTI x 10 times in the past year. 

Interesting.  I would say at most, maybe 10% of my UTIs come back with no growth (or contaminated sample).  I would say about 5-10% of the positive ones come back resistant to Bactrim or Macrobid. 

[skyblu]

We switched labs recently (I’m in UC) and we suddenly have an enormous number of “no growth” on positive UAs w/ 500 leuks, nitrites, etc.

Our new lab is a “budget lab” and sucks on so many levels, I am partially convinced they are somehow improperly incubating the urine cultures.


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