Tag Archives: Antibacterial

Consequences of Inappropriate Antibiotic Use

General Health and Wellness, Infectious Disease, Respiratory/Lungs, , , , , , , , , , , ,

Introduction

This Straight, No Chaser discusses inappropriate antibiotic use.

inappropriate antibiotic use

Whenever physicians attempt to discuss inappropriate antibiotic use with patients, too often fear replaces logic. These days, antibiotic use is treated as a convenience consideration, regardless if there’s actually a disease present that can be treated by antibiotics. Here are some principles your physician is mindful of when deciding if you actually need antibiotics.

We Want to Treat You!

Significant complications exist from missing any disease. If a heart attack is missed, your heart can rupture, and you can die. When a fracture is missed, you can develop necrosis, arthritis and loss of limb. If pneumonia is missed, you can go into respiratory failure and die. Etc., etc. As an emergency physician, my colleagues and I are more in tune than any other specialty of physicians with the risks and consequences of misdiagnosing critical illness; in fact it’s one of the main components of the speciality.

The point is giving medicine is not based on either fear or treating conditions that have a low probability of existing. Any physician is weighing the value of the information you provide to determine what appropriate management will be; that’s the Art of Medicine, and that will always be left to the individual judgment of your treating physician.

That said, the days of such absolute power by physicians are going the way of the dinosaur. Evidence-based medicine and outcomes-based medicine are here to stay. Multiple guidelines for best practices exist across many medical conditions, including when to order ankle x-rays and not, when to order neck x-rays and not, when to treat various infections and not. What’s new here is identifying opportunities to avoid exposing patients to unnecessary, costly medical interventions. What’s also new is you the patient can be better empowered and knowledgeable about the conditions you have and the care you receive.
abx

Antibiotics Come with Risks!

The risk of inappropriate antibiotic use is more real, more present and more important than practicing defensive medicine. 

There are classes of antibiotics that we can no longer use. I mentioned previously how Staph is resistant to several of the penicillins we’ve used for decades due to resistance, which occurs from overuse and inappropriate use, most frequently seen in treatment of viral illnesses. Yes readers, MRSA stands for methicillin-resistant Staph Aureus, and that’s why it’s known as a ‘super-bug’. Approximately 80% of those ear, nose and throat infections you’re coming to the emergency room for and asking/receiving antibiotics for are viral illness and would be better on their own in 48-72 hours.

Have you heard about what happened to gonorrhea due to inappropriate antibiotic use?

Similarly, treatment of gonorrhea has recently been revised by the Center for Disease Control and Prevention (CDC) because of the emergence of resistance to the medications used against it. Again, this has resulted from overuse and inappropriate use of these medications, largely in treatment of viral illnesses. One of the more powerful antibiotics we had at our disposal (a member of the fluoroquinolone class) just got pulled back from its 15 different indications for usage due to emerging resistance. This particularly powerful entity, instead of being withheld for serious diseases, was being used for urinary tract infections, minor skin and soft tissue illness and other conditions that eventually led to a loss of effectiveness. Why would such things be done? Profits and defensive medicine are two reasons that rapidly come to mind.

This is a lot more serious than just overusing medications. Sepsis occurs when an infection overwhelms the body and isn’t just limited to the local site where the infection originated. It can be so devastating that your body goes into shock, losing its ability to function and deliver blood throughout your body. Initial treatment of real illness suffers when we’re using medications that are less effective because bacteria have had time to mutate or otherwise become resistant due to non-lethal exposures.

getsmart_16_3731609472

The CDC and the American Academy of Pediatrics have consistently promoted this philosophy. It’s been included in JAMA, the Journal of the American Medical Association. Inappropriate antibiotic use has consequences!

Illnesses that Don’t Need Antibiotics

Consider the following lists of conditions that commonly can be treated without antibiotics.

  • Common colds and upper respiratory illnesses, including non-strep pharyngitis
  • Influenza (flu)
  • Most coughs and bronchitis (chest cold with a cough)
  • Many ear infections (also called otitis media)
  • Many skin rashes

To be clear, no one is recommending or promoting inappropriate or less than appropriate treatment of conditions that actually exist. No one is suggesting that anything you read here or anywhere else is more important than the real-time judgement of your physician. Just appreciate that opportunities exist to do the right thing and the wrong thing, and medicine is better with an informed patient.

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Straight, No Chaser: Inappropriate Antibiotic Use

General Health and Wellness, Infectious Disease, Respiratory/Lungs, , , , , , , , , , , ,

antibiotics

Whenever physicians attempt to discuss inappropriate antibiotic use with patients, too often fear replaces logic. These days, antibiotic use is treated as a convenience consideration, regardless if there’s actually a disease present that can be treated by antibiotics. Here are some principles your physician is mindful of when deciding if you actually need antibiotics.
Significant complications exist from missing any disease. If a heart attack is missed, your heart can rupture, and you can die. If a fracture is missed, you can develop necrosis, arthritis and loss of limb. If pneumonia is missed, you can go into respiratory failure and die. Etc., etc. As an emergency physician, my colleagues and I are more in tune than any other specialty of physicians with the risks and consequences of misdiagnosing critical illness; in fact it’s one of the main components of the speciality.
The point is giving medicine is not based on either fear or treating conditions that have a low probability of existing. Any physician is weighing the value of the information you provide to determine what appropriate management will be; that’s the Art of Medicine, and that will always be left to the individual judgment of your treating physician. That said, the days of such absolute power by physicians are going the way of the dinosaur. Evidence-based medicine and outcomes-based medicine are here to stay. Multiple guidelines for best practices exist across many medical conditions, including when to order ankle x-rays and not, when to order neck x-rays and not, when to treat various infections and not. What’s new here is identifying opportunities to avoid exposing patients to unnecessary, costly medical interventions. What’s also new is you the patient can be better empowered and knowledgeable about the conditions you have and the care you receive.
abx
The risk of inappropriate antibiotic use is more real, more present and more important than practicing defensive medicine. There are classes of antibiotics that we can no longer use. I mentioned previously how Staph is resistant to several of the penicillins we’ve used for decades due to resistance, which occurs from overuse and inappropriate use, most frequently seen in treatment of viral illnesses. Yes readers, MRSA stands for methicillin-resistant Staph Aureus, and that’s why it’s known as a ‘super-bug’. Approximately 80% of those ear, nose and throat infections you’re coming to the emergency room for and asking/receiving antibiotics for are viral illness and would be better on their own in 48-72 hours. Similarly, treatment of gonorrhea has recently been revised by the Center for Disease Control and Prevention (CDC) because of the emergence of resistance to the medications used against it. Again, this has resulted from overuse and inappropriate use of these medications, largely in treatment of viral illnesses. One of the more powerful antibiotics we had at our disposal (a member of the fluoroquinolone class) just got pulled back from its 15 different indications for usage due to emerging resistance. This particularly powerful entity, instead of being withheld for serious diseases, was being used for urinary tract infections, minor skin and soft tissue illness and other conditions that eventually led to a loss of effectiveness. Why would such things be done? Profits and defensive medicine are two reasons that rapidly come to mind.
This is a lot more serious than just overusing medications. Sepsis is a condition where an infection overwhelms the body and isn’t just limited to the local site where the infection originated. It can be so devastating that your body goes into shock, losing its ability to function and deliver blood throughout your body. Initial treatment of real illness suffers when we’re using medications that are less effective because bacteria have had time to mutate or otherwise become resistant due to non-lethal exposures.

getsmart_16_3731609472

The CDC and the American Academy of Pediatrics have consistently promoted this philosophy. It’s been included in JAMA, the Journal of the American Medical Association. Inappropriate antibiotic use has consequences!

Consider the following lists of conditions that commonly can be treated without antibiotics.

  • Common colds and upper respiratory illnesses, including non-strep pharyngitis
  • Influenza (flu)
  • Most coughs and bronchitis (chest cold with a cough)
  • Many ear infections (also called otitis media)
  • Many skin rashes

To be clear, no one is recommending or promoting inappropriate or less than appropriate treatment of conditions that actually exist. No one is suggesting that anything you read here or anywhere else is more important than the real-time judgement of your physician. Just appreciate that opportunities exist to do the right thing and the wrong thing, and medicine is better with an informed patient.
Feel free to ask your SMA expert consultant any questions you may have on this topic.
Order your copy of Dr. Sterling’s new book Behind The Curtain: A Peek at Life from within the ER at jeffreysterlingbooks.com, iTunes, Amazon, Barnes and Nobles and wherever books are sold.
Thanks for liking and following Straight, No Chaser! This public service provides a sample of what http://www.SterlingMedicalAdvice.com (SMA) and 844-SMA-TALK offers. Please share our page with your friends on WordPress, like us on Facebook @ SterlingMedicalAdvice.com and follow us on Twitter at @asksterlingmd.
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Straight, No Chaser: Fifteen Tips to Care for Diabetic Skin

Endocrine/Metabolic, Health Prevention, , , , , , , , , ,

DiabeticskindmgangreneDiabetic Foot

In this previous post, we discussed the frailty of the diabetic skin and discussed how that sets one up for skin infections, abscesses, ulcers, amputations and even death. Your best defense from these set of illnesses and tragedies is knowledge, prevention and prompt action.  Here are some concern steps you can take to better care for the diabetic in your life. In the event you know a diabetic who appears healthy, I want you to pay special attention to him/her. Diabetes is a chronic and insidious disease. These changes occur over years, and your challenge is to slow the process down as long as possible.
If you have diabetes, these tips may help prevent skin damage and infections:

  1. Do the best to can to control your blood glucose levels. The more out of control it is, the most damage it causes.
  2. You must check your feet every single day for the rest of your life. Diabetes develop decreased sensitivity to their feet. It is extremely common to step on a sharp object and not realize that you’ve done so. A splinter or nail is an excellent medium for an infection.
  3. Eat fruits and vegetables. Your skin needs all the nourishment it can get.
  4. Develop better hygiene. Wash and dry your skin often and thoroughly; this will keep you less exposed to infections.
  5. Make a point of keeping your groin, armpits and other areas prone to heavy sweat dry. Those moist areas in particular are most prone to becoming infected. Talcum powder is a good choice to use.
  6. Stay hydrated. It’s an uphill battle with the frequent urination and high blood sugar (glucose) levels. Dehydration causes your skin to be more brittle and prone to infections.
  7. Stay moisturized! Apply lotion early and often, especially after baths. Note those dry, cracked feet and get ahead of that happening if possible.
  8. Remember: if you’re diabetic, at some point your hands will retain sensation longer than your finger. It’s common to see scald injuries from stepping in water hot enough to burn you without you feeling it initially. Check the water with your hands before stepping into a tub.
  9. Use a milder, less irritating soaps that include moisturizer. Speaking of tubs, avoid bubble baths. Sorry.
  10. Consider investing in a humidifier to prevent skin drying, especially in dry or cold climates.
  11. Always take any skin wounds seriously, especially those on your feet. Avoid placing alcohol on any of your wounds.
  12. Invest in some sterile gauze. If you develop a scratch or other wound, control the wound with it after cleaning.
  13. Limit your self-help to cleaning and gauze wrapping. Only place topical antibiotics or take antibiotics for a skin infection under your physician’s supervision.
  14. Always ask your physician to check your skin during an examination and ask him/her to teach you what to look for.
  15. Immediately consult your physician or access the local emergency room if you have a burn, scratch, abscess (boil) or laceration that seems serious.

Feel free to contact your SMA expert consultant if you have any questions on this topic.
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From the Health Library of SterlingMedicalAdvice.com: "Is It OK to Take Leftover Antibiotics to Treat a Current Infection?"

General Health and Wellness, Health Prevention, , , , , , , ,

oldabx
 
You should never use any leftover antibiotics to treat a current infection. The various antibiotics that are available are effective only against specific bacteria, so do not assume that the old medication will take care of your current infection. Your physician should determine the cause of your infection and prescribe appropriate treatment.
It also is important to note that any time your doctor prescribes an antibiotic, you should take all the medicine you are given on the schedule your doctor provides—even when you start to feel better. Unless your doctor tells you to discontinue the antibiotic, you should not have any left over. Not finishing the prescription means some bacteria could survive and possibly come back even stronger. The surviving bacteria can then become resistant to the antibiotic, make the infection worse, and make it harder to treat.
Thanks for liking and following Straight, No Chaser! This public service provides a sample of what http://www.SterlingMedicalAdvice.com (SMA) will offer beginning November 1. Until then enjoy some our favorite posts and frequently asked questions as well as a daily note explaining the benefits of SMA membership. Please share our page with your Friends on WordPress, and we can be found on Facebook at SterlingMedicalAdvice.com and on Twitter at @asksterlingmd.
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Straight, No Chaser: Inappropriate Antibiotic Use

Cardiology/Heart, General Health and Wellness, Infectious Disease, Medical Treatment, Public Health, , , , , , ,

antibioticsabx

Here’s a great concern regarding strep throat and the previous post that leads to a much more important topic (I’ll take the liberty of paraphrasing.): What about the concern of missing strep throat? Significant complications can result, including damage to the kidney (in a condition caused post-streptococcal glomerulonephritis). First I’ll address the concern, then I’ll get to the topic at hand.
Significant complications exist from missing any disease. If a heart attack is missed, your heart can rupture, and you can die. If a fracture is missed, you can develop necrosis, arthritis and loss of limb. If pneumonia is missed, you can go into respiratory failure and die. Etc., etc. As an emergency physician, my colleagues and I are more in tune than any other specialty of physicians with the risks and consequences of misdiagnosing critical illness; in fact it’s one of the main components of the speciality.
The point is medicine is not based on either fear or treating conditions that have a low probability of existing. Any physician is weighing the value of the information you provide to determine what appropriate management will be; that’s the Art of Medicine, and that will always be left to the individual judgment of your treating physician. That said, the days of such absolute power by physicians are going the way of the dinosaur. Evidence-based medicine and outcomes-based medicine are here to stay. Multiple guidelines for best practices exist across many medical conditions, including when to order ankle x-rays and not, when to order neck x-rays and not, when to treat various infections and not. What’s new here is identifying opportunities to avoid exposing patients to unnecessary, costly medical interventions. What’s also new is you the patient can be better empowered and knowledgeable about the conditions you have and the care you receive.
The risk of inappropriate antibiotic use is more real, more present and more important than practicing defensive medicine. There are classes of antibiotics that we can no longer use. I mentioned just this week how Staph is resistant to several of the penicillins we’ve used for decades due to resistance, which occurs from overuse and inappropriate use, most frequently seen in treatment of viral illnesses. Yes readers, MRSA stands for methicillin-resistant Staph Aureus, and that’s why it’s known as a ‘super-bug’. Approximately 80% of those ear, nose and throat infections you’re coming to the emergency room for and asking/receiving antibiotics for are viral illness and would be better on their own in 48-72 hours. Similarly, treatment of gonorrhea has recently been revised by the Center for Disease Control and Prevention (CDC) because of the emergence of resistance to the medications used against it. Again, this has resulted from overuse and inappropriate use of these medications, largely in treatment of viral illnesses. One of the more powerful antibiotics we had at our disposal (a member of the fluoroquinolone class) just got pulled back from its 15 different indications for usage due to emerging resistance. This particularly powerful entity, instead of being withheld for serious diseases, was being used for urinary tract infections, minor skin and soft tissue illness and other conditions that eventually led to a loss of effectiveness. Why would such things be done? Profits and defensive medicine are two reasons that rapidly come to mind.
This is a lot more serious than just overusing medications. Sepsis is a condition where an infection overwhelms the body and isn’t just limited to the local site where the infection originated. It can be so devastating that your body goes into shock, losing its ability to function and deliver blood throughout your body. Initial treatment of real illness suffers when we’re using medications that are less effective because bacteria have had time to mutate or otherwise become resistant due to non-lethal exposures.
The CDC and the American Academy of Pediatrics have consistently promoted this philosophy. It’s been included in JAMA, the Journal of the American Medical Association. Inappropriate antibiotic use has consequences!

Consider the following lists of conditions that commonly can be treated without antibiotics.

  • Common colds and upper respiratory illnesses, including non-strep pharyngitis
  • Influenza (flu)
  • Most coughs and bronchitis (chest cold with a cough)
  • Many ear infections (also called otitis media)
  • Many skin rashes

To be clear, no one is recommending or promoting inappropriate or less than appropriate treatment of conditions that actually exist. No one is suggesting that anything you read here or anywhere else is more important than the real-time judgement of your physician. Just appreciate that opportunities exist to do the right thing and the wrong thing, and medicine is better with an informed patient.

Straight No Chaser: About that 'Strep Throat'

General Health and Wellness, Head/Eyes/Ears/Nose/Throat, Pediatrics/Kids Health, , , , , , ,

strep-throat Strep-Throat-without-use-of-antibiotics-300x202
Here’s a pretty common scenario. You’re a first time parent with the most adorable kid in the world. You’re in full tiger mom or dad mode, and you’re not going to let anything in the world hurt your baby. Your child has a sore throat, and you’re worried that it could be strep throat. You want to know if s/he needs antibiotics (Actually, you’re demanding antibiotics, but that’s another conversation!).
If a physician is actually using evidence based medicine to treat you instead of just throwing antibiotics at you to make you feel better (We call that ‘treating the parents’), there are criteria (based on what is called a Centor score) that determines when antibiotics are indicated and will make a difference (because most sore throats are caused by viruses and don’t respond to antibiotics; they’ll get better on their own in time). The Centor score is simple enough that you could figure it out yourself. Here are the components.
The patients are judged on six criteria, with one point added for each positive component.

  • History of fever
  • Tonsillar exudates (those white patches in the back of the throat)
  • Tender anterior cervical lymph nodes (those swollen lumps in the upper neck right below the angle of the jaw)
  • No coughing
  • Age <15 add 1 point (because strep is more likely at this age)
  • Age >44 subtract 1 point (because strep is way less likely at this age)

After that, you’ll have a number. Physicians use that number to guide management as follows:

  • 0 or 1 points – No antibiotic or throat culture is necessary; the risk of strep. infection is less than 10%.
  • 2 or 3 points – A throat culture should be done, and the patient should be treated with an antibiotic if the culture is positive.
  • 4 or 5 points – The patient should be treated with an antibiotic (The risk of strep. infection is 56%), and no throat culture needs to be done.

So… if you do this calculation at home and get a 0 or 1, don’t expect antibiotics, and don’t get mad when you don’t get them. There are consequences to inappropriate usage of antibiotics. As I’ve discussed in the past (as with Staph becoming MRSA, for example), antibiotic resistance is a real phenomenon with dangerous ramifications for patients. At a patient, you really don’t want to take medications unnecessarily. Microorganisms develop resistance when you’re taking medications inappropriately. You want to remain such that when you need them, they work.
I’m happy to answer any questions or take any comments. Thank you.
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Straight, No Chaser: Hot Tub and Barbershop Folliculitis (Yep, Even More Staph Infections!)

Skin/Dermatology, Health Prevention, , , , , , , , ,

hottubfolliculitis_20 Folliculitis
Follulicitis. You know it well as hot tub rash, barber bumps, ingrown hairs and many other names. The first thing you need to know is the ‘itis’ means inflammation, and the follicle is the pouch from which your hair grows. Any inflammation of that area is folliculitis. You’ll typically see white-headed pimples with or without itching, pain and redness. So what? Let’s quickly run through causes, problems, prevention and treatment.
Causes

  • It’s usually caused by microorganisms (usually bacteria, including Staph and others, but also yeast, fungi and viruses may do the same).
  • Blocking skin pores will also get you there (think heavy application of make-up or oils, or heavy sweating in tight spandex-type clothing).
  • External irritation can be a cause (think long-term topical steroid use, tight clothing, untreated scratches or lacerations, improperly chlorinated hot tubs, whirlpools or swimming pools).

Problems
It’s inflammation that most commonly is an infection. The irritation can progress to a skin infection (cellulitis) and/or a boil (abscess). These can range from annoyances to ‘not-fun’ to outright problematic, particularly if you’re diabetic, have HIV or otherwise have a compromised immune system.
Prevention
I’m just going to give you a list of healthy hygiene tips that will serve you well in many circumstances, including prevention of folliculitis.

  • Use antimicrobial soap.
  • Don’t share towels, and avoid using the same towel multiple times (Sorry, hotel chains!).
  • Shower immediately after getting out of the swimming pool, whirlpool or hot tub.
  • Don’t shave (and avoid otherwise irritating) areas where razor bumps exist.
  • Be moderate with application of lotions, makeups and other moisturizers.

Treatment
Most cases of folliculitis, whether an inflammation or an infection, resolve in 1-2 weeks, assuming you don’t further irritate it to the point where an substantial skin infection sets in. Consider the following a treatment progression for the overwhelming majority of cases; cases more severe (or any you may be concerned with) require consultation with your individual physician.

  • Warm compresses (clean, hot towels) to the area do a world of good.
  • Wash with antimicrobial soap, and consider using medicated shampoo, particularly if the discomfort is on the scalp and/or beard.
  • Your physician may consider topical or oral antibiotics if the situation warrants or worsens. That means you need to be alert for spreading of the bumps, fever, drainage or worsening of pain, swelling or redness.

Good luck, and I welcome your questions or comments.
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Straight, No Chaser: Find Something Better to Chew On! Ingrown Toenails

Skin/Dermatology, , , , , , ,

ingrown_toenail

The overwhelming majority of cases of ingrown toenails I see come from people chewing on their toenails.  So the really, really Quick Tip is keep your feet out of your mouth.  If only it was that simple.

Ingrown toenails themselves aren’t the problem.  The resulting skin infection and pain are what bring you in to see me.  Remember that the ingrown toenail is caused by the nail burrowing into the skin of the toe instead of growing out and over it.  I’ve always found it interesting that people wait so long for such things, but in this instance, if you are going to wait, there actually are things you can do to potentially make it better.  You’ll know you need to do this if you have a red, swollen, painful toe and especially short toenails.

  • Soak your feet two-three times a day for 15 minutes at a time.
  • Attempt to lift the nail by placing cotton or dental floss under the toenail after you soak.  The goal is to get that nail corner above the skin.
  • Wear open-toed shoes.  This is not the time when you’d want to have any pressure on your toes.
  • Place a topical antibiotic on the area.

Have you ever seen a bad ingrown toenail get removed?  If you have, you’ll likely agree that it’s a deterrent to having another one.  Treatment usually involves lots of local anesthesia (i.e. needles) and partial manual removal of the toenail.  It’s not a good day when this has to happen.

So, you can avoid this fate.  Just follow a few simple steps to avoid it in the first place.

  • Don’t bite your nails.  As discussed in the human bites blog post, you’ve just added really bad bacterial to the mix for when the infection occurs.
  • Don’t cut your toenail so short that you can’t see some of the white tips.  Be sure to let the corners extend past the skin.
  • Don’t wear excessively tight shoes that literally smash your toes onto themselves.

Here’s a final note: if you’re diabetic or otherwise immunocompromised, these infections can spread rapidly and extend into the bone – these infections are very serious.  In some cases this has led to amputated toes.  If an ingrown toenail happens to you, I’d suggest getting seen sooner rather than later.