On Antibiotic Stewardship

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DrMike
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On Antibiotic Stewardship

Postby DrMike » Mon Jul 17, 2017 6:03 pm

Most of us got into this mess from taking antibiotics. Now, I am positively *sure* that I don't need to lecture anyone here on why willy-nilly antibiotic use is a bad thing. :-) But I want to talk for a moment about being an informed patient. This is a very long post, but it could save your kid's life.

One thing I've learned in my career as a physician is that sadly:

A LOT OF DOCTORS SUCK AT THEIR JOBS. And if you want to find someone who has a high probability of being not very good, go to an urgent care. I don't know why this is. Maybe it's because they went into medicine for the wrong reason or didn't bail out in time. Maybe it's just caregiver fatigue or burn-out, but I see patterns of failure that repeat. I'll get into these patterns in a bit, but in the end, it frightens me and it angers me.

See, when you bring me your child, you are trusting me with the most valuable thing you have: your child's health. In fact, you are even going to let me touch your child's genitals at some point. I am literally the only non-related adult in society who is allowed to do that. Why do people trust me like this? Because my predecessors have, over centuries, built a reputation for being trustworthy and ethical. Those letters behind my name mean something and when another physician abuses that trust through intellectual laziness, arrogance, overtreatment, abandonment of duty, or frank assault/abuse, it makes me see red. You *should* be able to trust all of us, but you can't.

Now, I'm a pediatrician, so I'm just going to talk about children and antibiotic use. It is OK to thank a doctor and then go find a different doctor if you see these patterns. REMEMBER: this stuff applies to *kids only.* Maybe one day a friendly adult doc will talk to you about all the horrible antibiotic abuses he or she sees in adults.

1) DO YOU KNOW IT'S ACTUALLY A BACTERIAL INFECTION? You should *never* treat strep throat without a positive rapid strep antigen test or positive culture. I don't care who else in the house had it. You should not get these tests in children under 36 mo of age unless there is scarlatiniform rash. The reason for this is that the reason to treat strep throat is to prevent rheumatic fever. Strep throat is very rare in children under 36mo of age and rheumatic fever is even rarer in that age group. You're more likely to kill the child with an allergic reaction to penicillin than you are to prevent a case of rheumatic fever, so unless the child has scarlet fever, don't even test.

I also view with extreme suspicion any diagnosis of "pneumonia" made in a child by X-ray. As per Crain & Gershel's "PEDIATRIC EMERGENCY MEDICINE" (2006) chest X-ray in children is a poor tool for diagnosing pneumonia. Hazy patches caused by local tissue collapse (atelectasis), which happens during viral lower respiratory infections, are indistinguishable from pneumonia on X-ray, especially in children who are wheezing. In one Turkish study published 2003, a whopping 88% of pediatric pneumonia diagnoses were not correct. Pneumonia is a clinical diagnosis. The child with a true pneumonia is breathing quickly but without labor, appears very sick (even lethargic), and almost always has a fever. If an urgent care wants to shoot a chest X-ray for your kid's cough, decline it and go find someone competent who knows how to use a brain and a stethoscope. Chest X-ray in children is good for foreign body, air around the lung (pneumothorax), and pleural effusion (pus around the lung).

Another red flag is the "ear infection on both sides!" Ear infections are uncommon enough, especially in the era of the pneumococcal vaccination. For a child to have an ear infection on both sides? I see it maybe once every couple of years. If you get that diagnosis, your follow-up question should be: "Are you a Board-Certified pediatrician or a Board-Certified ENT?" If not, get an opinion from someone who is. A *BIG* red flag is a diagnosis of "ear infection" when the child has no ear complaint. Acute infection has four signs, CALOR (heat), RUBOR (redness), TUMOR (swelling), and DOLOR (pain). This is a lesson that was hammered into my head over and over again from the first year of medical school and I am utterly stunned when physicians forget it. An ear drum can look awful, but IF IT DOESN'T HURT, IT'S NOT INFECTED. Same is true for bug bites. They can get big and red and swell up a whole arm and yet if they're just itchy...no antibiotics.

If you see these patterns GET OUT and go to someone competent.

2) IS ANTIBIOTIC TREATMENT ACTUALLY INDICATED? According to the 2013 AAP position statement on ear infections, 95% of ear infections in children are caused by viruses, not bacteria. That means that if you just shell out antibiotics to every kid with an ear infection (assuming you made the diagnosis correctly), you will have to treat 20 kids to make one kid better. That's an awful number. So we only treat if the child has had ear symptoms greater than 48 hours, the ear symptoms aren't responding to appropriately dosed pain meds, the ear drum has ruptured (pus draining out), the child is under 6mo of age, or the child has special risk factors (like he's on chemotherapy for leukemia or something). That reduces the number to something more like 2-5, which is a much better number. To put this in perspective, I saw about 5,000 patients last year and prescribed antibiotics for ear infections 7 times.

In children, you should *never* treat a bacterial sinusitis without at least seven days of symptoms first, barring some compelling exception.

And remember, Azithromycin and amoxicillin are not cough and fever meds.

3) CAN THE DOCTOR NAME THE LIKELY ORGANISMS AND CAN S/HE TARGET THE ANTIBIOTIC APPROPRIATELY? I am *sick and tired* of seeing Z-packs prescrbed for "sinusitis." The three most likely organisms are Streptococcus pyogenes/pneumoniae, Moraxella catarrhalis, and Hemophilus influenzae. Sometimes, anaerobic bacteria can get in there and muck things up, too. Streptococcus pneumoniae exhibits penicillin resistance by altering the target protein, but this can be overcome by increasing the dose of amoxicillin. Both M. catarrhalis and H. flu degrade penicillins (as do the anaerobes), so the addition of the clavulanic acid to the amoxicillin (AUGMENTIN) overcomes that resistance mechanism. In the penicillin-allergic patient, fluoroquinolones like levofloxacin and moxifloxacin ("LEVAQUIN" and "AVELOX," respectively) are acceptable. Can your doctor recite those facts? No? Get a new one.

For strep throat, penicillin is the correct choice. I use amoxicillin in children too young to take pills only because the penicillin liquid tastes nasty and the kids won't take it.

So what's a Z-pack good for? Well, mycoplasma pneumonia ("walking pneumonia") and mycoplasma tracheobronchitis. There's 15% resistance to with strep (and 0% resistance with penicillin) but we use it instead of amoxicillin in truly strep-allergic patients. It'll also treat an ear infection in a truly penicillin-allergic child, but you run into the same resistance issues. It's great for chlamydia and campylobacter, though.

If the doc tries to give you azithromycin for "bronchitis," get out of there. Unless you are coughing so badly you can't finish a sentence and the doctor says the words: "mycoplasma tracheobronchitis," don't accept that Z-pack.

4) IS THE DOSE RIGHT? This one is my biggest telltale, but unfortunately most patients can't calculate the correct doses on their own. But, at least for children, the doctor should be able to answer: "What milligram per kilogram dosing regimen are you using?" Whenever I see kids get the requisite "5mL PO BID" and they don't weight 10kg, I always calculate. It's always wrong, too. That's an easy way for me to tell that this doc has no idea what he's doing and needs to go back to residency/med school.

TL;DR If you take your sick kid to an urgent care and they tell you that he a) has pneumonia (off a chest X-ray), b) has ear infections on both sides, or c) try to give him azithromycin without a compelling reason why, go get a second opinion. This is how we prevent C. diff (and other nasty things, like Stephens Johnson Syndrome or bacterial resistance).

beth22
Long Time Contributor
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Joined: Tue Apr 07, 2009 2:23 pm

Re: On Antibiotic Stewardship

Postby beth22 » Mon Jul 17, 2017 7:35 pm

Thanks for posting - good information.

NikaNik
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Joined: Wed Mar 11, 2015 11:52 am

Re: On Antibiotic Stewardship

Postby NikaNik » Mon Jul 17, 2017 7:45 pm

This is fabulous! Thank you, Dr. Mike. Great info!

I would also strongly suggest that adults, kids, everyone keep their hands out of their mouths unless they are washed, particularly in medical environments or while visiting nursing homes. C diff first gets into the gut through ingestion of the spores which can lay on surfaces, healthcare providers' hands etc. In order to help stop c diff from ever being inside the gut where antibiotics can then activate it, not ingesting it is a huge item of importance. Many of us (myself included) had it sitting dormant in our gut for a long while and weren't in a hospital when we were diagnosed. I suspect I ingested it while getting an outpatient surgery with no antibiotics about a year before I took an antibiotic for a sinus infection, that was probably viral! I was never one to take them willy nilly but...Urgent Care (shocker, I know). I remember using sanitizer in the hospital room I had, touching my lips etc. Probably gave myself a nice c diff sandwich which my gut flora held back until the Augmentin. I sometimes wonder if I never took it if the c diff would've cleaned itself out without me ever knowing I carried it. I'm thankful to be c diff free just over two years now (still have some minor post-infectious IBS).

Again, thank you for the posts here and I wish you a speedy recovery!

kmr92
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Joined: Tue May 16, 2017 10:28 pm

Re: On Antibiotic Stewardship

Postby kmr92 » Tue Jul 18, 2017 8:47 am

Love this post!


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