Posts Tagged antibiotics

Severe CNS Infections

Severe CNS Infections are time dependent diagnoses! You must have a high index of suspicion, a good plan for your work-up, and rapid provision of treatment. After seeing a severely ill meningitis patient, I figured I would do a podcast on some tips and pearls on this topic.

[Click Here to Read More and to hear the Podcast]

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How I Missed The 6 Hour Pneumonia Antibiotics Window

When you come in morbidly obese, in this corner, weighing in at 350+ pounds and your physician is having to confirm that you will not break the CT scanner, let’s all just admit that everything gets a lot harder: making diagnoses, finding veins, dosing medications.

When you’re a nonsmoker, nonasthmatic morbidly obese person who comes in short of breath with leg swelling for the past several days, you’re on Lasix at home, and you’ve got some wheezing in your gigantic lung fields, and your chest x-ray looks like pulmonary edema, your doctor thinks he’s made the diagnosis.

But you’re very hypoxic — O2 sat in the 70s on room air — even after 6 hours in the ED, after lasix and some nitroglycerin. So we scan you for pulmonary embolus, worried about a PE. You have no PE, not really much pulmonary edema, but you have evidence of pulmonary hypertension (hi, obstructive sleep apnea) and a small consolidation, even without cough, or fever rectally, we hang your classic ceftriaxone/azithromycin. Missed that all important “6 hour window.”

And thus, our rant begineth.

Similar to my medical errors rant, I think a lot of emergency physicians have problems with these guidelines, which are described as quality indicators and let the public evaluate a hospital based on these guidelines. This assumes that a score of “100%” is the absolute best score for a hospital. So, batter up:

  1. Hey! Medicare! These are guidelines. Not rules. These are to help us physicians guide our therapy, not to control it for us. Individual patients come with individual problems that cannot always be boiled down in a document.
  2. Give humans (in this case, physicians) a perverse incentive, and we’ll start acting perverse. This can go in two ways.
    • Don’t want to be dinged for not giving antibiotics on time? Admit the patient with a diagnosis of “shortness of breath” instead of “pneumonia.” If you’re not in the inclusion criteria, you’ll sneak right by. (I’m not suggesting that physicians actually do this in practice, just giving an example.)
    • Want to make sure you meet those all-important guidelines? Maybe there’s an “early pneumonia,” or the diaphragm’s a little hazy on a portable film? Just give antibiotics to cover your ass (and your hospital’s), even though it might not be what’s best for the patient (example: the patient with hyponatremia who just last week finished a 2-month long battle with C. diff.)
  3. Scientific evidence indicates that the following process of care measures represent the best practices for the treatment of community-acquired pneumonia. Higher scores are better. Okay, so, what’s the data say?
    • One of the leading advocates of this is Dr. Peter Houck, who’s done a bunch of research showing better outcomes with early antibiotic administration. The problem? It’s all retrospective, data-mining from large data sets. (A huge slide deck from Dr. Houck from 2006 provides some rebuttals to this argument.) The data also shows that there’s a difference between antibiotics at before versus after 8 hours; perhaps the magic 6 hour window is a compromise?
    • Another “quality measure” is blood cultures before antibiotics given. And this one is simply just foolish. Antibiotics for pneumonia rarely if ever change clinical practice. This has been shown in multiple studies, from the pulmonology literature to the British Emergency Medicine literature (“30 (1.4% of all cultures) were “true positives” and 4 (0.18%) influenced subsequent patient management.”). Also multiple studies in our own Emergency Medicine journals refuse the need for cultures, too. They rarely, if ever change clinical management, yet they’re “quality indicators.” We might as well have a guideline to order ESR/CRP on patients with suspected pneumonia, too. Give me a break.
  4. And finally, the concept of an acceptable miss rate is — unacceptably — missing from the discussion. Like the general surgeon who misses a few appies or who removes a few normal ones, we should be wary of anyone that reports or preaches 100% compliance to some of these guidelines: are these physicians thinking about risks and benefits and weighing options, or just blindly following? Should we aim toward always getting things right 100% of the time? Absolutely. But the real and theoretical worlds collide. There probably is some small benefit for early antibiotics, and most people most of the time should get them earlier rather than later. (We already have incentives to do this: they can leave the ED faster and move to the floor!) But there should always be a small percentage of cases that don’t fit inside the 95% confidence interval (usually around 5% of them): a group of people who live outside the standard deviations. Aspirin for an MI? Almost always. But how about the MI with the GI bleed with the hematocrit of 10? Or the patient with the anaphylactic aspirin allergy? Risk, benefit. No right answer.

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Has Treating Fever Burned Us?

courtesy wikimedia commons

courtesy wikimedia commons

During the days of the height of the swine flu panic, our pediatric emergency department was especially swamped, seeing several hundred children per day, usually 3-4 times our normal pediatric patient dosage per kilogram. Most everyone was a kid with a fever, plus or minus sore throat, cough, or runny nose. Part of it was sheer media-induced terror, sure. But I can’t help but wonder if another part of it was medical-induced panic: “My child has a fever, that must mean it’s serious!” (We know that there’s little to no correlation between fever and bacterial vs. viral infections.)

We are certainly notorious for this “treat the fever” business. Most of my discharge instructions include “You may give motrin or tylenol for fever or pain.” But we treat fever in our patients for different reasons than parents do: we want to improve vital signs, and see if the kid’s heart rate and respiratory rate improve once the fever is controlled; we want the kid to perk up once the fever is improved. Otherwise, we start thinking badness. (It’ll also slow their metabolic rate, leading to less dehydration and, in really frail kids, less weight loss.)

Parents treat fever for several reasons:

  • They think fever in and of itself is bad, and especially that a high fever is especially bad;
  • Often kids feel better, eat and drink better, and are less cranky without a fever.

I’m certainly not going to blame parents for bringing in their febrile child. One could argue we ourselves as emergency physicians spent a good deal of our residency just learning “sick” from “not sick” (but the experienced parent on child two or three usually figures it out pretty quickly, too). Fever is one of the simple ways to say “Hey, there’s probably an infection going on,” and we doctors are Masters of Infections ™, so it makes logical sense. Often reassurance is the most important part of the pediatric visit: I think it’s a virus, the lungs are clear, the ears are normal, and the child is behaving normally, yada yada yada.

Too often I think people also equate fever with “needs antibiotics” or “needs medicine,” for which we’re to blame as professionals as well. I once had a well-appearing, happy, normal-looking 5 year-old with an otitis media whose mother could not believe I was going to send him home with pain medicines but without antibiotics. “I have never, ever heard of such a thing,” she said, storming out at 4 in the morning, only to return with a script from her pediatrician and several choice words about me. It’s so strange that people have so little faith or respect or belief in their own immune systems — that without antibiotics, the human race would die out. We’ve also created a subculture of patients on day 3 or 4 of their cough who get a Z-Pak and then believe that the Z-Pak cured their bronchitis or URI. These are the patients who now are dependent on antibiotics for their magical antiviral properties and demand them immediately, preferring not to listen to reason, logic, or risk-benefit discussions.

It shouldn’t be up to parents to decide “sick/not sick” before coming to the ED, and if we decrease our sensitivity we just end up with more false negatives. If we tell parents not to bring kids in unless they have a fever AND they “don’t look right,” we’re going to have fewer kids overall but sicker ones who eventually find their way in.

There’s no great solution besides educating people about signs and symptoms of a potentially sick child, but we can certainly try to educate people about fevers: they’re not dangerous, they’re probably the body’s way of trying to fight off infection by “making the body work harder and faster than whatever’s attacking it” (my usual spiel), and usually we worry about children becoming dehydrated from viral infections more than the viral infections themselves. What else can we do?

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