No Hay Disculpas Por El Uso Excesivo!

"There aren't excuses for excessive use". So says the poster about antibiotic use. Shouldn't that be directed at physicians? Aren't we the ones who hold the power to give, or not, that overestimated, well-named Z-pak for sinusitis?

Just the other day a father came in with what sounded like a nasty sinus infection, daughter in tow, 6-month pregnant wife at home, and asked for something to 'wipe out' the nastiness in his head so he could take care of his family. Noble. Hard to refuse. It's not for his gain. The enemy is easy to visualize--the enemy is snot.

It's not, because the enemy is resistance, the best argument yet against the creationists that evolution, despite their protests about intelligent design, is real and happens constantly.

Is there evidence to support giving antibiotics? The studies are numerous. A British Medical Journal article in 2003 found no difference between placebo and Augmentin (amoxicillin plus an augmenting agent) in clinical cure rate, and the patients were selected with 'pus on rhinoscopy' which is how we often do it in the office, rather than x-ray or aspiration (needles into your sinuses). The Cochrane database, a respected organization that collates results, found at best moderate improvement and recommended amoxicillin. The British Medical Journal also has a 'Clinical Evidence' site that summarizes articles they found through 2004 that show no significant difference between treated and untreated patients given placebos in symptoms. So even if we think it will make our patients feel better, it won't, and according to the website, no surprise, there is a significant increase in diarrhea.

Of course, there are other reasons to avoid treating patients. MRSA, on the left, is increasing. A recent Emergency Medicine symposium sponsored by the University of Kentucky (as well as Ortho-McNeil) on CA-MRSA has some interesting points. Penicillin (a relative of amoxicillin, what we typically use for sinus infections) was first introduced in 1941. Resistant S. aureus, the SA in MRSA, was first reported in 1942. Isolated reports of community-acquired MRSA started in the 1980s. A Detroit outbreak in the 1980s showed an increase of resistance from 3% to 38% in only 19 months. In LA, one ED saw MRSA rates increase from 29% to 64% in 3 years. Across the country, an average of 59% of all soft tissue infections presenting to the ED are MRSA.

So what, you might say. What does this have to do with me wanting my Z-pak so I feel better the day after I get sick? Well, how are these increases occurring? We know MRSA is spread by contact, so maybe all these people are really close. Or...surveillance testing of MRSA is conducted by swabbing someone's nostril, where the MRSA lives when it's not invading the lungs or skin or CSF. As seen by the 1941-1942 time gap, penicillin and related antibiotics induce resistance. And we see a quick increase in communities. MRSA lives in the nose, and sinusitis is in the nose, too! So we know we're putting antibiotic pressure on a patient's upper airway.

How much is antibiotic pressure contributing to the rise of MRSA strains? If we give that person with acute sinusitis amoxicillin, are we contributing to the rise of MRSA? I haven't seen a study that documents one way or the other in specific patients with sinusitis, but overall misuse of antibiotics leads to resistance. This article breaks down the major primary care complaints--ear infections, sore throats, and sinus infections--as they relate to resistance.

It gets worse. The same article estimates that up to 10% of CA-MRSA infections are invasive. Osteomyelitis (bone infections, nasty) and pneumonia are being seen in previously healthy patients, and they seem, for whatever reason, to be in young patients. Mortality for CA-MRSA pneumonia ranges from 25-60%, according to the symposium mentioned above.

So there are good reasons not to treat. In the nice clean office with a person snuffling miserably imploring you for antibiotics, who has been told by all their friends that all they need is a Z-pak to 'nip that thing in the bud', it's hard to hold the line. I heard a story the other night of one parent telling another to go get a burst of prednisone, really strong medicine with significant side effects, for their kid's cough. Not trouble breathing or major asthma exacerbation, their cough. But what's our job? To make people comfortable? Sometimes. But we can do that with supportive care and empathy. Our other job is to try and prevent them from dying or being sick for the rest of their lives. For that part of our job, we should send them home most, if not all of the time, or at least until they've had 7 or more days of serious symptoms.