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.

MRSA Update

More reasons to get immunized.

Apparently, in a recent CDC update in Annals of EM, there were more cases of necrotizing pneumonia associated with flu-like illnesses--10 in 2 months, with 6 deaths.

The deaths were notable for the speed of worsening and the age, worse in younger people rather than older.

Still rare, MRSA pneumonia may be more virulent as it is apparently able to kill the very cells (PMNs) that the body uses to neutralize it. Some of these cases were associated with a preceding MRSA skin infection.

CA-MRSA, Bogeyman Extraordinaire

There's been a ton of news recently with regards to community-acquired MRSA--school closings, cancellation of sports events, deaths, rioting in the streets, mass panic. See this NY Times article.

The CDC has adroitly headlined recommendations on their website. One wonders how many hits they've gotten recently.

Wouldn't want to catch MRSA. It can kill you, you know. Keep your kids home from school. Keep them out of sports.

MRSA is now the most common cause of skin infections seen in the ED. It's a common question for med students--how would you treat CA-MRSA versus hospital-acquired MRSA, which is still much more common? The answer is a drug switch: Bactrim or clindamycin instead of vancomycin. Patients in contact isolation for MRSA are common. One of my first patients was a woman who likely turned septic and developed MRSA tracheobronchitis. Not so easy to treat; she was in the ICU for weeks. I've seen her since for a hysterectomy, and she seemed well. She had MRSA from her chronically open and weeping leg wounds. She was immobile.

Superbugs are scary, I admit. Clostridium dificile is scarier to me than MRSA because sepsis and invasive disease can just as easily be caused by bugs that are susceptible, and kill you anyway. So, MRSA is more difficult to treat--but the main problem with early invasive disease is recognizing it and treating it supportively until the correct antibiotic can be chosen. I therefore rate it as about the same on the scariness scale as susceptible staph infections, invasive strep infections like toxic shock syndrome, or meningitis--the kind that kills teenagers. Very scary. But not very common.

A recent JAMA article (not permalinked, may expire) placed the incidence of invasive CA-MRSA infections at 3 to 5 per 100,000 by examining 7 LARGE areas--for example, the whole state of Connecticut. Compare that to the incidence (i.e., only new cases) of diabetes, now at over 7 per 1000, or 200 times more common than invasive CA-MRSA infections. And diabetes is less scary but, over the long run, still loaded with significant morbidity and mortality. It is the leading cause of limb amputations in the US.

What about mortality? The mortality rate from what I can tell for CA-MRSA is 0.5 per 100,000 in the JAMA study above. Heart disease mortality, by contrast, was from 239 to over 430 per 100,000 depending on demographics in the year 2000.

It may well be that resistant infections turn out to be the defining adversary of our generation in health care. For now, though, I wonder if they don't just make good news. Even the CDC, who quotes the rising rates for MRSA infections overall, doesn't advocate the closing of schools. Even if you could eradicate MRSA from all surfaces, I have a feeling it just might be back as soon as the kids return.

So--Purell kills MRSA--wash your hands. And keep living. Because, like it or not, this bug--which lives on everyone's skin, for crying out loud--isn't leaving.