surgeons nose

Hans Erik Busk busk at inet.uni-c.dk
Wed Aug 9 02:20:12 EST 1995


bmorrell at ISNET.IS.WFU.EDU ("Robert Morrell Jr.") wrote:

>I said sadly, but I can see their perspective. In our environment (a 
>tertiary care facility) some doctors are never sure that the organism we 
>recover is in fact what is responsible for the infection. What if the 

Of course you can never be absolutely sure of anything in the
universe, but if the cliniciansdon´t use the result from the lab, then
what is the purpose of taking the specimens?

>staph aureus we recovered from the blood is in fact skin flora 
>contamination and the real culprit is an enterococci that was not 
>recovered? Then switching to oxacillin would hurt the patient. The best, 

That seems highly improbable, unless of course you have some other
clue pointing to an enterococcal infection.

>patient is getting better, and we tell them to switch, some doctors say, 
>leave well enough alone!

We have of course that probem too some times, and it feels like an
awfull waste of time to educate the doctor about the facts of life and
specially the way microbial colonization and infection works. But
eventually most of them will understand.

>Another complicating factor is the fact that when dosing costs are added 
>in, vanc can be cheaper than ox (since it can be dosed less often that 
>oxacillin.

I agree that the argument of cost can be a difficult one to handle. In
Denmark the greatest concern in this direction for the time is the
Ceftriaxone-galore once daily dosing even for infections treatable
with Penicillin-V. But in the long run the cost of using newer broad
spectrum antibiotics is much higher both mesured in money and in
complications.

>> Do you also routinely add ciprofloxacin, mefloquine, and amphotericin B 
>> to the treatment, just to be sure not to miss a typhus, malaria and 
>> yeast infection?

>You weren't listening. Our MRSA % are about 50% (10% of our community 
>acquired staph appear to be MRSA!) With that kind of 
>rate would you flip a coin and treat a suspected staph infection with 

The key word here is SUSPECTED. In order to use our valuable
antibiotics you should either have a specific etiology, preferably
with a susceptibility test, or the patients condition should be so
severe that treatment must be started immidiately. In the last case
you have to assemble the best possible knowledge about the patients
condition AND the microbiological environment in that specific ward.
Very often you don´t have to start an antibiotic treatment
immidiately. Fever in itself is not an indication for antibiotics.
Sometimes we see antibiotics used as "the doctors tranquillizer"

>This is not an academic game of chess, it is a battle to keep patients 
>alive. Waiting on lab reports on a specific case, ignoring cumulative 
>statistics, is not the way to keep them alive.

I would like to modify your statement a little. It ought to be an
academic battle to keep patients alive. 
Often you can wait for the lab report  - then do wait.
If you really feel that you can´t wait then use all your skill and
information available and consult your clinical mikrobiologist to find
the most appropriate (i.e. narrowest spectrum) treatment for that
specific patient.
As soon as you have more information use it to make the treatment as
selective as possible.

And remember: for every misuse of antibiotics today, we will probably
kill patients in the future. Due to untreatable infections.

>If you have such a problem with switching to higher powered antibiotics 
>when old ones become less effective, then why are you even using 
>oxacillin? Why not treat with penicillin, or sulfa drugs, until a lab 
>report comes back? Save lots of money...(NOT)

In Denmark we have been very restrictive with the "higher powered"
antibiotics. the methicillin group and cephalosporins  has not been
used by general practitioners except for very rare occasions, even
though the prevalence of penicillin resistant Staph. in the community
approaches 90%. Most Staph infections can be treated by mechanical
means, and intibiotics is merely an unnecessary adjuvans.

The widespread use of cephalosporins in the USA is probably the cause
for the high rate of MRSA and the high rate of enterococcal
infections. You have seen the first warnings of Vancomycinresistance,
and still there seems to be no hesitation to use Vancomycin, even for
less serious infections.

I am afraid that I don´t understand this shortsightedness, or myabe I
am just wrong ;-)

yours
Hans Erik Busk
Danmark

busk at inet.uni-c.dk





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