Tuesday, May 02, 2006

Staph infections

I had a patient ask about her father who I was treating for a sternal wound infection after a coronary bypass operation. She asked what MRSA was as she'd been told her father was infected with it and she was concerned over stories she'd heard on TV.

MRSA is methicillin-resistant Staphylococcus (staph) aureus bacteria that's become an increasingly prevalent issues in society. Previously mostly confined to hospitals & nursing homes, we've now seen rapid changes in community infection patterns to where in some areas, drug-resistant staph infections are the rule rather then the exception. I'm usually surprised now when it's not a resistant infection that shows up in the ER or wards.

Some recent well-publicized infections from football fields and neonatal units have made headlines. Predictably, the lawyers are also now advertising this as a new tort for class action lawsuits.

What's driving this emergence of MRSA? A lot of things are being implicated.

- Inappropriate antibiotic use in the outpatient setting (think getting antibiotics from your internist or pediatrician for the common cold, a viral process not sensitive to antibiotics)

- Inappropriate antibiotic use in the inpatient setting (prolonged prophylactic antibiotic use for surgery, unnecessary broad spectrum coverage, failure to change prescribing patterns to hospital bacteria sensitivity profiles)

- The rise since the early 1980's of powerful new Penicillin-class (Unasyn,Zosyn,Fortaz) antibiotics followed by other new class of antibiotics like the Quinolones (Cipro,Levaquin,Tequin) which put tremendous tools in our hands for fighting infection, but also produced "social Darwinism" among bacterial strains that resulted in resistant species

- Massive use of antibiotics given to livestock, which result in larger feed animals

- Consumer products that now contain anti-biotic material (mouthwash, soaps)

- Breakdowns in universal precautions (gowns, hand-washing) to avoid patient to patient spread (which isn't really causing MRSA but facilitates it's transfer)

What's this got to do with Plastic Surgery? Well, many of us do in fact treat some of the worst soft tissue infections you'll see. In addition, antibiotics have historically been given indiscriminately after many elective cosmetic procedures. Despite a lot of evidence not supporting antibiotic use beyond the peri-operative period (or possibly at most 24 hours), you see a lot of people continue to give 5-7 days of oral cephalosporins (eg. Keflex).

What drives this? Defensive medicine & patient's expectations. Many people have rationalized that if a infection develops & they did not have someone on antibiotics that there will be both medical liability & upset patients. You may not be able to avoid the latter, but there is increasing data that we may in fact be causing more problems (on a system-wide perspective) then we are avoiding. Unrequired antibiotics will result in more cases of anti-biotic colitis & drug-resistant infections.


Anonymous said...

I'm a medical student finishing up microbiology with plenty of doom and gloom antibiotic resistant bugs shoved down my throat including predictions of the "end of the age of antibiotics".

Still, this kind've utilitarian philosophy on antibiotic use, which is presented as the unquestionable standard considering MRSA and VRE (and god forbid future VRSA), does not sit well with me.

Not to get too personal but in high school as a completely healthy young man I came down with a pneumococcus pneumonia; a Z pack would've cured me. But I was walking around, I was fine, I was young, I had no risk factors, and so it wasn't generally considered.

Now, you can question my care, no doubt. For instance, I had no CXR. But to imagine that a more conservative use of antibiotics does not leave a small number of patients out in the cold is foolish.

Long story short, I don't drink, I don't eat because I don't feel well, my steriods for my cough contribute to kidney malfunction and I end up in the hospital. I get rehydrated leading to a pleural effusion (worst pain ever), which is thick and can't be aspirated by a needle. I end up with general anesthesia, a thoracotamy, and a four inch scar on my back.

It is a very utilitarian antibiotic policy which has been adopted -- a more conservative immediate care to protect against future antibiotic resistance. Without question, the costs of missed antibiotic prescription (which are inevitable in slightly greater numbers with more conservative antibiotic protocals) are far, far outweighed by the benefits gained over antibiotic resistant drugs.

But in very many ways this is an extremely slippery slope. Imagine applying this utilitarian principle to all of medicine. The humanity would dissappear.

Those with terminal diseases would recieve no care, better not to waste physicians or the training for such, on pain for instance, when there is unquestionably an issue of physician shortage in areas of true life and death.

The alarmist list goes on. Such obviously will never happen, but it shows the lengths to which the philosophy behind the what I'm being taught about antibiotic use can be extended.

Isn't there an obligation to treat the immediate patient to the absolute best of your ability in favor of concern for future consequences? I understand there's implications to liberal antibiotic use even in single patients, but clearly there are at least SOME potential benefits to the prescription of say an antibiotic to a patient suffering from a virus (indeed, it is difficult from a clinical diagnosis to be more than 99% sure of such a viral cause).

Dr. Rob Oliver said...

I'm confused by your statement as Pneumococcal pneumonia in a young person would not be an indication to withhold antibiotics. This is in contra-distinction to viral upper respiratory processes. You also mentioned being on steroids, which would be a big red flag for treating you more aggressively.

You posed that "Isn't there an obligation to treat the immediate patient to the absolute best of your ability in favor of concern for future consequences?". That is a question that poses a false choice as undirected antibiotics do in fact cause morbidity and mortality. Appropriate anti-biotic usage minimizes both resistance and anti-biotic related complications, which is reflected in surging cases of antibiotic related colitis and muti-drug resistant infections.