Friday, January 26, 2007

Resistance: Fall of Man

Right after the stomach bug made its way through the household (as described in The Circle of Bleccccccch), my wife came down with lower abdominal pain, suspicious for a UTI.

(It's okay, I've received the necessary clearance to discuss this with you.)

So I brought home a urine dipstick from the office, confirmed (+) leukocytes, and wrote her a prescription for ciprofloxacin for 3 days.

Five days later, she was having back pain. Seems like the UTI bug fought the cipro and won, and was now moving on to the kidneys.

I consulted my Sanford Guide, wrote a new prescription for bigger, badder Levaquin x 7d, and soon enough, we were good again.

Last night, as the Levaquin started clearing her system, the back pain returned.

We called her OB-GYN, who recommended a repeat urinalysis, this time with culture, as well as a renal ultrasound.

(I suppose we could talk about the ethics of treating family members, but I think my treatment to this point was very standard-of-care. One of the unwritten perks of marrying a primary care physician is easy access to treatment and prescriptions, at least for (apparently) straightforward issues.)

The renal ultrasound was normal. (Levaquin: $25. Renal ultrasound: $694. Peace of mind: priceless.)

Meanwhile, the OB-GYN heard from her partner, who had been talking with a local urologist, who described the exact same thing in 3 other patients recently. UTIs that failed to respond to cipro, followed by Levaquin, finally cured with Augmentin.

The Sanford Guide notes "increasing resistance of E. coli to both TMP-SMX [aka Bactrim] & FQs [fluoroquinolones such as cipro and Levaquin] a concern." We should know in a couple of days exactly what the bug is, and its antibiotic sensitivities, but we are seeing the evolution of antibiotic resistance in almost real-time. The standard, first-line antibiotics are no longer working, and we have to resort to stronger and/or more unusual treatments.

In a similar manner, skin infections such as boils and abscesses used to be treated with Augmentin or first-generation cephalosporins such as Keflex or Duricef. The bug that commonly causes these infections is known as staphylococcus aureus, or staph aureus, or staph. Within the past 3-4 years a particularly hardy variety of staph has emerged, known as MRSA (methicillin-resistant staph aureus). It laughs at Augmentin. It eats Keflex for breakfast. Pediatricians are now being advised to use Bactrim as the new first-line therapy against MRSA, and there are only about 3 or 4 other antibiotics total that have any effect. In some parts of the country, about 20% of the staph is now MRSA. In other places, it is 50%.

I don't get a bacterial culture of every skin infection that I see. However, I can say this: in my area of South Mississippi, over the past two years, every single abscess culture has been MRSA. 100%. Without exception.

And people wonder why I am stingy with my antibiotics.

115 comments:

DavidA said...

Just ran into your blog through Flea or something else linked to from PGR.

I'm a paramedic working in the ER in a small city (~100K). Trying to decide if I want to go back to finish up an undergrad degree with the intent of getting into med school.

I read your whole blog and look forward to hearing more of your katrina story. It's also nice to find another Neal Stephenson fan.
-David

Anonymous said...

It's very interesting to see how big concerns you only hear about come into play in the day-to-day practice of non-hospital Doctors. Definitely helped reveal a little perspective, to me at least.

DrGwenn said...

I hope your wife is feeling better!

As a pediatrician, one of my biggest fears is we'll only be left with the horrible tasting stuff - like bactrim! Hopefully more parents will start to embrace the wait and see approach we are using more and more but I fear we may be a day late and a dollar short on that front - the bugs may be winning.

Best,

Dr Scott said...

David--I don't know how old you are, but it's never too late for med school--a classmate of mine turned 40 before graduating with her M.D., one of my roommates was 30; best of luck. By the way, SciFi channel has announced George Clooney will be producing a mini-series of The Diamond Age; let's hope they don't screw it up.

Dr Gwenn--thanks, she is starting to feel better now.
As much as you or I try to prescribe judiciously, I find I'm also in a losing battle with many of my peers. The ER horribly overprescribes, sometimes even for a diagnosis of "URI." I half-jokingly tell them that if they are going to prescribe antibiotics, they at least have to write a semi-defensible diagnosis.

stockingup99 said...

Why didn't you use some dried cranberry tablets and probiotics? These work very well for me in the early stages.

Even if the bugs have grown enough to warrant antibiotics, I would still prefer to see the probiotics and dried cranberry used to prevent recurrences.

Have you evaluated her diet to look for a cause. Too much sugar or black tea were pervious causes of my trouble. The Complete Woman's Herbal has saved me many trips to the doctor by treating things while they were still minor.

Blueberries have recently gotten some very good press for preventing UTIs. Apparently they coat the bladder with something that prevents the bacteria from sticking to it.

Important note that dried cranberries are very different from Ocean Spray or other part cranberry, part sweetener juices. The sugars in the juices can actually promote the bad bacterial growth.

Augmentin ended up being a fertility treatment for me. After a year of not conceiving, I expressed concern. My Ob found a bladder infection and a quick round of Augmentin cured that, and stopped cooking his little swimmers. Pregnant the next cycle.

DrGwenn said...

Glad she's on the mend! I, too, feel like I'm swimming upstream at times but at least in the Boston area we have a savvy community of doctors and the ERs are finally catching on. Still if you compare the bacteria to all us docs that trying to do the right thing, they are a step ahead...scarry.

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