- ACT I -
Hello.
I think the world will end because of multi-drug resistant organisms.
The end.
LOL I lie.
Y'all wish.
<image from I Am Legend>
Like this really is how I envision it.
If you haven't seen that movie (*snort* at first I typed "video" not movie... tell me you're a child of the VHS era without telling me...), starring Will Smith, not sure how we are supposed to feel about him these days but... You should see it!
I also think that Global Warming would be/is being/was caused by all the unnecessary XRays and CT scans we do in healthcare. I said it first. #NeverForget!
Okay but for real. Antibiotics. Germs. Vaccines. Mutations. Multi-Drug Resistant Organisms... ...including GONORRHEA....
Multi : multiple, a bunch, more than 1 or 2
Drug : Antimicrobial Drug, Antibiotic
Resistant : It stays alive, it keeps replicating, it doesn't go away, you don't get better
Organisms : Germs
And there's another one, will keep this short:
"ESBL". Extended. Spectrum. Beta. Lactamases.
ESBL germs are germs that produce a chemical by-product called Beta-Lactamase.
Simply put, if you have an infection caused by a germ that makes this chemical (enzyme), you'll require more potent/not your basic middle-of-the-mall antibiotic treatment in order to clear that infection.
Extended Spectrum: there are more medications that this germ resists, compared to it's standard non-identical twin.
SO... in the Example: The most common UTI (urinary tract infection AKA bladder infection): E. Coli in your urine/bladder vs. ESBL E. Coli.
Shown above is a photo of what we call a "Urine Culture." I've talked about "Cultures" in past blogs, but, this is a report on an individual patient's urine sample, that tells me, the NP, precisely what infection that patient has. Here: plain E. Coli.
Under the column labeled "Susceptibility", are a list of antibiotics. The far right, all yellow column, tells me that ALL the drugs this lab includes in their culture report, can be used to help this patient!
ESBL E. Coli bladder infection is gonna take some bigger guns to clear out, not just your basic "first line" antibiotics. Shown below, is the Culture and Sensitivity report for a patient who has an ESBL E. Coli Infection... Check out how many drugs on the list their infection is "Resistant" to. Meaning, if I prescribe any of the antibiotics that are listed as "Resistant", might as well have prescribed a box of TicTacs. The patient won't get better. For the poor patient that belongs to this culture report... really bad news... They have to go INTO the HOSPITAL for this infection (by the way - of his new HEART VALVES), because the only drugs their infection can be treated with, are available by IV......
Y I K E S. Yikes, fam.
This is something that has gotten worse with time, and really just catapulted to the next level of ridiculousness now that we live in the "Patient Satisfaction" era... In my opinion.
It just really seems like nobody can tolerate being uncomfortable for a little while.
Steroid shots and antibiotics make the world go round... until they won't anymore...
It's also lost on me that despite the likely millions of conversations that have been had with prescribers and patients on this topic, y'all ALL still busting the doors down for steroid shots & ZPacks after 3 days of nasal congestion. Makes me Grumpy Dwarf.
- INTERMISSION -
ACT II
I watched a CE (continuing education) lecture on "Antibiotic Stewardship" recently.
Did you know that licensed healthcare providers (all kinds, MDs NPs, PAs, Pharmacists, etc..) have to do dozens of hours of continuing education every single year to stay licensed? We don't just go to school 1 time through and tap out on education, despite popular public opinion.
I chose this CE because this is a topic I much care about.
It is a battle I and many (not enough, because enough would be 100%) other prescribers choose to fight 90% of the time in clinical practice. And it is absolutely soul-sucking.
What is Antibiotic Stewardship?
The more accurate term would be "antimicrobial" because antibiotic would refer to anti-bacterial drugs versus an all-inclusive term such as... "microbial" which would account for viruses, fungi...
ANYWAY.
TANGENTS.
I now present to you, A Definition:
"Antimicrobial stewardship ... promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
Misuse and overuse of antimicrobials is one of the world’s most pressing public health problems. Infectious organisms adapt to the antimicrobials designed to kill them, making the drugs ineffective. People infected with antimicrobial-resistant organisms are more likely to have longer, more expensive hospital stays, and may be more likely to die as a result of an infection." (1)
...she said "one of the world's most pressing public health problems"... *shiver*
I don't know if a she or a he or an it wrote that definition but I felt like it was a she and ALL of everybody else from other organizations and fields are in consensus about this "pressing" matter. Including me.
Unless you do a job that requires you to have the same conversation dozens of times per day, repeat yourself over and over, week in week out, month in month out... I'm not sure you could appreciate how deeply we have created a society that understands nothing about any of this. Maybe you can appreciate it. I don't know, I shan't assume.
We are instant gratification trolls, need a quick fix, "a shot to knock it out", super narcissists that think our companies will crash without us there for 3 days and we can't possibly disrupt our week or plans for illness. Yet... We are a lazy bunch. (Did that make me sound British?)
Again, I say, not lazy enough to stay out the urgent care or the family doctor's office to demand an antibiotic for a 3-day runny nose and congestion which people from South Louisiana call "sinus"... that's it, just "sinus"... yet too lazy to take said antibiotic to completion once we have it in our possession.
My grammar for this blog is giving Britney Spears is now British vibes. It's giving British Britney.
Sigh. I do not digress.
I took this screen shot of one of the slides from the presentation I watched. It looks ratchet because it is. Her source is on her slide, but whatever, it's a good visual and this is a free-of-charge blog here:
If you are a prescriber reading this, you may be eye-rolling. But, even if you don't want to, or don't think you do, or you are cooler than being this considerate, you are more than likely contemplating a lot of these factors each time you give a prescription for an antibiotic to a patient.
Is treating Strep Throat or Pink Eye this complicated? Of course not, most of the time.
You'll always have the 1 zebra along the way that'll make things hairy... I had a kid in clinic a couple-few months back that had Strep, that I sent to ER to be worked up for Kawaski... NOT the norm, but it realllly does happen... The point is, if you found yourself a provider (doctor, nurse practitioner, physician assistant...) that cares about doing a good job, giving you appropriate medication, getting you better instead of shutting you up... we are considering a LOT of things when we give you ONE prescription.
HOW can we possibly KNOW what to pick out of ALL the medications available?
Well. That's what school was for. We are educated on drugs, how they work, what they work for, when to use them, how to choose alternatives, and a lot of additional details in school.
Wild.
MOST medicating of the public is "empiric". Pronouced: Em-PEER-ick.
This means that based on history, clinical research, and collective experience, certain conditions can be treated with a certain drug (or a few choices of drugs) WITHOUT knowing exactly what germ is causing the patient to be sick. Things like upper respiratory infections/colds, ear infections, throat infections, skin infections have actually been studied. Researchers have determined that the same organisms cause certain infections over and over, more than ___% of the time. These organisms/germs/groups of germs have things in common, are treatable by the same medications, and don't need to be identified anymore.
Example: A bright red, painful throat with yellow-green pus or white spots on the tonsils, red dots on the palate, big glands in the neck... Group A Strep is the most common germ causing this grouping of symptoms/signs. The FIRST LINE "drug of choice" for Strep Throat is PENICILLIN. Old school, OG Penicillin. Raise your hand if you're allergic to Penicillin (or you think you are cuz ya mama said so). That's a lotta y'all.
We typically do NOT give injectable Penicillin for Strep Throat, OR Penicillin VK pills for strep throat. But, there are circumstances where a shot of Penicillin is best for the patient, such as the kid I sent to ER to rule out Kawasaki who had a +Strep Test. Most of the time, we give Amoxicillin. You have to take this medication less frequently, it's better tolerated, and Amoxicillin can cover for more bugs than just plain Penicillin. If you are allergic to Penicillin, the prescriber would know to avoid those types of drugs, and move to a "Second Line" choice, which would be a group/class of medications called Cephalosporins. Pronounced: Cef-alo-spore-inz. Where the ph says f. Why? How do we know to do this?
School.
Here's what the American Academy of Family Physicians says:
"Pharyngitis is diagnosed in 11 million patients in U.S. emergency departments and ambulatory settings annually.1 Most episodes are viral. Group A beta-hemolytic streptococcus (GABHS), the most common bacterial etiology, accounts for 15 to 30 percent of cases of acute pharyngitis in children and 5 to 20 percent in adults.2" (4)
There are people that did Throat Cultures and blood draws on hundreds of thousands of people that got a sore throat and other symptoms. Researchers. They identified what organisms were making people sick with Strep-like symptoms, and they determined that it is actually "Group A Strep" 5%-30% of the time. Five to Thirty percent of the time. 5 to 30.
We have cheap, fast, easy tests that can tell us whether or not you have Group A Strep. We don't have to guess!
We KNOW these numbers to be true. "We" meaning, prescribers, doctors, NPs, PAs. You can know it too cuz it's all on the internet. Not the point. Here's another (last) example. I promise, show is almost over: EAR infections.
"Many bacteria normally thrive in the passages of the nose and throat. Most are not harmful. However, certain types of bacteria commonly cause ear infections. They are:
Streptococcus pneumoniae (also called S. pneumoniae or pneumococcus) is the most common bacterial cause of acute otitis media, causing about 40% to 80% of cases in the U.S.
Haemophilus influenzae, the next most common bacterium, is responsible for 20% to 30% of acute infections.
Since the introduction of the pneumococcal conjugate vaccine, the U.S. frequency of S. pneumoniae infections tended to decrease, while that of H. influenzae infections tended to increase. S. pneumoniae is still the leading microorganism to cause otitis media worldwide. Moraxella catarrhalis is responsible for 10% to 20% of infections.
Other bacteria include Streptococcus pyogenes and (rarely) Staphylococcus aureus." (5)
Knowing how to say all the names of those bugs is not important. What the point is, is that people have been studying this stuff for a long time. Specifically, American Academy of Pediatrics updates this information every 5 years. If we KNOW that the above germs are THE bacteria that cause middle ear infections, and we also KNOW that Amoxicillin, Augmentin, and other very common medications will cure almost ALL of the germs listed above... we don't HAVE to know which germ you have today. We KNOW the medication will clear it if it's on the list. And that is how Empiric Prescribing works.
Guess what: VIRUSES can cause ear infections too.
There are signs that make bacterial infections more likely: fevers with green/yellow pus in the middle ear, or even draining out of the ear, a lot of pain in the ear or when you move the outer ear around. Infection/Pain in only 1 ear, not both. "Bulging TMs had positive bacterial cultures 75% of the time. The percentage of positive cultures for a pathogen increased to 80% if the color of the TM was yellow. The conclusion is that moderate to severe bulging of the TM represents the most important characteristic in the diagnosis of AOM..." (5)
That's the stuff we learn in school and in our clinical rotations - "experience". What a "bulging TM [ear drum]" looks like compared to a normal one, or one that is just inflamed.
This next table down there, you DON'T have to understand it or memorize it. I am including it as an example. These types of tables are what we learn in school. How and when to choose specific drugs for specific bugs. Specific bugs, the same ones over and over, tend to infect the same areas of the body. You just really aren't gonna see "H. Influenza" infection in someone's urine/bladder. You aren't gonna see "E. Coli" infection in someone's middle ear.
People have studied this stuff.
Treating infections can sometimes mean opting out of an antibiotic, waiting 2-3 days to see if the patient's body clears the infection on it's own, or choosing to use an antibiotic then and there... but, every decision requires DISCRIMINATION. Yes. That highly offensive word, idea, is necessary when it comes to drugs for bugs. Plus, we haven't even talked about curve balls like diabetes, allergies to medications that eliminate whole classes, sometimes 2 classes of drugs for a patient, patients that over-use antibiotics, drug-drug interactions, patients that are known to have infections with drug-resistant organisms like "MRSA"... and you'll see, it's not as easy as we might make it seem, or as thoughtless as straightforward as patients like to think it is. A ZPack & a steroid shot just ain't it, fam.
And that, in a nut shell, a very long nut shell, is what antibiotic stewardship is.
The end.
*applause*