If you had to pick one antibiotic...

[Liff]

Why does no one ask, "What is the best blood pressure medicine I should stock for the paw?" Or, "Which corticosteroid should I have on hand?" Or even, "Which Type II diabetes medicine should I keep around, just in case?" Or an even smarter question, "Which inhaler lasts the longest?"

There is something about the desire to stock up on antibacterial medicine, "just in case". I don't understand it. Ask Dallas, abelru, me, or anyone else who has some formal pharmacology training and some formal infectious disease training and we don't think it is a great idea. Too many variables, and basic hygiene is a much, much better place to start.

So yeah, I don't understand the desire to acquire antibiotics. Maybe it is books and movies? Like in TWD: gun shot + antibiotics = no problem ? I don't know, but I do know that I am never going to be able to convince anyone to not do it, I just hope I can convince people to try to not hurt themselves, or others.

[duodecima]

I actually understand why people get so stuck on antibiotics. There's this really easily observed cause=>effect, which isn't there with antihypertensives. I believe the greatest increases in life expectancy in the last century have come from 1)hygiene! 2) vaccines! and #3 is antibiotics. Cool as corticosteroids and antihypertensives are, they don't extend life so dramatically.

abelru - I've been deliberately not even bringing up bronchitis and sinusitis, or the occasional catastrophic side effects of corticosteroids . But it's not a hell of a lot of fun to explain to somebody that they're likely to cough for 3 weeks and antibiotics aren't going to help. People got really pissy about it when I was still in private practice.

[rhi]

Is vancomycin still considered a "last resort" treatment? I know it was back in the mid-80s when we were working on isolating similar glycopeptides.

*ETA: Just in case someone got the wrong impression... I wasn't bringing this up to recommend this drug. It's not absorbed when taken orally and can have some pretty nasty side effects when administered IV. Even in the ZPAW, it would be best to steer clear of this one.

[duodecima]

Is vancomycin still considered a "last resort" treatment? I know it was back in the mid-80s when we were working on isolating similar glycopeptides.

It's one of the few things that almost always works (on appropriate bacteria), but there is growing resistance (vancomycin-resistant enterococcus is common enough it's just "VRE" now, like MRSA...), so we do try to reserve it for times when there are no other good options. It's getting used more and more often however.

(Note to those stocking up, vanco is NOT absorbed out of the gut worth a darn, the only role I'm aware of for oral vancomycin is in a diarrhea most commonly caused by ... antibiotics! There's no role for fish vancomycin in the PAW!)

[abelru]

Is vancomycin still considered a "last resort" treatment? I know it was back in the mid-80s when we were working on isolating similar glycopeptides.

It's one of the few things that almost always works (on appropriate bacteria), but there is growing resistance (vancomycin-resistant enterococcus is common enough it's just "VRE" now, like MRSA...), so we do try to reserve it for times when there are no other good options. It's getting used more and more often however.

(Note to those stocking up, vanco is NOT absorbed out of the gut worth a darn, the only role I'm aware of for oral vancomycin is in a diarrhea most commonly caused by ... antibiotics! There's no role for fish vancomycin in the PAW!)

The ID guys I work with will frequently start therapy with vanco for complex SSTI (skin/soft tissue infection), and pull back to something else (oxacillin, diclox, ancef, pen G, etc) once gram stain and/or cultures suggest something else is better suited. If MRSA, most stay on vanco for the parenteral course of therapy, and convert to novel oral therapy.

[abelru]

abelru - I've been deliberately not even bringing up bronchitis and sinusitis, or the occasional catastrophic side effects of corticosteroids . But it's not a hell of a lot of fun to explain to somebody that they're likely to cough for 3 weeks and antibiotics aren't going to help. People got really pissy about it when I was still in private practice.

Thankfully, my current practice has me FAR removed from sniveling noses, otitis, and the omnipresent and ever-deadly non-productive cough.
Previously, I was elbow deep in it. I tried hard to fight the good fight, until a colleague got a death threat (sounded legit) for refusing to provide some meathead with abx.
There was some seriously reckless prescribing behavior going down after that one.

Also, since we are on the topic of odd fixations, what is it with suturing? Seems like there has been a spate of suture threads lately. Even several poo-pooing primary closure. I suppose this falls into the "do 'x' and problem solved" category.

[Jamie]

I would argue that exposure to nasties has been a good prep for me...after 13 years of teaching 6th grade, I get sick much less than I used to do. In my first few years, the constant exposure to coughs and runny noses had me sick a number of times each year...but I recent years, I've gotten sick much less...I think I'm exposed to everything that comes down the pike, but it affects me less and less as time goes by...

Jamie

[painiac]

I would argue that exposure to nasties has been a good prep for me...after 13 years of teaching 6th grade, I get sick much less than I used to do. In my first few years, the constant exposure to coughs and runny noses had me sick a number of times each year...but I recent years, I've gotten sick much less...I think I'm exposed to everything that comes down the pike, but it affects me less and less as time goes by...

Jamie

You've just hit on one of the most important points of all: most of the illnesses that have people crying to their doctor to get antibiotics for are nothing more than a mild inconvenience, and keep our immune systems exercised. What follows is not really a response to you, Jamie: I'm just running off on a train of thought that was somewhat spurred by your comment.

Medicine isn't like business: the customer is not, in fact, always right. It's not like Burger King, either: you SHOULDN'T fucking have it your way. Unfortunately, business-minded administrators are extremely unlikely to see this. We are constantly dealing with Press-Ganey survey results, where head-in-the-ass statisticians solicit ratings and comments from patients. These surveys are fatally flawed for a number of reasons, but most importantly by the fact that the people most likely to bother responding are those with the strongest opinions, and the people with the strongest most vocal opinions are frequently the stupidest or most ignorant with the most unrealistic expectations about medical treatment. Then we are pressured by administration to provide patients with what they're expecting so they are satisfied, and what patients expect when they see a doctor is to go home with a prescription that will cure their complaint... catastrophic long-term consequences be damned.

A couple of the ER docs I work with are extremely good, and are very resistant to prescribing antibiotics for mild viral infections and very resistant to handing out Vicodin like it's candy. As a result, they were leaned on so hard by administration because patients kept complaining that they became fed up. One of them said, "fuck it", and for a couple months if anybody wanted Vicodin they got it. Shortly after that, the DEA started cracking down on "pill mills". We weren't and aren't involved in that at all, and that doctor ended up quitting.

[Tperkins]

I would argue that exposure to nasties has been a good prep for me...after 13 years of teaching 6th grade, I get sick much less than I used to do. In my first few years, the constant exposure to coughs and runny noses had me sick a number of times each year...but I recent years, I've gotten sick much less...I think I'm exposed to everything that comes down the pike, but it affects me less and less as time goes by...

Jamie

You've just hit on one of the most important points of all: most of the illnesses that have people crying to their doctor to get antibiotics for are nothing more than a mild inconvenience, and keep our immune systems exercised. What follows is not really a response to you, Jamie: I'm just running off on a train of thought that was somewhat spurred by your comment.

Medicine isn't like business: the customer is not, in fact, always right. It's not like Burger King, either: you SHOULDN'T fucking have it your way. Unfortunately, business-minded administrators are extremely unlikely to see this. We are constantly dealing with Press-Ganey survey results, where head-in-the-ass statisticians solicit ratings and comments from patients. These surveys are fatally flawed for a number of reasons, but most importantly by the fact that the people most likely to bother responding are those with the strongest opinions, and the people with the strongest most vocal opinions are frequently the stupidest or most ignorant with the most unrealistic expectations about medical treatment. Then we are pressured by administration to provide patients with what they're expecting so they are satisfied, and what patients expect when they see a doctor is to go home with a prescription that will cure their complaint... catastrophic long-term consequences be damned.

A couple of the ER docs I work with are extremely good, and are very resistant to prescribing antibiotics for mild viral infections and very resistant to handing out Vicodin like it's candy. As a result, they were leaned on so hard by administration because patients kept complaining that they became fed up. One of them said, "fuck it", and for a couple months if anybody wanted Vicodin they got it. Shortly after that, the DEA started cracking down on "pill mills". We weren't and aren't involved in that at all, and that doctor ended up quitting.

Ditto; and it's a sad consequence that the doctors who act like they should are the ones that often face consequences or end up quitting due to the BS they endure for doing what they should, instead of what aforementioned patients wish of them.

[painiac]

Sometimes I think it would be better in some ways if we went back to the way it was done in the old days, when the only pills doctors had in their bags were aspirin, laxative, and sugar placebos...

[Max_Rodriguez]

I have always had good results with cipro

[Doctorr Fabulous]

Sometimes I think it would be better in some ways if we went back to the way it was done in the old days, when the only pills doctors had in their bags were aspirin, laxative, and sugar placebos...

Before you go that far, also rememeber that back in the day the average lifespan was closer to fifty or so.

[duodecima]

Sometimes I think it would be better in some ways if we went back to the way it was done in the old days, when the only pills doctors had in their bags were aspirin, laxative, and sugar placebos...

Before you go that far, also rememeber that back in the day the average lifespan was closer to fifty or so.

Yeah. Watching a preemie who's blood cultures grew E. Coli at 12 hours ( ) graduate from NiCU without having had any significant instability in vitals, because he got put on Ampicillin & Gentamycin at birth? That's a frickin miracle. Ditto being able to treat endometritis (previously known as childbed fever) without even half thinking about it.

There's a real,serious role for antibiotics. It's just that the average healthy person with a miserable but non-serious problem who goes to see their doc, commonly doesn't need them. The fact that people have "no time" to be sick, and rest to get better, and that it's commonly inconvenient and expensive to see your doc, is a big part of the problem. Imo.

For me, I've got no problem politely but implacably refusing to practice bad medicine. I just can't let the "take antibiotic X because it always works for me," pass without comment.

[dallas]

I have always had good results with cipro

Was it for something that would get well just as fast with nothing? If you use it too much, it might not work when you really need it.

[lagna245]

I'm not that familiar with cipro, but my wife was prescribed some a while ago from a doctor and the list of side effects was a little intimidating, much more than the typical amoxicillin nausea, etc warnings, basically sounded like she would die by taking it. Because of that I'd opt for Cephalexin, which is Fish Flex. It is a broad spectrum antibiotic that works well with lots of different things. I've had good luck getting my fish antibiotics from http://www.fishmoxfishflex.com/ - they have free shipping on every order.

I'm interested to know others experience with cipro though, I need to do more research for sure.

[Liff]

Not sure if Spam or if you are the reason medical professionals are frustrated. I hope it is spam.

[duodecima]

I'm not that familiar with cipro, but my wife was prescribed some a while ago from a doctor and the list of side effects was a little intimidating, much more than the typical amoxicillin nausea, etc warnings, basically sounded like she would die by taking it. Because of that I'd opt for Cephalexin, which is Fish Flex. It is a broad spectrum antibiotic that works well with lots of different things. I've had good luck getting my fish antibiotics from http://www.fishmoxfishflex.com/ - they have free shipping on every order.

I'm interested to know others experience with cipro though, I need to do more research for sure.

Please, let's NOT select antibiotics based on other people's personal experiences with it, cipro, cephalexin, or anything else. There is science regarding which antibiotics are actually effective on which bacteria, which bacteria are likely causing a given problem (if the problem is indeed bacterial) and that's WITHOUT throwing in local resistance patterns, which are highly variable.

For example, cipro would be a reasonable choice for a urinary tract infection, and a poor choice for a bacterial throat infection. Cephalexin might be a good choice for the throat infection, but is a lot less likely to work in a urinary tract infection. This is presuming that the throat infection is in fact an infection, and is not a viral infection. Also, what's the rate of ciprofloxacin resistance in urinary pathogens in your AO? It's higher in mine than it was 5 years ago, altho not so high that we should stop using it for a while (this year, anyway). Cephalexin used to be a first choice for skin infections (if they actually needed antibiotics!) but the resistance rates are now high enough that we rarely use it for that, without a culture showing sensitivity. I don't prescribe a lot of it anymore.

Yes, these things absolutely have side effects - but if I've got a raging kidney infection I'll take the cipro, and take my chances with the occasional tendon rupture. But exposing someone to that potential side effect, in a case where cipro was not going to be helpful, or unlikely to be helpful, is bad medicine. But so's using cephalexin on a kidney infection unless you've got a culture showing a bacteria that's sensitive to it (which is not common for that type of infection).

What's the best antibiotic for a simple pus pocket, 1 inch big, in the skin, cipro or cephalexin? Trick question! Neither, nor any other antibiotic. Simple pus pocket does best with drainage of pus alone, no antibiotic at all.

Before you figure out what antibiotic to stock - figure out who on your team has the ability to figure out if and when they're needed! If you don't have such a person, your resources are better spent on finding or training such a person.

[Vicarious_Lee]

Sometimes I think it would be better in some ways if we went back to the way it was done in the old days, when the only pills doctors had in their bags were aspirin, laxative, and sugar placebos...

One of those few ways being our Social Security burden. That would pretty much fix itself overnight.

[painiac]

Sometimes I think it would be better in some ways if we went back to the way it was done in the old days, when the only pills doctors had in their bags were aspirin, laxative, and sugar placebos...

Before you go that far, also rememeber that back in the day the average lifespan was closer to fifty or so.

Of course I'm not really going that far. I was careful to qualify that statement "Sometimes, in some ways". I'm strongly entrenched in medical science and know well how far we've come, though there are many days I'd like to send the mere whiners home with a placebo.

[dallas]

Sometimes I think it would be better in some ways if we went back to the way it was done in the old days, when the only pills doctors had in their bags were aspirin, laxative, and sugar placebos...

Before you go that far, also rememeber that back in the day the average lifespan was closer to fifty or so.

Of course I'm not really going that far. I was careful to qualify that statement "Sometimes, in some ways". I'm strongly entrenched in medical science and know well how far we've come, though there are many days I'd like to send the mere whiners home with a placebo.

What scares me is that we will be back in the "good ole" pre-antibiotic days unless we stop misusing antibiotics. What will we do when the bugs are resistant to everything? You do not need an antibiotic for every little cough, sniffle or even sinus infection.

[Liff]

We'll probably be back there, I have no idea when though. MDR TB was the start, now there is something called XDR TB. Maybe Cipro will work for that. Or Cephalexin. Tetracyclines are very broad spectrum, that should work, right? Tetracyclines used to be very broad spectrum, but the bacteria beat that abtibacterial pretty quickly.

Salvarsan anyone? (Not sarcastic.)

[Tperkins]

We'll probably be back there, I have no idea when though. MDR TB was the start, now there is something called XDR TB. Maybe Cipro will work for that. Or Cephalexin. Tetracyclines are very broad spectrum, that should work, right? Tetracyclines used to be very broad spectrum, but the bacteria beat that abtibacterial pretty quickly.

Salvarsan anyone? (Not sarcastic.)

I'd be ironic if we ended up having to replace Penicillin with Arsphenamine, considering Penicillin was what replaced Arsphenamine.

[rhi]

OK, so we've had some really good discussions here about antibiotic use/misuse. Would you guys be interested in taking this thread a bit into the area of "What Would You Do" territory with some hypothetical scenarios? I realize that administering antibiotics without a 'script is illegal - and by definition outside the parameters of this forum - but it seems we have a quorum of folks here that could have a rational discussion of this issue, given that it was in the ZPAW context.

[Mods: If this is uncool, feel free to delete]

[abelru]

OK, so we've had some really good discussions here about antibiotic use/misuse. Would you guys be interested in taking this thread a bit into the area of "What Would You Do" territory with some hypothetical scenarios? I realize that administering antibiotics without a 'script is illegal - and by definition outside the parameters of this forum - but it seems we have a quorum of folks here that could have a rational discussion of this issue, given that it was in the ZPAW context.

[Mods: If this is uncool, feel free to delete]

Cool-ness and legality issues aside, I would say no... We cannot do a "what would you do" deal (IMHO)
Reason being (as many of us have been saying) way, way, WAY too many variables. The art and science of antibiotic selection is so complex, and so riddled with pit-falls and trap doors that it is a poorly condensed subject. It does not lend itself to distillation at all.

Do I wish we could? Sure...

But I am answering your question from a stance of pure, detached pragmatism. I do not think it can be done and be of any real value.