The antibiotic casebook

The practice of medicine on the front lines is a challenging mixture of science and art. At times it is like doing stand-up improvisation. Your patients present with a previously unknown scenario and you have to react without rehearsal in immediate real time.  As a practitioner you are being pressed by increasing regulations and pushed toward statistical goals apparently representing “good care.” Patients at the same time are demanding all of the new treatments and investigations available (as presented on the Internet and in the lay press).  Many of our patients fit easily within these practice parameters but many do not and it is with the latter in mind that the following scenarios are offered here and in the next two issues. The names and antibiotic flavors are fictitious but the stories are as real as daily practice. Many of you will be able to immediately put your own names on the participants.  The purpose is to capture some challenging clinical primary care issues using a touch of humor and provide an easy link to the research base for guidance and learning. If we as primary care physicians are to escape rigid controls we must maintain our positions as leaders and professionals in our various communities.  It is only then that we can have the freedom to provide good care for our more challenging patients – using guidelines when appropriate but using good clinical sense and judgment when the guidelines do not fit. Thank you for reading.  Time: Friday afternoon 4:30.  Place: The office.  The setting: Nurse Gibbons hands me a chart and gives me the “eye sign.” Young Winslow Parker-Smith hadn’t been on my day sheet but then his mother rarely made appointments for her sundry medical “emergencies” and the “eye sign” told me this was one of those times.  The problem: “Winslow has an ear infection” she said. “He needs that ‘English Mocha’ medication.moonlakerx pharmacy antibiotics It’s the weekend you know. He’ll get worse.”  The exam: Winslow had no chance to answer my questions. His mother described in detail his suffering since the pain began two hours previously. To my great relief his right tympanic membrane was at least 2+ inflamed and bulging slightly – certainly not a severe infection but valid and I could at least consider antibiotic use without feeling guilty.  The rest of my examination was normal. He did not seem to be in the distress that his mother described. He appeared to be quiet and comfortable but rather reserved in his mom’s presence.  The challenge: How do I deal with this one I wondered? Clinically the treatment was easy (or was it? More and more references suggest that otitis media will get better without antibiotics 1 and that they should not be used in most cases). Still it is standard treatment 2 in Canada to give the drugs.  With luck I could talk her into the most appropriate medication 2346 but to suggest no antibiotic at all would invite derision. The challenge was not so much what to do but how to have Mrs. Parker-Smith accept optimal treatment instead of what she thought she wanted (“I don’t care what I need give me what I want”).  The office was busy and I had promised to be on time tonight. I dreaded getting that “I knew you couldn’t do it” look again from my wife.  The resolution: I began by suggesting the ‘Kiwi’ and almost ducked with the force of her response (even though it was expected).  “The ‘Kiwi’ never works. I always come back for the ‘Mocha’ and I refuse to wait again in that waiting room” she said.  Several clever responses flashed through my mind (none of which would look appropriate in the papers or on a CMPA desk). But after all this was about Winslow and he really did have a red ear.  It took all of my Friday afternoon patience but with a deep sigh (and visions of “the look” on my wife’s face) I took the next step by showing her the page in the guidelines3 that recommended the standard ‘Kiwi.’ I also had an article that showed how the use of antibiotics may actually leave Winslow susceptible to more invasive infections over the next three months. 4   The pictures helped. They showed differing severities of otitis media and I was able to point out that Winslow was only about 4/10 in severity. She accepted the simple approach. 5   I actually beat one of my guests to dinner but then he was also a family physician and my wife said it didn’t count. I got “the look.”  1. An excellent review article by Richard Rosenfeld includes the following:  “Over 80% of acute otitis media cases resolve spontaneously without antibiotic treatment within 10 to 14 days. The use of beta-lactamase stable antibiotics has not been found to improve cure rates over aminopenicillins.”

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