The Secret of Great Health Care
Of the top ten diagnoses made in a family medicine practice, six of them are caused by a bacteria or virus. The use of antibiotics is a major part of the primary care doctor's practice.
It is often a knee jerk reaction for primary care doctors to prescribe antibiotics for any infectious illness, but many illnesses do not need antibiotics.
What are common problems you visit the primary care provider for?
The common cold is a common cause of head congestion. The common cold is a virus and antibiotics do NOT treat a common cold. Over 200 different viruses can cause the common cold and because of the variety of germs that may cause the condition, it can present in a variety of ways.
Rhinovirus is one of the most common viruses that cause the common cold and it typically presents with a sore throat, nasal congestion, low-grade fever and cough. The fever typically resolves within two to three days. Nasal discharge often accompanies a cold and is clear and thin, but often becomes thick and turns yellow or green after a few days.
Many people think that thick discolored mucus indicates a bacterial infection and an antibiotic is needed. It is common to have thick off-colored nasal discharge for a few days, but it should revert back to clear discharge or the discharge should stop by day 5-7. Nasal congestion and cough may continue for 2 weeks after the onset of a cough.
Understanding the natural course of the common cold is essential. The common cold can make you feel terrible – it can lead to tremendous head pressure and a significant reduction in productivity. Even though it makes you feel bad, antibiotics do not help the common cold.
The common cold is sometimes followed by complications that may require antibiotics. Everyone should understand the common path of the common cold and know when an antibiotic will be helpful.
The average adult is plagued with 2-4 colds each year and children are afflicted with 6-8 colds each year ([i]). The common cold is associated with symptoms that make you feel sick – sinus pressure, sinus congestion, sneezing, runny nose and fever. Symptoms usually improve over a 3-7 day period and if they do not get better or get worse, a bacterial sinus infection may be present.
When symptoms persist beyond 10-14 days bacteria may be causing some of the symptoms and the use of antibiotics may resolve the infection. Some patients may actually clear their infection without the assistance of antibiotic even if symptoms have persisted beyond 10-14 days ([ii]).
The majority of inner ear infections will clear in 1-2 weeks without antibiotics ([iii]). Many people should consider a delay in antibiotics when diagnosed with an ear infection. It has become an unwritten social standard that antibiotics are needed for ear infections. But, this is not true. Some people will heal the infection without antibiotics. By avoiding antibiotics the patient will reduce the risk of side effects and lessen the burden of antibiotic resistance.
It is important for the public to have an understanding about when antibiotics are needed for ear infections and when their use can be delayed or avoided. The doctor needs to determine who has severe versus non-severe infection and those who have certain versus uncertain diagnosis. In addition to these factors age needs to be looked at.
If you know these three pieces of information, you can use the chart below to determine if you need an antibiotic.
Table 1: Treatment for Ear Infections
|
Less than 6- months-old |
6 months to 2- years-old |
Over 2-years-old |
|
Treat for ear infection if the diagnosis is suspected. |
Certain diagnosis and/or severe disease – treat with antibiotics |
Treat with antibiotics if there is severe illness when the diagnosis is certain. |
|
|
Uncertain diagnosis and non-severe disease – may wait and see |
If the diagnosis is uncertain or if certain and non-severe symptoms than an observation period can be implemented. |
As you can see from the above table, not everyone with a diagnosed ear infection needs to be treated with antibiotics. Some patients may participate in the wait and see approach to ear infections.
The wait and see approach involves monitoring the disease for 48-72 hours. Over this period of time the person with the ear infection is given pain medications including: acetaminophen, ibuprofen or numbing eardrops.
In most cases the body will heal itself while pain medications are given to treat the symptoms during the healing process. If the patient worsens over that period of time than a re-evaluation should ensue. Worsening is indicated by: worsening pain or increased fever.
These new guidelines are endorsed by the Center for Disease Control and focus on judicious use of antibiotics. Inner ear infections are a common reason for an antibiotic prescription in the United States for children. In Europe the standard is initial observation. With the rising concern about antibiotic resistance it is important that antibiotics are used appropriately. Over 80% of patients with ear infections will clear the infection without antibiotics.
Swimmer's ear – also known as otitis externa (OE) – is a common problem that afflicts mostly children who are involved in water activities. Its cause is usually bacteria, but sometimes fungus grows in the ear or allergy or trauma causes the problem. The condition should be prevented if possible but treatment of active disease will reduce the duration of the disease and reduce the risk of complications.
Sometimes the ear canal needs to be cleaned out by the health care provider so a more compete look at the ear can be done. This will also improve the ability of any medication prescribed to penetrate deeper into the ear. Cleaning the ear can be painful in some and may not be possible
The mainstay of treatment is antibiotic eardrops. Certain eardrops are dangerous if there is a tear in the eardrum.
Conjunctivitis is an inflammation of part of the eye called the conjunctiva. The most common causes of conjunctivitis include allergic, bacterial and viral. It must be remembered that a red eye may be related to other causes such as trauma, foreign body, herpes simplex or a blocked tear duct.
While school aged children are more likely to be afflicted by a viral cause of conjunctivitis, children under the age of six-years-old are more likely to be afflicted with a bacterial conjunctivitis ([iv]).
The most common cause of viral conjunctivitis is adenovirus. This is very contagious and no treatment is available for preventing its replication. It may be contagious for over a week.
Bacterial conjunctivitis is often self-limiting but is associated with significant symptoms. Although bacterial conjunctivitis is much more common in younger children there are occasional outbreaks in adults. Untreated bacterial conjunctivitis lasts about 8-10 days.
Conjunctivitis presents with redness, discharge, swelling, burning and grittiness of the eye. These symptoms are common to all types of conjunctivitis. The degree of the symptoms may vary with the severity of the disease or the type of conjunctivitis. Certain factors help differentiate the type of conjunctivitis.
Bacterial conjunctivitis is associated with discomfort/pain, redness and discharge from the eye. Bacterial infections typically start in one eye and then spread to the other. Thick, purulent discharge is typically noted and it is associated with the eyes being stuck together in the morning.
Viral conjunctivitis can cause mild pain and mild discomfort in bright light. Like bacterial infections, symptoms may start in one eye, but often spreads. Diffuse redness with a stringy white discharge is often noticed. It usually occurs in someone with an upper respiratory tract infection. Adenovirus is a common cause of conjunctivitis and it can present very similarly to bacterial conjunctivitis.
Allergic conjunctivitis is often secondary to allergens. The most common symptom in allergic conjunctivitis is itching with clear watery discharge. It usually affects both eyes and is not associated with pain.
Pharyngitis is the term doctors use to describe sore throat and it accounts for 10-15 percent of all pediatric office visits. Group A beta-hemolytic streptococcal pharyngitis (GABHS), more commonly known as strep throat, is a primary concern of a person with a sore throat. GABHS is more common in children than adults. In both kids and adults viruses are the most common cause of sore throat.
Because group A beta-hemolytic streptococcal (GABHS) pharyngitis could result in heart complications it should be recognized and treated. Certain factors will help predict if the cause of the sore throat is GABHS or a viral infection. The factors are not perfect and the use of a throat culture is needed in many cases in order to rule out strep throat.
Important factors to know about strep include:
· It most commonly affects children between 5-15 years old.
· It does not commonly affect children under three years old.
· It has an incubation period of 2-5 days. This means that if you have been in contact with someone who is infected and are infected your disease may not show up for 2-5 days.
· Respiratory secretions (saliva/mucus) spread the infection.
Antibiotics should not be prescribed for bronchitis in healthy patients with acute bronchitis. Almost every case of acute bronchitis is viral. The overuse of antibiotics in bronchitis is a common reason for antibiotic resistance.
It is essential to differentiate acute bronchitis from pneumonia. Individual with pneumonia do need antibiotics, as do those with other health problems who are unable to tolerate a bacterial infection. Patients who are sick for more than 10 days or those with a specific type of infection (Mycoplasma) warrant antibiotics.
Pneumonia is an inflammation in the lung caused by microorganisms. It is one of the most common causes of death due to infectious disease. Signs and symptoms can be variable depending on the severity of the disease as well as the organism affecting the patient. The disease often starts with the onset of a productive cough with purulent sputum, shortness of breath, increased heart rate, chest pain, fever and chills. The symptoms come on over a 1 to 10-hour period. Other symptoms that may be present include: headache, diarrhea, nausea, vomiting and malaise.
Young healthy patients without distress do not need to be hospitalized. Hospitalization is indicated for patients who are older and have other medical problems.
Urinary tract infections (UTI) are a common and costly medical problem. Urinary tract infections occur eight times more commonly in women than in men. It is responsible for 6 to 11 million office visits in the United States each year ([v], [vi]). Over half of women experience a urinary tract infection at least once in their life (5) but only 13% of men have a UTI in their live (6).
On average, UTIs cause symptoms that disrupt the lives of women for 6 days, restricts activity for 2.5 days, causes one day of missed work and a half a day of bed rest ([vii]). Kidney infections are responsible for 250,000 hospitalizations each year in America. They occur one time to every 18-28 cases of UTI. Bacteria invading the urinary tract cause UTIs. The most common community acquired bacteria that causes UTIs is Escherichia coli (responsible for 85% of UTIs that occur outside of the hospital).
Certain individuals are at higher risk for UTIs than others including those with urinary tract tumors or stones, congenital anomalies and those who were recently catheritized. Women are at greater risk than men as they have a shorter straighter urethra, which allows easier ascent of bacteria. Other risk factors for women include: intercourse, antibiotic use, pregnancy, use of spermicides and low estrogen levels.
Classic signs and symptoms of a UTI include painful urination, the need to urinate urgently and frequently. Other signs/symptoms that characterize a UTI include: having to urinate at night, blood in the urine, urinary incontinence and pain over the bladder.
UTIs are managed with antibiotics, but other measures may be used to help the healing process. Simple UTIs should be treated with rest and adequate fluid intake. Symptom management is important and can be accomplished with the use of pain medications. Ibuprofen can provide some mild relief. Pain medication for the bladder - Phenazopyrdine (Pyridium) is a prescription dosed at 200 mg three times a day for two days - may be more effective. The use of cranberry juice is also recommended as a treatment option for patient. It may decrease the ability of bacteria to adhere to the wall of the bladder as well as preventing inflammation of the bladder (5).
Antibiotics are usually needed to treat UTIs, even though some will go away on their own ([viii]). Since you cannot know who will spontaneously resolve their UTI, it is standard care to treat everyone with a UTI with antibiotics.
Skin infections caused by bacteria are common. They are most commonly caused by Staphylococcus aureus and streptococcus. Cellulitis is a dangerous form of bacterial skin infection. It is contracted when there is a break in the skin via cut, scrap or ulcer. The bacteria leaks into the skin and infection results.
Cellulitis will typically cause fever and fatigue. The area of the skin is red, tender and warm. Red streaks coming from the infected area and lymph nodes that become swollen indicate a more severe infection. Adults often get cellulitis in the legs or arms while kids often get it in the neck or head.
Based on the clinical exam the diagnosis is often made. The use of blood work is often needed to evaluate the severity of the infection. Pus from the wound can sometimes be cultured to determine the bacteria that is causing the infection.
Treatment of the infection is with antibiotics. Oral antibiotics are given for mild infections and intravenous antibiotics are given for severe infections. A patient who is sick, who also has diabetes or peripheral artery disease is classified as having a serious infection.
To prevent infections it is important to take care of good care of any skin wound. Including cleaning the wound, applying topical antibiotics and keeping it covered with a bandage.
Other types of skin infections include:
Antibiotics commonly used for the treatment of minor skin infections are cephalexin, dicloxacillin, TMP-SMZ and doxycycline.
There are multiple causes of vaginal infections. They typically present with a constellation of vaginal discharge, irritation and foul odor. Severe infections can present with pain. Below is a listing of some common causes of vaginal infections and the medications used to treat them. The antibiotic listed below will be described in more detail during in the book.
[i] The American Academy of Pediatrics. Clinical Practice Guideline: The Management of Sinusitis. Pediatrics 2001; 108(3): 7898-808.
[ii] Young J, DeSutter A, Merenstein D, van Essen GA, Kaiser L, Varonen H, Williamson I & Bucher HC. Antibiotics for Adults with Clinically Diagnosed Acute Rhinosinusitis: A Meta-Analysis of Individual Patient Data. Lancet 2008; 371(9616): 908-914
[iii] Rosenfeld RM & Kay D. Natural History of Untreated Otitis Media. Laryngoscope 2003; 113: 1645-57.
[iv] Wagner RS. Conjunctivitis in Kids: Elusive to Diagnose, Challenging to Treat. 2008. (cited 2009 January 12). Available from: URL: www.mycme.com
[v] Rahn DD. Urinary Tract Infections: Contemporary Management. Urological Nursing 2008 28(5): 333-341.
[vi] Watring N & Mason JD. Deciphering dysuria. Clinician Reviews 2008; 18(2): 16-22.
[vii] Hooten T. Urinary Tract Infections Audio-Digest Internal Medicine Dec 7, 2008 Volume 55(23).
[viii] Yamamoto S, Akiyama K & Yoshimoto. Clinical efficacy of oral administration of 200 mg gatifloxacin once daily for 3 days for the treatment of patients with uncomplicated cystitis. Journal of Infectious Chemotherapy 2009; 15(2): 104-107.
