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PED-EM-L  July 1995

PED-EM-L July 1995

Subject:

Re: foot lacs

From:

Joseph Sachter <[log in to unmask]>

Reply-To:

Pediatric Emergency Medicine Discussion List <[log in to unmask]>

Date:

Sat, 22 Jul 1995 14:36:12 -0400

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (62 lines)

In a message dated 95-07-22 12:23:39 EDT, Jeff Hoffman writes:
 
>-- concerning use of abx for viral URI's expecting that some pts. will
>develop OM
>
>This is a crazy argument! I can't believe that some subscribe to this
>position. It reminds me of the argument for the varicella vaccine that
>focused on all the time parents miss from work (ignorning the potential
>devastation that varicella might cause in an adult population with waning
>vaccine immunity). In the ER, we always say "come back if it gets worse"
>without blinking. Why does this apply to appendicitis and not to colds? Why
>is giving abx to a patient with a clearly viral URI so as to prevent a
second
>visit in a few days different from having an abx vending machine in your
>waiting room?!? The physician is using abx instead of education.  Is the use
>of abx so "benign" as to allow their indescriminant use. I don't think so.
>Anyone who doubts the effect of widespread use of antibiotics on antibiotic
>resistance needs only to look at the experience with the quinolones (Cipro,
>etc.). When I was in medical school, they were just arriving on the scene.
>They killed everything. It seemed liked a miracle drug. Then, it started to
>be used as first-line for everything... and wouldn't you know it, quinolone
>resistance is here (and it's only been a few short years). We've been using
>PCN for 50 years. It's a miracle we've lasted this long. I'm afraid we're
>heading for the day when previously-simple infections become
life-threatening
>once more.
 
 
I agree 100% that to give antibiotics to someone with a clear viral syndrome
to possibly forestall an OM is crazy. As I recall the thread, the issue is
giving antibiotics when the possibility of a bacterial, rather than viral,
etiology is small, but present, especially when leaving a bacterial infection
untreated - even for a few days - can have signifcant consequences (eg: an
asthmatic on steroids with productive cough and a fever, or diabetic).  To
tell a mother (or father) that, after waiting four (or more) hours with a
sick child, their child just has a cold, they should give Tylenol, and if
he/she gets worse in a day or two you can come back, wait another four (or
more) hours, get billed (another) $300  is a recipe for disaster that ignores
the reality of a busy Peds ED (at least in NYC).  It can take 20 minutes just
to placate the parent - time which you just don't have - and they'll probably
just go to another ED, and start the process all over again.
 
Now before - or as - evryone jumps on me,  let me making the following
points...
 
1.  We're talking about a situation where there is a reasonable possibility
of  a bacterial infection; a healthy, afebrile pt with the sniffles doesn't
get a Rx regardless of what the parent wants.
 
2.  I agree that the new, expensive antibiotics are being abused, and
quinolones are a prime example. BTW, just yesterday a resident showed me a
note from a private that stated (direct quote, I swear):  "Patient with low
back pain after a fall three days ago. Ceclor not helping. Please evaluate."
 I think a more productive strategy would focus on the following: the less
likely a pt has a serious bacterial infection, the more appropriate is an
economical "old-line" Rx (pen, 1st gen, etc), if you're going to give an
antibiotic at all.
 
Joseph J Sachter, MD, FACEP ([log in to unmask])
Program Director
The Brooklyn Hospital Center

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