A Country Doctor Reads: March 2, 2019

Risk of dying from delayed treatment of UTI – BMJ

In the nursing home, we worry about complications from antibiotic use, like Clostridium Difficile colitis. It is now common practice not to start antibiotics, even with typical symptoms, until a culture confirms the diagnosis.

This week’s BMJ has a sobering review of that practice:

“Finally, 2.0% (6193/312 896) of the participants older than 65 years who presented to their GP with a UTI died within 60 days; 5.4% (1217/22 534) for no antibiotics, 2.8% (545/19 292) for deferred antibiotics, and 1.6% (4431/271 070) for immediate antibiotics (table 1). The NNH estimate for death within 60 days was lower with no antibiotics (NNH=27) than with deferred antibiotics (NNH=83), with a calculated risk relative to immediate antibiotics. The Kaplan-Meier curves showed a significant reduction of the 60 day survival for older adults prescribed no antibiotics or deferred antibiotics compared with those prescribed immediate antibiotics.”

https://www.bmj.com/content/364/bmj.l525

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Adverse Effects of Fluoroquinolones: Where Do We Stand? – NEJM Journal Watch

A long time ago a patient of mine ended up hospitalized from an interaction between levofloxacin and warfarin. I have seen a handful of cases of tendon pain from quinolones, but never a tendon rupture. I have seen a grown man tremble as he described the demonic nightmare he had after his first dose of levofloxacin. So I worry a lot about this class of antibiotic.

In Britain, there is talk of restricting GPs from prescribing quinolones; not only do we have tendon ruptures and psychiatric side effects to consider, we also have the recent FDA warning about vascular complications such as aortic rupture.

NEJM Journal Watch has a nuanced review of the dilemma of whether or not to prescribe quinolones:

“The risk for aortic rupture or dissection from quinolones is approximately 1 to 2 cases per 10,000 treatment courses…

…The new FDA warning clashes indirectly with Infectious Diseases Society of America community-acquired pneumonia (CAP) treatment guidelines, which suggest use of fluoroquinolones in high-risk patients with comorbid conditions and patients at risk for drug-resistant Streptococcus pneumoniae (Clin Infect Dis 2007; 44 Suppl 2:S27). These patients — who frequently are elderly and have hypertension or vascular disease — are precisely those for whom “health care professionals should avoid prescribing fluoroquinolone antibiotics,” according to the FDA warning. The rates of resistance of S. pneumoniaeto doxycycline and macrolides may be as high as 15% to 30%, whereas rates of resistance to quinolones remain at or below 1%. Therefore, if quinolones were abandoned for such patients, the number of patients receiving inadequate antimicrobial coverage would likely exceed the number of patients who would be spared aortic rupture. For example, assuming that one third of CAP cases are caused by S. pneumoniaeand that one quarter of these cases are resistant to nonquinolone therapy, about 8% of patients with CAP would receive inadequate treatment.”

https://www.jwatch.org/na48248/2019/02/13/adverse-effects-fluoroquinolones-where-do-we-stand

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.

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