john banks

Everything I know is from Google

It can match combinations of symptoms in a way a textbook can't, and it is great for foreign drugs, patient info leaflets and does tap into good literature, you just need to be selective and discerning with the results.

Seriously, I use Google medically several times a day!

andy97

iTrader: (1)

John. I remember reading that antibiotic doses are not sufficient for adults, therefore only being partially effective at treating the condition, leading to bacteria becoming immune to treatment. Do you adjust the dose to the size of person

john banks

Present doses are based on age apart from those that have a narrow therapeutic index, but most can be doubled in severe infection. Not just size affects, but genetics, liver and renal function, interaction with other medication.

http://en.wikipedia.org/wiki/Minimum..._concentration

Lydia72

I've only had antibiotics twice in my life and haven't seen a GP for twelve years now. I would hope that if/ when I do need to see a doc he or she would take me seriously based on the fact I'm not there every other week.
My last GP was sent to prison for molesting female patients so not being prescribed antibiotics would be low down on my list of complaints!

Leslie

If that is really true than I am surprised that a man of your apparent perspicacity does not change to another doctor!

I have a very good doctor and have always trusted what he tells me. He has always been right so far too!

Les

bigsinky

**** Lydia that's not good

Lydia72

I know, he'd been our family doctor for years so it was quite shocking to read it in the paper.
From what I understand it had been going on for quite a while so who knows how many women he'd assaulted. He had been visited by the police regarding one complaint but it was his word against the patient's. The police told him to make sure a nurse was present when he had to examine women so that no one could make an accusation against him again but obviously he ignored that and carried on. Then when it all came to light more women came forward. It wasn't things that could be explained away either, it was proper sexual assault.

The worst thing is it makes you wonder if he was ever behaving correctly. Like I know he didn't molest me but did I need to unbutton my top that time so he could listen to my chest, know what I mean?

jef

iTrader: (13)

is testing these functions common practice before anti-biotic prescription? how are these values tested for? interesting stuff.

john banks

Cytochrome P450 enzymes are the major recognised group that are involved in drug metabolism. The most common relevance of this in antibiotic prescribing is that macrolides (the second most common group we prescribe after penicillins, that become the most commonly used antibiotics in those allergic to penicillins) inhibit CYP3A4 and in combination with statins (which many of our patients are on) can cause rhabdomyolysis. Other drug metabolism is affected by genetic differences in the P450 system, and whilst testing is not routinely done, adverse effects can be related. There are interesting and relevant differences in P450 activity between racial groups. There are varying recommendations for cholesterol and blood pressure treatment between races too.

Gilbert's syndrome is a common but usually mild inborn error of metabolism that can affect drug use.

http://en.wikipedia.org/wiki/Cytochrome_P450

Overall, testing for genetic variants is not done before antibiotic prescription, but if issues are known they are accounted for where information is available. [speculation follows] It may well be in future that more will be tailored to genetic profiles as testing is cheaper and quicker. It is a very interesting area, but as of yet nowhere near the fringes of daily practice.

Liver and renal function will often be known in those with problems, so dose adjustments can be made if required, I look up each prescription to see what adjustments are necessary as it varies drug to drug.

Some drugs have a mandate for monitoring depending on what toxicities they are likely to cause.

Most commonly used antibiotics do not have a narrow therapeutic index (if that is they are actually active against the patient's infection which is often viral). For example, in an adult you can give amoxicillin 3g (3000mg) in one go or as little as 250mg three times a day.

http://en.wikipedia.org/wiki/Therapeutic_index

J4CKO

iTrader: (1)

I dont know why anyone would not use Google, it isnt an admission of defeat or that you dont know what you are doing, it is a tool, and one that, if use effectively is mind blowing, half of the reason for me being where I am at work is the ability to sift, digest and quickly locate info, I run rings round my colleagues, some of whom have been to Oxbridge, I just assimilate information quickly and reject invalid stuff, they still get there but slower, it is a skill and an under recognised one.

jef

iTrader: (13)

john, why is overall function not a routine test? in my 35 years expieriance ive never seen a gp perform a blood sample test before anti biotic prescription? maybe just my gp's though

just finacial restraint, or perceived likely patient implication? great info btw

john banks

It really comes down to the wide therapeutic index of most antibiotics, so that if they are used when the bacteria is sensitive to them (this is a test we do order on sputum, urine, swabs, blood or other samples) then the standard dose is adequate and unlikely to give dose related side effects. We know who most of our patients are with renal impairment, and most of them are mild to moderate where no dose adjustment is necessary.

So it comes down to lack of benefit. Using good guidelines to use antibiotics appropriately and more often than not avoid them in the first place is more useful.

Seeking opinion here from this thread is part of my never ending quest to reduce my antibiotic prescribing. It really upsets quite a few patients though. I have put up signs in the surgery asking for patients to believe us when we tell them they don't need antibiotics, that we are trying to protect our community from adverse reactions and multi resistant bacteria. It is an uphill struggle I feel due to patient pressure so it is a flashpoint for conflict.

jef

iTrader: (13)

instead of putting signs up, asking them to beleive you,

could you not show them, the evidence and explain it - a simple explanition,
even carry out a comprhensive testing on a selection of particularly stubborn patients to show outcomes, a small investment , worth results yielded?

and why do you need to reduce your anti biotic prescribing? surley they are a controlled/prescription only medicine that should only be prescribed appropriatley.

why has this situation come about to start with? GP's lack of initial experience with them, over prescribing, lack of the prescribers knowledge, or just down to unexpected tolerances/evolution of targeted bacteria?

and why do the public now feel like they "need" them, where has this information come from?

john banks

The sign mentions the evidence from a recent study that shows that only 1 in 14 patients treated with an antibiotic for uncomplicated cough showed a benefit. I've discussed sputum results from stubborn patients with them and spent a long time doing so yet some still ask for their "usual" antibiotics at the end of it all.

The most stubborn will ring or consult repeatedly until they get what they want, even shown the evidence. Friday was bad before a bank holiday weekend as they were all concerned it would get worse when we were not open. Prescriptions issued in these circumstances with instructions not to use them unless specific things happen don't get followed as I've tried that, because they return a week later asking for a second course yet it still didn't merit the original course. They try to play one doctor off against another, and threaten that if they deteriorate they will sue you. They show disgust at your refusal.

The situation has arisen partly due to doctor over-prescribing, over-medicalisation of self limiting illness, patient expectation and belief and fear over being sued.

There is a desire to please patients, a huge expectation to receive a prescription because there is a pill for every ill.

I'm on pretty good ground medico-legally to support my ongoing quest to minimise antibiotic prescribing, but it is an uphill struggle.

jef

iTrader: (13)

i understand these patients may play gp's off each other,

but still is it not possible to just point blank refuse to prescribe inappropriate medication? i mean why are the wrong medicines being prescribed, and in accordance with patient persistance?
it wouldnt happen in most other POM scenarios, why the lax attitude to anti-biotics? they have side effects, and potentially dangerous ones.

is it not that the anti-biotics do infact help, but the patients condition doesnt merit the use, its perceived the body will recouperate in adequate time without ill effect and gp's now reluctance to prescribing due to evidence of bacterial tolerance increases - and trying to maintain long term care?

or is it simply a fact, that they just have zero effect in many cases?

ive heard my gp say, my sons infection/s have been viral, and therefore antibiotics will do absolutley nothing - i just beleived her, is that true?

GC8

Surely the issue is the patients misguided expectations, rather than how they react?

If I have the clap, an ear infection or acne Id expect erythromycin. If I have a cold Id expect a tissue, a sick note and a cup of tea.



Simon

john banks

It is a strong belief that they work especially if they feel they hav benefitted before even though they were going to get better anyway. There is some evidence that the average duration of a sore throat can be shortened by about half a day, and included in this average there are better results for those that are bacterial but still self limiting. If you speed recovery by a day or two in some patients who you cannot identify up front, but overall you shorten by hours in the whole group then you would consider that when resistance and side effects are not worth it.

There is a lot of debate over ear infections and sinusitis too. Antibiotics seem to be overused.

So the grey areas don't help. For example, if I refuse antibiotics and a patient goes on to be hospitalised with pneumonia, or die suddenly from pneumonia, or worsen and due from meningitis, and I repeated denied their persistent equest for antibiotics, I would feel liable even if there was no forewarning that they could be in the groups that would deteriorate. Some GPs admit virtually every bad headache they see because they once got dragged over the coals because one had meningitis or a subarachnoid. Some overuse antibiotics because they were dragged over the coals because what seemed to be a simple war infection developed into a brain abscess.

GC8

The ear infection was an example, but I stand by the clap and acne!

pimmo2000

iTrader: (6)

You see all these adverts for when to see a doctor, for example when you have a persistent cough, as it might be cancer, I always wondered who would be stupid enough not to see a doctor .. now I know, its everyone on SN

Leslie

A rather silly generalisation!

Les

Scooby Jo

I don't trust, based on being told by a locum that I had flu one day, then being admitted to hospital 2 days later with pneumonia and subsequently having a third of my lung removed because it wasn't caught early enough. So no I don't trust them, which is difficult as they are supposedly the experts

jef

iTrader: (13)

that just opens up so much questioning, id get lost or bored lol

seems like anti-biotics have been used or atleast had an influence in prescribng antibiotics as an "insurance from liabiltiy/moral standing" purpose rather than effective treatment by many- at end of the day, you can only treat the symptoms you are presented with and then using training/experience to assess - and if in doubt refer to a specialist in chosen field.

how easy or hard that is to actually do, ive no idea - but atleast it gives a mild insight into previous "habits" or fears that GP's may feel, afterall its potentially someones life your dealing with.

what about pharamacutical companies input - they must depend on a viruses ability to evelove to carry on development ect ect??

john banks

Scooby Jo's situation is the fear. We don't know if it was due to the locum making an incorrect decision based on the available information, or whether it was an unforseeable complication. That is why, whether I give antibiotics or not, I record the reasons for the decisions, inform the patient, and warn them if they worsen to contact.

Scooby Jo

Not just the locum John, paramedics thought I'd cracked a rib due to coughing despite the fact that my blood pressure being so low that I kept losing my sight. I was initially diagnosed with swine flu and only transferred to a specialist hospital when that was ruled out. My faith in the medical profession was severely shaken. The specialist heart & lung hospital were amazing and I am only here because of them. There are some brilliant medical people out there but it sometimes takes a while to find them.

RobJenks

Whatever way you look at it , the locum made the wrong decision.
If there was insufficient information to make the correct diagnosis , then further tests should have been conducted , before discounting the use of AB's.
He choose to eliminate AB's , before fully evaluating all the patients symptoms . Obviously if he had , the infection would not have progressed.

Saxo Boy

John, I suspect you are asking the wrong demographic by posting this on Scoobynet. (particularly NSR). As much as we poke fun at SN, the social standard in NSR isn't that bad. Most contributors are fairly well educated, rational thinking people. I would imagine your poll would have a significantly different outcome if you posted it on a forum for BrightHouse or Wonga.com.

john banks

Kenny, agree.

Scooby Jo, blood pressure low enough to be losing your vision is a bad sign. Was this dismissed?

RobJenks, it sounds from what Scooby Jo said that there is more to this story, but there are other situations where all the available information, "fully evaluating all the patient's symptoms", supports giving advice and no antibiotic, yet a small proportion still go on to complications.

http://www.nice.org.uk/nicemedia/liv...1322/41322.pdf page 5 shows the group at more risk of complications but doesn't catch them all.

pimmo2000

iTrader: (6)

A rather general sillyeralisation

Leslie

What a good word, but not that easy to say, not without practice anyway!

Les

Leslie

Seems to me that if Google has got all that much accurate information about drugs etc. that it is only sensible to look something up before prescribing it if only as a reminder about its capabilities and possible reactions since it would not be very easy to be able to remember all that sort of thing about the vast number of medicines which are available.

Les