Housekeeping–CT, antibiotics

I just want to take time in this post for some “housekeeping” and touch very quickly on 2 subjects that have been fairly regular features of this blog.

#1 is the use and overuse of CT scanning, especially in the ED.  A recent study from the Netherlands Cancer Institute reinforced earlier information I had presented regarding cancer risk from the large radiation doses in CT scans.  I support the thoughtful statement of the authors who say:

“CT scans for children represent a potentially life-saving and quality of life-improving technique for many patients. In addition, the tumors evaluated here are associated with small absolute excess risks. Nonetheless, careful justification of pediatric CT scans and dose optimization, as are customary in many hospitals, are essential to minimize risks.”

Specifically, I have spoken of the use of CT at the ED in evaluating for possible appendicitis.  This month’s American Family Physician includes an article about that subject, which diagrams the evaluation process from an article by Dr. G Santilles from Academy of Emergency Medicine in 2012.  For negative CT, the authors say, possible discharge with follow up in 6-12 hours is appropriate.  In other words, if that person is sick enough to need a CT at that time then they are sick enough to need to be seen and re-evaluated in less than 24 hours.  Ideally, the ED doctor should call and speak directly to the primary care doctor to insure proper “hand off” of these cases, I believe.  This is of particular concern for weekend incidents when office hours may be more limited.  So, my advise?  If you are in this situation with your child, do not hesitate to request that the ED doc call your primary care to “touch base.”  It’s the right thing to do.  Safety first.  And BE SURE to be seen next day.

The other subject is the overuse of antibiotics.  Another recent study found that urgent care center visits for respiratory illness result in prescriptions for antibiotics in 40% of cases.  However, careful scientific analysis shows that bacteria are actually responsible for perhaps 5% of these illnesses.  The rest are viral; the antibiotics are unnecessary, unhelpful, and not infrequently can themselves cause harm.  Now, I understand the convenience of these urgent care centers; not too small an issue for busy parents.  However we should keep in mind the old consumer adage that “you get what you pay for” and this data shows pretty clearly that, in too many instances, the advantage of convenience comes at the cost of a lot of over treatment and not useful medicines.  So, again,–my advise?  If at all possible, wait for your doctor’s office to be open the next day. Doing it right is almost always better than doing it fast.

For a review of the risks of antibiotic misuse please check here.

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Penicillin Allergy

Let’s talk a bit about antibiotic allergy. While I have gone on forever about the dangers of overuse, of course antibiotics are one of modern medicine’s most useful tools. It is therefore of benefit to have the option to use any of these agents should the appropriate picture present.

And, naturally, the first among equals in this medicine class are penicillins (and related cephalosporins).  While being able to prescribe is great, seeing a patient develop complications is troubling.  Most know the typical side effects of drug allergy: hives and swelling, as well as coughing or wheezing; also there are more serious ones like “serum sickness” (fever, joint pains, nausea, also rash), and more threatening allergy reaction with thready pulse, shock, throat closing, loss of consciousness.

And reports of penicillin allergy are quite common–10% of patients.  But HOLD ON–careful study demonstrates that the large majority of those reports actually have no medical basis.  Adverse side effects like abdominal discomfort, nausea, vomiting, diarrhea, are common, as well as vaginal itch, discharge, thrush, and mild body rashes.  Many of these problems are inaccurately labelled “allergy” by lay public and even well meaning if uninformed medical providers.  Additionally, some report “penicillin allergy” based on vague personal history from distant past or even because of close family members reporting allergy.  While these problems can be annoying, they have no predictive value of the more dangerous medical allergy reactions listed in the previous paragraph.  Those true allergic reactions are caused by activation of the body’s allergy/immune/IgE system which can progress to dangerous problems and must be taken more seriously.  Therefore, that diagnosis should be made carefully and cautiously. One study from Mayo Clinic demonstrated that of 384 people claiming “penicillin allergy” 94% actually were not when tested scientifically and these people all subsequently tolerated penicillin well.  The incidence of anaphylaxis is only 0.1-0.5%.

Over diagnosis is not a trivial problem.  People diagnosed as penicillin allergic are then given other “broad spectrum” antibiotics that typically have greater risk of side effects like abdominal problems compared to penicillin.  There is also a significant cost factor.  One recent study demonstrated a savings of over $192,000 in one year in one large municipal ER alone by accurately assessing children labelled “penicillin allergic” and avoiding the use of  more expensive alternatives.  Those patients, again, were administered penicillins safely.  Of greater importance and concern is the risk of infection caused by these alternative drugs themselves.  A large study from Massachusetts General Hospital reported its findings that use of these agents increased the risk of MRSA infection by 69% and of Clostridium dificile (“C dif”) infection by 26%.  That is a major concern both individually and as a matter of public health.

So I urge those designated “penicillin allergic” to carry a healthy dose of caution and skepticism regarding that diagnosis for your child.  Please come in to discuss it with me.  Let’s explore it carefully and diagnose it accurately, for your child’s best health and protection.

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