Bugs and Drugs

I have spent the last few days doing largely orthopaedic "emergencies". While this is good mindless work, it has entailed administering multiple doses of Ancef.

When I first started out in medicine, the dose of Ancef was 500 mg. Now 1 g is the routine dose, 2 g is more common and 3 g no longer surprises me. Nobody seems to comment on this dose inflation.

While published data suggests that if Ancef is to work , it must be administered 2 hours early, normal practice is for it to be administered by the anaesthesiologist in the OR at the beginning of the case. This is a practical matter as most patients have their IV started in the OR; even patients however who have been in hospital for several days on IV fluids are sent to down to have their first dose of Ancef given "just in time". This means that Ancef is usually administered at an inopportune time at the beginning of the case, when you are trying to give other drugs watching the blood pressure on induction, moving and positioning the patient etc. It is hard to predict in which patients the surgeon wants Ancef, some of them just assume you will give it and get mad when you haven't correctly read their mind. Not infrequently the surgeon doesn't want Ancef until after he has taken cultures (you are supposed to figure this out too!) Quite frequently I find the little mini-bag in the chart in the middle of case well after the tourniquet is up or I find that the nurse has placed it in an inconspicuous spot on my table.

Other surgeons just ask, "Can the patient have some antibiotics?". While I am quite pleased that they think highly enough of my bacteriologic and pharmacological knowledge to chose what antibiotic they want, I usually ask, "Any particular antibiotic?"

Anyway you get the impression that I find giving Ancef to be distasteful.

Part of the whole issue for me is the cognitive dissonance of the whole issue. I don't remember much from medical school but I do remember something about microbiology and the action of antibiotics. I also took a course in population genetics as an undergraduate.

The bacteria that is giving or is going to give you an infection is actually a heterogeneous group of individuals. This means that every little cocci or bacilli has a different degree of susceptibility to antibiotics. The weaker ones may succumb to one dose, some may require 10 days or more. Now if a patient gets only one dose of antibiotic as quite a few of these patients do, this means that the weaker bacteria are killed off leaving a population of slightly more strong bacteria. This well known with tuberculosis where incomplete treatment of TB has lead to drug resistant strains. The same thing is of course happening to our garden variety bacteria as well.

Another thing, as I found out when I had to buy Ancef for a medical mission (who better to buy Ancef than an anaesthesiologist) Ancef cost $7.00 for 1 g. That is by the way for generic Ancef. So what $7, not even 2 lattes. Remember when Propofol came out? It cost $8 a bottle. Do you remember the hassle we had to go thru to get the bean counters in pharmacy to let us use it, the rationing, the special populations. In fairness to pharmacy they have cracked down on the use of some of the more expensive antibiotics.

Which brings me to a case I did on the weekend amongst all the ortho cases.

This case was debridment of an infected ankle in a patient with Methicillin Resistant Staph Aureus (MRSA). When one of those patient known to have MRSA comes to the OR, the whole OR springs to an even higher level of paranoia and irrationality. The patient comes down from the floor gowned, hatted and masked and is whisked an OR that has been stripped of all it's equipment except what is absolutely necessary. This means aside from the anaesthetic machine, all your equipment is also not in the room. You have to figure out what what you might need, and bring it into the room with you, otherwise you have to ask someone outside the door to pass in the syringes or drugs you need. Having usually no idea what the surgeon is doing or for how long, the case usually involves me repeated going back and forth between the head of the bed and the door to ask for stuff.

Afterwards, the room is closed for cleaning and the patient is parked in a far corner of the recovery room.

All this makes some sense. Nobody wants innocent bystanders in the hospital infected with MRSA, or VRE or even C Diff.

Except quite often a couple of days later, you will inevitably run into the same patient, sitting outside smoking, having walked from his room, into elevator (touching door handles and elevator buttons on the way) and thru the lobby in a cloud of MRSA. Nobody seems to care.

Now a significant number of these patients originally acquired their infection in a hospital. And where do you think these supercharged bacteria originated. Could it be the single doses of Ancef? Am I the only person who has made the connection.

On another tangent, we frequently see in the press estimates of numbers of patient who have died as a consequence of infection with one of these bad bugs like MRSA, VRE or C. Diff. All these are of course the consequence of promiscuous use of antibiotics. Now as a consequence of working at the CofE which among other things is a cesspool of nasty bacteria I probably carry all three of these bugs plus several other nasty ones. But I feel fine.

No doubt many elderly patients or younger patients with significant medical conditions succumb to these bugs. This is however rarely the sole cause of their demise, it was just the final straw that pushed them over the edge. In most cases we are talking of maybe a few weeks taken off their lives. (A nephrologist where I trained always said, nobody dies of renal failure; he was quite right, if you keep dialyzing them you can keep their numbers correct every 2 days until they die of complications of renal failure or of dialysis or even from VRE, MRSA or C. Diff. A fine distinction)

Now occasionally healthy people do succumb to nasty infections like "flesh eating disease" or meningococemia. These are however bugs that are largely sensitive to antibiotics if you can get them in soon enough and in the correct doses.