OMG! :eek: I bet you don’t get any crap from any of your incarcerated patients! Must be hard to hold surgical instruments in those claws.
I have to agree with this, in the past 40 years, there has been what, three new classes of antibiotics? Besides that there have only been minor improvements on the current ones.
I do have to agree on the 2nd part of your post, the last major new antibiotic that I know of (not including hospital only, aka IV drugs) is Azithromycin (Zithromax, a macrolide). It was patented in 1981, and I believe it was approved by the FDA around 1991. It was approved as effective against a wide range of different bacteria, and was WAY over prescribed. At this point, I believe (I’ll have to ask my teacher for a cite if needed, but he mentioned in class) about 50% of the bacteria that were vulnerable to it are no longer so.
So, by the time the patent was expired, the drug wasn’t nearly as effective as when it was issued. I think a large part of this is probably due to the drug companies trying to get as much money as they could from it while it was under patent, not caring about the resistance to it.
I am not suggesting that antibiotic resistance is not problem; only that it’s not a new problem. I am not particularly concerned that a super bacterium will kill us all as my personal observation is that host defense is more important than nasty bacteria (on average, of course). I do worry about a supervirus and I wonder if that’s just an odd quirk in my personality or something.
I am not going to pretend expertise in antibiotic chemistry, but it’s a bit of an overstatement to make a broad comment about new classes of antibiotics as if the absence of an entirely new class reflects lack of progress. 1,3-oxazolidinones, for example, were developed in the 90s with Linezolid being the first one marketed around 2002. That “class” (oxazolidinones) in general goes back to the 50s, when it was used for TB, but most of us in practical medicine would consider Linezolid a brand new antibiotic and functionally a new category even if it’s not a new “class” technically.
Your point about the money it costs to develop and market new agents is well taken. I note that QtM’s skin poppers should probably get Cipro (a few bucks) for their MRSA skin infection and not Linezolid, however (depending on his local sensitivities, of course, but it wouldn’t be unreasonable to expect a 75% sensitivity rate to Cipro). And of course ciprofloxacin is itself an antibiotic that was “new” in the late 80s even though its quinolone “class” had existed for some time. So even though MRSA might be methicillin-resistant or multiply-resistant doesn’t mean you have to use the Big Gun, even if Pfizer wants you to think MRSA=Linezolid. And of course if we want to fine-point the idea of “sensitivity” in general, what happens in a petri dish to determine technical sensitivity with artificial cutoff points is quite different from what happens in vivo. As you can probably tell, I am not overwhelmed with the germ theory of disease, and in fact I think buying into it too much on the part of both physicians and the polloi is one of the underpinnings of antibiotic overuse (which is a real, and legitimate problem–just not my particular hotbutton).
I am all about robust hosts and less about bugs and the poisons that kill them. Like most ED physicians I’ve seen a crappy host crump from Neisseria Meningitidis in front of my eyes while 10% of his college buddies carry it around in their nasopharynx asymptomatically during outbreaks. Another topic.
But yes, we use too many antibiotics, new ones are too expensive to develop and yes I am part of the problem, although hopefully not as much as the next guy over.
And yes, narcotics and other recreational drugs should be decriminalized. The war on drugs is a farce. Also another topic on which I have posted elsewhere.
I had one bad year I kept getting step throat and each time the doctor did the swab test but he was like “Here take these antibiotics 'cause it’ll take three or four days to get the results back and we want to get you started now.”
I can see the doctor’s points, if I have to wait three or four days for test to come back to see exactly what kind of bacteria it is, that isn’t a great way to do things.
Markxxx, as posted above, there’s not much benefit to taking antibiotics for strep throat. Treating infections empirically while waiting for culture results is often used when the patient will be harmed while waiting, such as in pneumonia or sepsis, but the argument against using antibiotics for strep throat is that the risks of treatment (risks to patient and population) do not outweigh the slim to nonexistent benefits.
The average party line for approaching a sore throat is:
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If it meets all four strep clinical criteria (no cough; positive exudate; positive fever; tender anterior cervical nodes) go ahead and give an antibiotic.
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If it meets fewer than all four criteria, use a rapid bedside test to confirm the presence of strep, unless it meets only one criterion. In that case, follow.
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Preferred antibiotics are penicillins, followed by macrolides. Injectable penicillin has the highest clearance of strep on follow-up testing. However follow up testing is not necessary in asymptomatic patient.
Sample link for the pary line: http://www.aafp.org/afp/20010415/1557.pdf
Now the problem is that every one of these points is fraught with fine points, and the truth is that these are just practical guidelines, endlessly debated by academicians. For example:
Asymptomatic carrier states are common, so using a strep test (antigen or culture) as a “gold standard” is not only costly but inaccurate. As I mentioned above, only a rising ASO titre is truly a gold standard.
Patients have an annoying habit of soft symptoms. “Maybe a little cough.” “A little tender when you press there…”
Penicillin “allergy” is incredibly common but often inaccurate. Maybe the kid had a viral infection that caused a rash, got a beta-lactam antibiotic, and was told it was an allergy. Maybe he vomited after taking it. Whatever, it’s not gonna kill him to get penicillin again, but you sure aren’t going to inject it just in case, and you will probably just give zithromax because it’s easier than arguing.
Nobody likes injection, so the gold standard for treatment isn’t used. On the other hand, nobody takes all ten days of their pills. On the third hand the idea that you should take antibiotics until the “whole course is finished” has absolutely no basis for being a good idea, other than that it may help diminish the number of people who test positive for strep at the end of ten days. On the fourth hand such testing has nothing to do with how the patient clears clinically, so it doesn’t make any difference to make a negative strep an end point…
And on and on and on… Loads of fun.
A really dumb guy and a really smart guy can both come to the same conclusion about how to approach strep, and two smart guys can come to opposite conclusions with very good cites for their approaches.
And in the end, what we’ve gained by treating strep (even a true acute symptomatic acute streptococcal pharyngitis) is a little diminution is duration of acute symptomatology (particularly if we use injectable penicillin as the treating agent) and a diminution of already-rare post-streptococcal rheumatic fever. And since we treat a lot of sore throats to get to the streps to get to the rheumatic fever, that’s a whole lotta treatin’ going on.
In terms of my world, where we “just write the prescription, and send the patient out the door” I’d just like to say that in no world do I have an hour to explore all the nuances with the patient. You basically would have to teach them medicine and then explore the scientific papers. So I can fall back on the simplified clinical guidelines (see the citation) knowing that even there, the conclusions are not absolutes.
We (not his parents) sometimes refer to The Nephew as “the calf” because he was on “preventive antibiotics” for a year… just like calves in some farms. I don’t know how prevalent it is to add antibiotics to the feed “to prevent infections” (you know, rather than give the calves some room to move and maybe a sight of the sun once in their lives), but I suspect it may be a lot more common than recommended (heck, if it’s done once, it’s more common than it should be).
Now, now, Qadgop, you know full well that personal insults are not… oh, wait. Hmmm. I don’t think we have a rule that covers this. 
OK, on the serious side, I have heard that suppositories are a faster and more efficient way of getting antibiotics into the bloodstream. Of course, they wouldn’t be popular for all the obvious reasons, but have any of y’all got some facts to prove or debunk that statement?
Actually, I do always take the full course of my antibiotics, however long that course happens to be, unless I develop an allergy to that medicine. I’m afraid that my husband WILL stop taking his pills as soon as he thinks that the infection is gone.
I had rheumatic fever and Sydenham’s Chorea in first grade because I didn’t have antibiotics for a strep throat. I didn’t have permanent heart damage. The Sydenham’s Chorea severely messed up my life for decades. Having a very debilitation neural disease for most of your life because someone thinks people shouldn’t get an antibiotic is bullshit.
A second cousin had rheumatic fever and heart damage for the same reason.
Now let’s look at going in for a shot every day for two weeks as a cost to health care. You increase the costs astronomically and the person is more likely to miss doses or stop when they have to go to a clinic everyday to get cured instead of taking their pill at work at lunch.
The rectal route of administration is one of the fastest routes into the blood stream, plus it has the advantage of bypassing first pass metabolism by the liver. The fastest by far is IV, then you have sub-lingual and rectal.
As you said, rectal is the least liked route of administration, in fact since most people don’t like it, the only major systemic drugs given by the route is ones for little babies, and anti-nausea medication. However pharmacists can compound many other drugs into suppositories if desired.
Hear hear! (But we long ago stopped doing this, and passed it on to compounding pharmacies. Our suppository molds sit forgotten on the shelf with the other compounding supplies, collecting dust. 
It was the highlight of my day Monday when we ran out of Tamiflu suspension and I got to compound some.)
You actually got to compound some? Good for you. The pharmacy I work for doesn’t stock the syrup to use as a vehicle, so we can’t compound it.
Technically speaking, some of the medication doesn’t even need to be compounded into a suppository. Some of the medications commonly used in hospice were just inserted in whole tablet form during my hospice rotation and seemed to work just fine.
We dissolve metronidazole tablets in water and give them per rectum in horses when they are NPO, and it seems to work fine.
Wow! Has any human ever tried to inject themselves with something like that? I mean, how different is Agri-cillin from the Penicillin my doctor might give me? How would they figure the dosage? And outside of Seinfeld episodes on TV, how often do people try to take animal medicine?
I completely disagree. After seeing two people close to me get MRSA in the last two years and hearing stuff like “well, if this doesnt do it, then you might be in trouble” along with reading the mortality rates involved… well, its fucking scary.
As far as science keeping up goes, my understanding is that we’re pretty close to the end of our rope here and all the big breakthroughs early in the 20th century were the low hanging fruits of antibiotic science. We just arent going to have another period with so many new substances because they probably dont exist.
Also, draining MRSA wounds isnt fun either.
Oh, I don’t know. They smell better than both perirectal abscesses and pilonidal cysts. And a chance to cut them is a chance to cure them! Antibiotics aren’t really even necessary for most uncomplicated MRSA soft tissue abscesses. Just drain the damn things and the patient gets better.
Of course the patients demand antibiotics, and threaten to sue if you don’t give them.
With your patients I’m surprised they don’t demand hydrocodone or oxycodone instead!