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Dermatology Practice Today

Super Bugs, Super Scary

Published July 16, 2014 10:39 AM by Debra Shelby

In our programs, we learned about antibiotic abuse and “super bugs.” Years of prescribing these antibiotics have come to a point where treating skin infections have become very difficult. The incidence with MRSA has increased and years of treating this infection has made it resistant to many antibiotics. These bugs are bionic and we are the ones that help create them.

Through private practice experience, I made it a point to ask the patient what treatments were given prior to coming to me. Unfortunately, the patients may or may not remember. When I started treating patients in nursing homes and ALFs, I saw that providers are forgetting the basics of prescribing antibiotics. One rule that we were taught was not to repeat the same antibiotic within 90 days. Culture before prescribing and wait, if possible, before selecting an antibiotic. Time and time again, I see multiple antibiotics being prescribed without a culture. I even had an experience where I prescribed Doxycycline for MRSA only to have it repeated within two weeks because the primary care provider did not review the chart before prescribing.

I was watching a special on TV last week and an infectious disease specialist from the CDC was speaking about how science has not kept up with the development of new antibiotics to treat these resistant bacteria. The reality is health care providers will be faced with limited to no options for treatment.  One suggestion they made was for providers to use narrow spectrum antibiotics instead of broad spectrum.

So for what it’s worth, I have come up with some tips for treatment. I welcome others to share stories or clinical pearls with situations they may have encountered. I think this is a really important topic to share with other providers in order to educate those through constructive communication about changing practice. While this is not all inclusive, it is a good start.

1.      When treating a skin infection especially MRSA, always culture and treat the nares with Bactroban ointment. I prescribe it TID x 10 days. This will help reduce recurrence.

 

2.      Stasis dermatitis is NOT cellulitis. I see this basic inflammatory dermatosis being treated with antibiotics. While a secondary bacterial infection may be possible over time, typically this condition improves with support hose, leg elevation, diuretics, and topical corticosteroids. I had a MD provider prescribe Doxycycline two times within a month because her bilateral, fluctuating mild-moderate erythema was not resolving in her lower legs. When I tried to explain that the patient needed leg elevation, topical corticosteroids and an increase in her diuretic for her + 2 edema, he told me I was wrong with my diagnosis. Sigh…… unfortunately the patient suffers.   

 

3.      Hibiclens and topical antibiotics should be first choice for colonized skin infections. Use caution with prescribing oral antibiotics, especially with the geriatric patients. So many of them end up with C. Diff because of providers prescribing repeated antibiotics.

 

4.      Make sure that the primary cause of the skin disease is treated. For example, eczema may get a secondary bacterial infection. Some providers make an error thinking the condition is not improving because they fail to treat the primary condition along with the infection. Topical corticosteroids need to be used in addition to the antibiotics.

 

5.      When I prescribe an antibiotic, I look back 90 days to see what was given to the patient.

I may try to treat topically if I see that the patient has been exposed to multiple oral antibiotics. Communicate with the primary care provider if you see an overlap of orders for the same condition.

 

6.      Don’t forget that there may be a fungal infection involved. Make sure you biopsy or culture to confirm. Treat the fungal infection appropriately. Candida and dermatophyte infections respond to specific medications.  For example, Nystatin is not effective on dermatophyte infections. I use econazole for tinea infections. There is a difference between fungicidal versus fungistatic!

 

One thing for sure, I will focus more on infectious disease at next year’s conference. We need to put it on the forefront of everyone’s mind. I compare it to global warming. If it’s not right in front of us we tend to forget the massive impact our practice can have on future patient outcomes. If we don’t change our practice now we will be faced with more people losing the battle of these infections.

 

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    Occupation: Physician assistant and nurse practitioners
    Setting: Various dermatology settings
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