Thursday, January 30, 2014

Antibiotic-seeking behaviour and booties to prevent interdigital dermatitis

Superman blows a snot bubble: not every runny nose should be treated with antibiotics.
Antibiotic-seeking behaviour is common in any health care setting, partly because most of us were raised in the era when antimicrobials were prescribed willy-nilly. Guidelines about prudent use have since emerged, as has data on increasing antimicrobial resistance and the real prospect of a "post-antibiotic era". But owners still ask for them and clinicians feel a pressure to prescribe.

In an interesting study lead by Mohammed Mustafa, family medical physicians assumed that most patients or parents of patients wanted antibiotics to treat acute upper respiratory tract infections. In humans, as in many animal species, most of these are caused by viral pathogens that aren't susceptible to antibiotics. And antibiotic use isn't eactly benign - it can be associated with side effects such as minor gastrointestinal upsets to severe alteration of gut flora and subsequent colonisation with bugs like C. difficile. 

Some authors have recommended that physicians simply ask patients point blank: do you want antibiotics? The problem is, if they say yes, then the recommendation is no, it gets uncomfortable for everyone.

Instead, family physicians would "build a case" against antimicrobials by providing a running commentry around the physical exam. And it makes sense...clients bring their animals to us at least in part for reassurance that there is nothing sinister going on. Being able to provide evidence for that assessment is one of the most helpful things we can do. Its not enough to simply state "I'm not giving your cat antibiotics because its a virus". We should be explaining in more detail our differentials and indicators of bacterial involvement that clients can look out for.

What was interesting was that a lot of clinicians knowingly over- or understated findings of the physical examination to fit with their recommendation. The problem with this stance is that it can backfire.

So we need evaluate the evidence we accrue objectively and draw conclusions AFTER and not BEFORE we gather the evidence.

When it comes to non-prudent use of antimicrobials, the clients are only one part of the equation. The suppliers (prescribing physicians or vets) are human and are influenced by patient demand, percieved patient expectations, previous bad experiences where antimicrobials were not used and the physician-patient relationship.

We can forget that while we are bombarded with literature on antimicrobial resistance and guidelines for prudent use, clients may not be - and it is really helpful information! Sharing this kind of information and making our decision making explicit can aid in shared decision making. We can also utilise diagnostic tests to determine whether infection is present.

Booties for dogs

Making world news this week is this story (if nothing else, click on this link for a great photo) about Bluey, a weimeranar with interdigital dermatitis. Its a bit of a stretch to claim that Bluey's vets would have been "stumped" by the "bizarre" condition, since allergic dermatitis commonly affects the feet and booties are a great way to minimise exposure to allergens. Its just that many dogs won't accept them initially.

But minimising contact with surface allergens can help reduce exposure and subsequent itching. Similarly, dog-clothes, custom rashies and other clothing items can be used to minimise exposure - so long as one remembers that it can get awfully hot under those layers.

Mustafa M, Wood F, Butler CC and Elwyn G (2014) Managing expectations of antibiotics for upper respiratory tract infections: a qualitative study. Annals of Family Medicine 12(1):29-36.