Know Your Antibiotics!

“What are the five commonly prescribed Antibiotics by you?"

I asked. A very unpleasant question this was for one of our residents seated in a room of about thirty odd doctors during today's very pleasant Bangalore afternoon.

“Augmentin…

Piptaz….

Clindamycin…

Metrogyl…

….mumble…

Dalacin”

He completed after a lot of contemplation. For those commoners who lack the knowledge of antibiotics, the third and the fifth one are the same, the former being the generic name and the latter being its brand name. While he was happy that he got his five, I thought it would never hurt to ask more and went ahead with my rapid five.

Me: “So….what do you give it for?” 

He: ‘Blank’

Me: “How many patients do you give it to on an average?”

He: ‘Blank’

Me: “And how many of them recover”?

He: ‘Blank’

Me: “Do you look at the antibiotic policy of the hospital before prescribing?”

He: ‘Blank’

Me: “Do we have an antibiotic policy in the hospital?”

He: ‘Blank’

I could have gone ahead with my minor dissection on his prescription practice and rationale but the general reaction in the room with department heads, senior consultants, residents and interns was a sight to behold. Working with microbes and antibiotics day in and day out I am of the opinion that the most resistant of all are us Doctors, nobody or nothing else. We are way ahead of all the Multi-Drug, Pan-Drug and Extremely Drug Resistant Microbes that we fret about and deal with in our hospitals.

In the periodical class on Infection Prevention and Control that we conduct for consultants and residents wherein we brief about NABH standards, Standard Precautions, Personal Protective Equipment, Hand Hygiene, Bio-hazard Spill Management, Biomedical Waste Management, Health Care Associated Infections, Surveillance Charts, Antibiotic Policy and Post exposure Prophylaxis the most I could do as a Medical Microbiologist and an Infection Control Officer was to share my little knowledge I have about these issues.

Some days there are few consultants with a ‘rock-solid-will-never-change-my-unit-my-antibiotic-my decision-my responsibility-my patient-I-know-better’ attitude and then some days there are only residents with ‘i-will-only-follow-what-my-head-says’ [read: not the head above his shoulder but the unit head] attitude. Some days there are five in the room, some days about ten and some days there are none. And on all days the laboratory doctors are considered ‘para’-medical and not medical because they see samples, not the patients. The samples are from their own patients is something long forgotten.

Despite all this our quest for training and data collection continues. “To measure is to know, if you cannot measure it, you cannot improve it” so said the great Scots-Irish mathematical physicist and engineer Lord Kelvin. It has not been an easy ride and it will never be, likewise for all doctors dealing with Infection Control especially in small health care settings where constraints are not just with resources but also with the lack of awareness and drive amongst our own peers, it has always been so in most of our Indian hospitals with regards to other situations.

Microbes with novel beta-lactamase enzymes have reached the United Kingdom from our capital and are christened with the city’s name too! New Delhi Metallo Beta-Lactamase! If it sounds very cool and you are a health care personnel you should be more than sorry. At the grass root level we still are far away from deciding on whether to check or not on what happens to the antibiotics that we scribble on our prescription pads. Only the kinds of Nipah Virus can wake us up.

Guidelines and policies are slowly falling into place at all levels but there are hundred other institution and speciality specific issues of Antibiotic Resistance and in the way we approach them, we are facing a silent epidemic and we have a long way to go!

Right Choice, Right Route, Right Dose, Right Frequency & Right Duration-the 5 Rs of Antibiotic Prescription apart, a 6th R would definitely do a lot of good to our patients and also all of us who belong to the medical fraternity- RIGHT ATTITUDE.

A kind request to all my fellow doctors- Know The Antibiotic You Prescribe! If not, we are here at the lab to help.🙂

As you all know we are facing a huge problem of Antibiotic Resistance across the world and India is considered as one of the epicentre of what we call as Superbugs, they are even named after our towns and cities like the famous NDM-New Delhi Metallobetalactamase!🤔

Healthcare associated infections are a huge problem due to antibiotic resistant microbes which increase our hospital stay, they also are a huge expenditure and carry a high risk for mortality.😢

Public perception of the issue is very important in this regard which my doctor fraternity seldom considers for discussion. Since we have to begin somewhere I am carrying out a small survey titled ANTIBIOTIC AWARENESS SURVEY with a few questions to be answered.

If this healthcare issue is of concern to you please participate and help us doctors analyze where we all stand. Thank you, your participation and feedback is highly valuable.🙂

Here is the link :

https://www.surveymonkey.com/r/WN7FKHG

-R.

For The Sweet People

“Daktre nange sugar ide!”

This is something I get to hear from every fourth person I meet. ”Doctor, I have sugar!” With India being the diabetes capital of the world, a spacious home to about 60 million people living with this disorder there is a lot more that needs to be done in this regard. As a  doctor I would like to share a few thoughts today on World Diabetes Day. 'Healthy Living And Diabetes' is the theme for the period 2014-2016.

 

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Diabetes has no longer remained a problem of the rich. A day ago one of the house keeping staff of my laboratory came to me.

“Madam! 279 Madam! Is it because of the Diwali sweets?”

I gave him some serious advice. I told him to go for a check up, for some more laboratory tests and for a dietitian consultation, but the indifference with which he responded only made me realize that this diabetes problem is a tough one to deal with in this country. It requires a multifaceted approach. Do visit the Diabetes Foundation Of India to know more on what is being done in India.

 My concern is that there are innumerable myths around this non-communicable disease. I would like to throw some light on the most popular.   

• SUGAR is synonymous with DIABETES.

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 No. Diabetes has reached such magnitude that we need to be a tad serious about it. Sugar does not mean diabetes, let us get more rational and scientific. 

• INSULIN is worse than TABLETS. 

 

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No. Treatment has to be monitored by a diabetologist. Do visit one before getting into self medications. What works for one patient may not work for the other. 

• I only have to STOP EATING SWEETS.

 

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No. Diabetics require a diet. There is nothing like no sweets. We all are born with a sweet tooth, aren’t we? And that too with so many festivals that have to be celebrated every fortnight! But yes, we need to watch what we eat, when we eat and how much we eat!  

• My PARENTS DON’T HAVE DIABETES, So I WON’T GET IT. 

No. Although there is familial predisposition there is no science behind this baseless thought. Diabetes is a lifestyle disorder, mind you it is a DISORDER and not a disease.  

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• I HAVE 'ONLY' DIABETES.  

NO. This is a major misconception among diabetics. You know that constant feeling of self assurance 'Nothing is wrong, it is only diabetes' The first step towards living with and solving a problem is accepting it followed by gaining knowledge about it. Diabetes can lead to multiple health issues, if I were to list it as a risk factor for the number of other diseases I can begin and end a major medicine textbook.

 

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 Some diabetics do good and live with it like they have no problem at all, what I see in them is the difference in attitude - diet, exercise, medicines, health updates and most importantly 'HAPPINESS'- Hakunamatata! :-)

My mother is someone who believes not in fighting with diabetes, but in living smart with it :-D

She was the one who reminded me this morning.

 “Aren’t you going to wish me today?” she asked.

“Why?” I questioned in reply looking at her adorable smile.

“Today is World Diabetes Day, it is kind of my day” she said.

And we laughed.

We had gorged on this last week. Haha! :-)

-R.

B or P- Issues Raising Blood Pressure

"There are some atypical cells probably" said the pathologist.

The doctor was worried, it was his wife's PAP* smear report after all. After a brief discussion they both decided to go for a Human Papilloma Virus detection just to ensure that the picture does not turn out to be bad. He walked to another section and spoke with the Microbiologist regarding the case, the investigation would be outsourced from there to another laboratory which carries out molecular diagnostics.

A couple of minutes later.

"What sample is required for HPV-PCR** pa?" he called the microbiology laboratory and asked.

"EDTA-sample Sir" a technician replied.

The doctor billed for a HPV-PCR test from the billing section and sent the sample from the sample collection centre as told.

 The EDTA vacutainer reached the laboratory through the house-keeping. Another technician received it and took a printout of the worksheet and kept everything ready for the test to be outsourced.

Now one may wonder what this is all about and what happened after that.Let me tell you what the final report was:

Hepatitis B Virus- Not Detected

Human Papilloma Virus

Eh? B or P, what is in a letter? Definitely a great raise in Blood Pressure! I did fall of the chair when I heard this. Everything is pretty much kicked to Pluto if there is a miss or a change, especially in a health care setting when this happens it is not at all pardonable. I am sharing this because it is a necessary learning, unfortunately I wasn't around when this happened. I heard various versions from the technicians regarding this matter, what I understood was the kind of miscommunication that happen over telephonic conversations. The doctor called asking for HPV, the technician heard it as HBV and advised him to send a EDTA vacutainer, but in reality it is either a cervical swab or cytology fluid that needs to be sent. Well even after that with the mismatch in the bill, nobody really bothered to cross check. The outsourced test was for HBV-PCR since it was an EDTA vacutainer. The realization dawned only when the doctor called asking for the HPV-PCR report after two days. HPV is a virus associated with cervical cancer and HBV is a virus associated with hepatitis and liver cancer, two different clinical presentations and diagnoses. The matter is getting sorted out, and we hope not to have such disastrous events again.

  

Hepatitis B Virus

What bothers me is the mechanical nature of work that happens in most of the hospitals. This happened with a hospital staff, a doctor, I cannot imagine the scenario if it was a patient. It does happen nevertheless. Nobody talks about it, the matter is hushed up or sorted out by us doctors or dealt by the patient relations section. I am talking about it because this kind of maleficence is something we all need to be aware of, as doctors and as patients. We need to always ensure that abbreviations or short forms are not used for drugs or tests during diagnosis and treatment. After all it is a matter of someone's life or death. There is a thin line, a very thin one. Thankfully this incident was something that could be handled, if it was something else I couldn't have forgiven myself for being a part of such a work team! It sends a shiver down my spine, every time I think of it. "Do No Harm" is sometimes easier said than done.

*PAP Smear- The Pap smear is a screening test for cervical cancer. Cells scraped from the opening of the cervix are examined under a microscope. The cervix is the lower part of the uterus (womb) that opens at the top of the vagina.

**PCR- The polymerase chain reaction (PCR) is a technology in molecular biology used to amplify a single copy or a few copies of a piece of DNA across several orders of magnitude, generating thousands to millions of copies of a particular DNA sequence.

-R. 

Dengue Season Lessons

“Hello, calling from emergency, can you tell us the dengue report of…”a resident doctor asks from the other end.

“Positive for NS1 and IgM…”says our laboratory technician.

Seconds later.           

“Hello, calling from the ICU, SDP* needed for….are they ready?” asks a staff nurse.

“Ready, you can send someone right now” replies a blood bank technician.

At the same time.

“Hello Ma’am, calling from reception, can you please verify the dengue report of…”a data entry operator from the other end.

“We will do it in a couple of minutes…” I reply.

Seconds later.

“Hello, calling from the ward can you run a Dengue IgM ELISA for my patient with the previous sample, his platelet counts are low, I strongly suspect Dengue…”a clinician from the other end.

“No problem Ma’am, we will add it to the run today” one of us reply and agree to do it.

This diagnostic and treatment process runs in the various departments of every other hospital in India twenty four seven these days. All thanks to the ‘Dengue Season’ like we choose to call it. At this point of time, as you are reading this I bet there is at least one person you know who has had dengue this year. The emergency and outpatient department is busy with cases of fever, the doctors with every third patient coming with signs and symptoms of dengue, the blood bank is worked up with platelet transfusions and the laboratory with monitoring platelet counts and serological tests.

Dengue is a serious public health concern, like many other diseases and disorders it turns into a red alert when mortality rate surges. Remember the H1N1 a couple of months ago? Keep that for memory, there could be is always a next. I initially thought of writing a post on the ‘dos and donts’ to avoid the transmission of dengue thinking that would be helpful, and then it occurred to me that most of us know about the Aedes mosquito, water stagnation, sanitation, coils, nets, electric bats, repellents, papaya juice and what not. It is not the lack of this knowledge that causes the dengue outbreak every year in a tropical country like ours. There is more to the picture.

 What bothers me as a laboratory physician is our failure at many levels of health care to handle such a situation. There is a great lack of responsibility from all sides- hospitals, doctors and patients alike. The extreme variability in the standard and costs of testing and treatment has recently grabbed attention in Karnataka. Read this to know more-Government Fixes Dengue Test Rate for Pvt Hospitals. Such measures although put the government in a Samaritan position, the real problem is something else. None of us is bothered about any preventive measures or a long term solution to such vector borne diseases. ‘Odomos’, ‘Good Knight’ and 'Mortein’ can think of new advertisements. Doctors, laboratories and blood bank can think of their work load and price revision. And the government can think of regulating them. Until the same time next year! 

Ek machar kaafi hai, par ek soch nahi :-P

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Do share your opinions and experience.

*SDP-Single donor platelets

-R.