Skip to Navigation

Antibiotic Use (transcript)
Share This:

DR. SALGO: ONCE KNOWN AS "WONDER DRUGS", NOW THEY CAN ACTUALLY BE HARMFUL TO YOUR HEALTH.  AHEAD, THE AMAZING TRUTH ABOUT A REMEDY YOU ALWAYS THOUGHT WOULD MAKE YOU WELL.  NEXT ON SECOND OPINION.

MAJOR FUNDING FOR SECOND OPINION IS PROVIDED BY THE GUIDANT FOUNDATION.  THROUGH PHILANTHROPIC PARTNERSHIPS, THE GUIDANT FOUNDATION IS COMMITTED TO INCREASING PATIENT AWARENESS AND ACCESS TO ADVANCEMENTS IN CARDIOVASCULAR CARE.  WITH ADDITIONAL SUPPORT FROM THE FOLLOWING.  THE JOSIAH MACY JR. FOUNDATION AND THE PARK FOUNDATION.

DR. SALGO: WELCOME TO SECOND OPINION WHERE EVERY WEEK YOU CAN HELP SOLVE A MEDICAL MYSTERY AND LEARN MORE ABOUT YOUR OWN HEALTH CARE AS WELL.  I'M YOUR HOST, DR. PETER SALGO.  EVERY WEEK WE PUT TOGETHER A HEALTH CARE TEAM TO TAKE APART A MEDICAL CASE.  SOME OF THE TEAM ARE DOCTORS AND SOME ARE NOT.  AND JUST LIKE YOU, THE DOCTORS ARE HEARING THE CASE FOR THE FIRST TIME.  ELISSA ORLANDO IS OUR CIVILIAN OVER HERE.  AND SHE ALREADY KNOWS THE CASE, AS WE'VE SAID BEFORE,  SHE'S CHEATING, BUT IT'S OKAY.  OUR PRIMARY CARE PHYSICIAN TODAY IS DR. LOUIS  PAPA. HOW ARE YOU DOING LOU?

DR. PAPA: I'M FINE, PETER.

DR. SALGO: WELCOME BACK.  ALRIGHT, WHY DON'T WE JUMP INTO THIS CASE?  HERE WE GO.  WE'RE TALKING ABOUT A GENTLEMAN NAMED BRAD.  BRAD IS A HIGH SCHOOL SENIOR AND A STAR BASKETBALL PLAYER AND HIS PARENTS ARE VERY INVOLVED IN HIS SCHOOL WORK AND THEY REALLY LIKE THE FACT THAT HE PLAYS BASKETBALL.  THEY WANT TO KEEP HIM INVOLVED IN ALL OF THESE ACTIVITIES.  SO HIS MOM TAKES HIM TO THE DOCTOR ONE DAY, BECAUSE BRAD HAS A RED, SWOLLEN 3-BY-4-INCH TENDER SPOT ON HIS ARM NEAR HIS ELBOW.  THIS SPOT IS WARM TO THE TOUCH.  SO THE FIRST QUESTION WE HAVE TO ASK TO ALL OUR INFECTIOUS DISEASE SPECIALISTS, WHAT THE HECK IS WRONG WITH BRAD?

DR. HALL: IS IT JUST AN EVEN RED AREA, OR DOES IT HAVE A LITTLE SORT OF SCAB IN THE MIDDLE? 

DR. SALGO: NO, IT'S KIND OF AN EVEN RED AREA, THAT'S ALL.  AND IT'S KINDA ANNOYING,  I DON'T LIKE THIS THING, SAYS BRAD. 

DR. BETTS:  IS IT ON THE SKIN OR IS IT ON THE ELBOW ITSELF?

DR. SALGO: IT'S ON THE SKIN.

DR. HALL: IS HE SICK WITH IT?

DR. SALGO: DOESN'T FEEL SICK, BUT HE DOESN'T LIKE-

DR. HALL: DOESN'T HAVE A FEVER?  HE'S ACTING ALRIGHT.

DR. SALGO: NO FEVER

DR. PAPA: NOTHING DRAINING FROM IT?

DR. SALGO: NOTHING IS DRAINING FROM THIS THING.  SO WHAT'S GOING ON HERE?  WHAT DOES IT SOUND LIKE?

DR. BETTS: HE OBVIOUSLY HAS HE'S A KID THAT BANGS UP AGAINST PEOPLE.

DR. HARRIS:  WHAT KIND OF TRAUMA DOES HE HAVE?

DR. SALGO:  HE'S HAD NO TRAUMA

DR. HALL: HE'S A SPORTS GUY.

 DR. SALGO: YEAH, BUT HE'S A CLEAN PLAYER, WHICH PROBABLY MEANS HE'S NOT GOING TO GET INTO THE NBA DRAFT.

 DR. HALL: HE'S NOT GOING LIKE THIS, ELBOWING PEOPLE.

 DR. SALGO: HE HASN'T BEEN ELBOWING PEOPLE, HE JUST HAS THIS PATCH OF RED SKIN.  I'LL TELL YOU ONE MORE THING...IT FEELS WARM TO THE TOUCH.

 DR. SALYERS: ACTUALLY, WHAT MAY BE GOING ON HERE, AND THE CLUES SUGGEST THAT THERE IS SOME SORT OF INFLAMMATION TO THE SWELLING AND REDNESS..... 

 DR. SALGO: YOU'VE GOT A SWOLLEN AND RED AREA HERE.  IT'S INFLAMED.  IS THERE A WORD THAT YOU CAN CALL IT?

 DR. BETTS: YES, INFECTION.

 DR. HALL: WE CAN CALL IT CELLULITIS, AND IT COULD BE TRAUMA, WHICH WE NOW DECIDED THAT HE DIDN'T HAVE, SINCE HE'S SUCH A CLEAN PLAYER.  NOTHING HAPPENED. AND SO NOW WE HAVE AN INFECTION, IS THE MOST LIKELY.

 DR. SALGO:  I CAN SEE ELISSA POISED.

 ORLANDO: WELL IF IT'S AN INFECTION, IT'S AN INFECTION.  WHAT DO WE HAVE TO DO ABOUT IT IF THAT'S WHAT IT IS?

 DR. SALGO: COULD YOU PLEASE MAKE BRAD BETTER?  WHAT ARE YOU GOING TO DO?

 DR. HALL: WELL, WE WOULD LIKE TO LOOK AND SEE IF WE CAN FIND A PLACE TO CULTURE IT BECAUSE...

 DR. SALGO: WHAT DOES THAT MEAN, CULTURE?

 DR. SALYERS: YOU TRY TO OBTAIN A SPECIMEN THAT WILL YIELD THE BACTERIA THAT WILL HELP DIRECT YOUR THERAPY BECAUSE THESE DAYS THERE ARE SO MANY RESISTANT BACTERIAS OUT THERE THAT YOU CAN NO LONGER COUNT ON STANDARD ANTIBIOTICS BEING EFFECTIVE.

 DR. SALGO: ALL RIGHT GUYS, I'M GOING TO TELL YOU WHAT I'M GOING TO LET YOU DO.  I'M GOING TO LET YOU CULTURE THIS THING.  BUT I'M GOING TO TELL YOU SOMETHING. THAT CULTURE IS NOT COMING BACK UNTIL AT LEAST A WEEK FROM NOW.  SO, YOU'RE THE PRIMARY CARE PHYSICIAN, WHAT DO YOU WANT TO DO?  DO YOU WANT TO TREAT IT OR NOT?

 DR. PAPA: I THINK IN REALITY, THE CULTURES ARE VERY DIFFICULT TO GET IN THIS SETTING FOR SOMETHING LIKE THIS. IDEALLY WHAT I'D LIKE TO HAVE IS A LITTLE MORE TIME.

 DR. SALGO: YOU KNOW WHAT THEY DID?  THEY RESPONDED TO PARENTAL PRESSURE AND MAYBE THE DOCTOR THOUGHT IT WAS A GOOD IDEA AND THEY DECIDED TO PUT BRAD ON ANTIBIOTICS.  THEY PUT HIM ON DOXYCYCLINE  RIGHT OFF THE BAT FOR WHAT WAS INTERPRETED AS AN INFECTIOUS DISEASES OF CELLULITIS. HE GOES HOME AND GUESS WHAT HAPPENS?  TWO DAYS LATER, BRAD COMES BACK TO THE DOCTOR'S OFFICE BECAUSE THINGS ARE GETTING WORSE AND THIS TIME THE DOCTOR CHANGES ANTIBIOTICS, STILL WITHOUT THE BENEFIT OF A CULTURE, IT HAS NOT COME BACK YET. THEY DON'T KNOW WHAT THEY'RE DEALING WITH. AND THIS TIME PUTS HIM ON CEPHALEXIN. SENDS HIM HOME AGAIN.  FOUR DAYS LATER BRAD IS BACK IN THE DOCTOR'S OFFICE, THIS TIME BECAUSE HIS BASKETBALL COACH PULLED HIM OUT OF PRACTICE BECAUSE THIS THING ON HIS ARM OPENED UP AND BEGAN TO DRAIN.  SO NOW WE'VE GOT SOMETHING SERIOUS GOING ON, THIS INFECTION IS NOT CLEARING UP. WHY NOT?

 DR. HALL: IT COULD BE THAT HE ISN'T GETTING ENOUGH ANTIBIOTIC AND THE REASON.....

 DR. SALGO: WHY DON'T WE ASSUME THAT THE DOSE IS CORRECT? I THINK THAT'S FAIR TO THE DOCTOR.

 DR. HALL: BUT HE MAY NOT BE COMPLIANT.

 DR. BETTS:  I DON'T THINK WE CAN ASSUME THAT, BECAUSE THE DOSE CEPHALEXIN IS ALWAYS, ALMOST ALWAYS INSUFFICIENT, BECAUSE THE DRUG IS EXCRETED SO RAPIDLY, THAT IT DOESN'T GET TO A HIGH ENOUGH CONCENTRATION IN THE BLOOD.

 ORLANDO:  BUT WAIT, I DON'T EVEN UNDERSTAND THE DIFFERENCE AMONG ALL THESE ANTIBIOTICS, BECAUSE HE'S GOT THREE, ARE THEY ALL THE SAME, OR ARE THEY JUST SWITCHING AROUND?  ARE THEY TRYING DIFFERENT DOSAGES, WHAT ARE THEY DOING?

 DR.BETTS:  DICLOXACILLIN AND CEPHALEXIN CAN BE EFFECTIVE AGAINST THE SAME ORGANISMS IN WHICH STAPHYLOCOCCUS AND STREPTOCOCCUS

 DR. HALL:  WHICH IS ONE OF THE MOST COMMON THAT, YOU'D EXPECT TO BE THE CAUSE OF THIS PARTICULAR INFECTION.

 DR. SALGO: LET ME ASK A MORE GENERAL QUESTION THEN. IN YOUR OPINION, WAS PRESCRIBING ANTIBIOTICS THIS WAY THE CORRECT THING TO DO? AND IF IT WAS, WHY DIDN'T THEY WORK?

 DR. BETTS: IT'S POSSIBLE IT'S THE WRONG DRUG, BECAUSE AS I SAID EARLIER THERE ARE SO MANY RESISTANT BACTERIA OUT THERE NOW, THAT A  IT'S POSSIBLE ...I THINK ONE OF THE CRITICAL THINGS HERE, YOU DESCRIBED TO US A SLOW PROGRESS, THIS SUGGESTS TO ME STAPHYLOCOCCUS RATHER THAN STREPTO-COCCUS.

 DR. SALYERS: SO THERE ARE TWO WAYS THAT THEY CAN BECOME RESISTANT. ONE WAY IS TO MUTATE THE RESISTANCE, BUT THAT MEANS THEY THROW THE GENETIC DICE AND MANY BACTERIA WILL DIE IN THE PROCESS. AND SO WHAT MANY OF THEM HAVE CHOSEN TO DO, IF YOU CAN THINK OF A BACTERIA CHOOSING TO DO SOMETHING, IS TO ACQUIRE A PIECE OF DNA FROM ANOTHER BACTERIA.

 DR. SALGO:  HOW DOES A BACTERIA ACQUIRE SOMETHING?

 DR. SALYERS:  WELL THEY DO IT BY GETTING TOGETHER VERY TIGHTLY AND TRANSFERRING DNA, THAT'S WHY IT'S CALLED BACTERIAL SEX.  AND SO BACTERIA DO THIS VERY READILY, THE PROPER NAME IS CONJUGATION, BUT EVEN SCIENTISTS CALL IT BACTERIAL SEX, AND SO, THEY TRANSMIT DNA TO EACH OTHER FROM ONE TO ANOTHER AND SO THE BACTERIA CAN IN ONE STEP ACQUIRE A GENE THAT MAKES IT RESISTANT.

 DR. SALGO: I'LL TELL YOU...I'LL ADVANCE THIS A LITTLE BIT FOR YOU AND I'LL TELL YOU WHAT THE DOCTOR DOES. THE DOCTOR IS TALKING TO THE PARENT NOW, TAKING A MORE DETAILED HISTORY AND OF COURSE THE MOTHER, WHO IS VERY CONCERNED ABOUT HER SON, IS THINKING AS HARD AS SHE CAN ABOUT ANY EXPOSURE TO ANY POSSIBLE BACTERIA.  SHE REMEMBERS THAT HER SON PLAYS PAINTBALL, AND SHE REMEMBERS THAT HE MIGHT HAVE BEEN OUT IN THE WOODS--PROBABLY WAS.  THESE ARE WOODS WHERE THERE ARE TICKS, WHICH CARRY LYME DISEASE, AND MOM SAYS...DO YOU THINK MY KID HAS LYME?  THE DOCTOR SAYS NO I DON'T.  THE DOCTOR SAYS HOWEVER, I'M GOING TO TAKE THIS NOW THAT THERE'S SOME DRAINAGE HERE.  YUCKIE STUFF. PUSS COMING OUT OF IT, CULTURE THAT. NOW THERE ARE TWO CULTURES BREWING IN THE LABORATORY, AND , I'M GOING TO CHANGE ANTIBIOTICS AND EVEN THOUGH I DON'T THINK THIS IS LYME, TO MAKE YOU, THE MOTHER, HAPPY WITH THIS I'M GOING TO PUT THIS CHILD ON A THIRD ANTIBIOTIC AND THIS ONE COVERS LYME.

 DR. HALL:  DO YOU THINK THAT'S THE REASON HE'S DOING IT?

 DR. SALGO:  THAT'S RIGHT.  HE SAYS I'M GOING TO COVER LYME EVEN THOUGH I DON'T THINK IT'S A GOOD IDEA.  SO NOW WE'RE ON OUR THIRD ANTIBIOTIC.

 ORLANDO:  WAIT, WHY IS IT NOT A GOOD IDEA, I MEAN SHE'S BEING A GOOD MOTHER HERE RIGHT?  I MEAN SHE'S PUTTING TOGETHER SOME THINGS THAT MIGHT BE GOING ON WITH HER SON.  SHE THOUGHT ABOUT THIS.  SHE'S LOOKED BACK AT HIS OWN RECENT HISTORY.  SHE'S LOOKED OUT INTO THE WOODS AND HE'S PLAYING PAINT BALL, AND SHE THINKS IT MIGHT BE HELPFUL.  WHY WOULD THAT NOT BE A GOOD IDEA TO COVER THAT?

 DR. BETTS: WELL, BECAUSE THIS DOES NOT LOOK LIKE...THAT DOES NOT SOUND AT ALL LIKE LYME DISEASE.

 DR. SALGO: YOU GUYS DON'T WANT TO GIVE AN ANTIBIOTIC FOR TWO REASONS, ONE IT COULD BE THE WRONG ANTIBIOTIC AND YOU ARE NOT DOING ANY GOOD. BUT YOU ARE AFRAID OF DOING HARM. WHAT IS THE HARM?

 DR. HALL: I THINK THAT THERE ARE TWO HARMS.

 DR. SALGO: WHAT ARE THE TWO HARMS?

 DR. HALL: ONE IS TO THE PERSON ITSELF, HIMSELF, HERSELF. AND THE OTHER IS TO THE GENERAL SOCIETAL PROBLEM.

 DR. SALGO: WHAT DOES THAT MEAN?

 DR. HALL: MEANING THAT WE ARE INCREASING THE CHANCE OF MORE RESISTANT BUGS.

 DR. SALYERS: BUT I WOULD LIKE TO TAKE YOU BACK TO SOMETHING THAT YOU SAID BEFORE BECAUSE I THINK YOU MIS-STATED WHAT WE WERE SAYING. YOU SAID THAT WE DID NOT WANT TO GIVE AN ANTIBIOTIC, THAT IS NOT CORRECT, WHAT THE PHYSICIANS WOULD WANT TO DO IS GIVE THE RIGHT ANTIBIOTIC. THAT IS WHAT'S IMPORTANT AND THAT IS WHAT IS SO TRICKY HERE.  NOW SOMETHING THAT WE ALLUDED TO EARLIER COMES INTO PLAY HERE THOUGH, BECAUSE CULTURING OF THE ORGANISM TO DETERMINE WHAT IT IS AND WHAT IT'S SUSCEPTIBLE TO, CAN TAKE OVER A WEEK AND SOMETIMES MORE THAN TWO WEEKS TO GET THE RESULTS BACK AND SO NO MOTHER IS GOING TO SIT BY FOR THAT.

 DR. SALGO: WHAT I REALLY WANT TO FOCUS ON IS THIS PROTOTYPIC CONVERSATION BETWEEN MOTHER AND DOCTOR. DOCTOR I WANT THE DRUG FOR MY CHILD, PLEASE...THE  DOCTOR SAYS IT IS BAD FOR SOCIETY WE ARE GOING TO HAVE ALL THESE BACTERIA THAT ARE RESISTANT, WE'LL NEVER BE ABLE TO GET A JUMP ON THESE BACTERIA. THIS HAPPENS EVERY DAY RIGHT?

 DR. PAPA: IT HAPPENS ALL THE TIME AND I'LL BE HONEST WITH YOU MYSELF INCLUDED, I AM GOING TO PRESCRIBE ANTIBIOTICS TO SOME OF THESE PATIENTS, BUT WHAT I TRY TO DO MOST OF THE TIME IS TRY TO LEAVE SOME LEVEL OF COMMUNICATION OPEN. THIS IS HERE, THIS BOY IS NOT SICK, IT HASN'T INCREASED RAPIDLY IN SIZE, THERE IS A PHONE. IF IT DOES INCREASE IN SIZE, YOU CAN CALL ME. I WOULD LIKE TO GET MORE INFORMATION, I WOULD LIKE TO SEE WHAT IS HAPPENING BECAUSE I WOULD NOT LIKE TO KEEP YOU ON THE SAME ANTIBIOTIC.  

 DR. SALGO: LET ME GIVE YOU SOME NUMBERS AS A REALITY CHECK. THE NUMBERS I HAVE HERE ARE ONE HALF TO THREE QUARTERS OF ALL ANTIBIOTICS PRESCRIBED IN THE UNITED STATES ARE PRESCRIBED EITHER INAPPROPRIATELY OR THEY ARE SIMPLY DOING NO GOOD FOR WHATEVER REASON. THAT'S A GIGANTIC NUMBER. MORE AND MORE ANTIBIOTICS ARE PRESCRIBED INAPPROPRIATELY THAN ARE PRESCRIBED APPROPRIATELY IN THIS COUNTRY.

 DR. SALGO: IS IT ALL LOU'S FAULT?  IS IT  ALL...YOU KNOW...

 DR. HALL: WELL MOST OF THE TIME I IMAGINE, YOU'RE NOT TALKING INAPPROPRIATE USE WHERE IT IS THIS KIND OF LESION OR THIS KIND OF PROBLEM. IT IS MORE LIKELY TO BE A VIRAL COLD. WITH CHILDREN, THE MAJOR PROBLEM IS OF COURSE, THE FEAR OR POSSIBLE MISDIAGNOSIS OF HAVING AN EAR INFECTION ASSOCIATED WITH IT.

DR. SALGO:  WELL HOW ABOUT THIS.  I'M SORRY- GO AHEAD.

 ORLANDO: WELL I AM JUST SAYING, AS A PARENT, IF THAT IS WHAT YOU ARE SAYING, AND I KNOW WHAT YOU ARE SAYING BECAUSE WHEN YOU TALK ABOUT CULTURES, I DON'T REMEMBER THE LAST TIME I HAD A SORE THROAT AND GOT A THROAT CULTURE, I GOT ANTIBIOTICS INSTEAD YOU KNOW. BUT WITH PARENTS, IF I BRING MY CHILD IN WITH A COLD IT DOESN'T REALLY MAKE A DIFFERENCE TO ME WHETHER IT'S VIRAL OR BACTERIAL, I JUST WANT IT OUT OF THEIR SYSTEM. AND IT MIGHT BE INAPPROPRIATELY USED, BUT THE FACT IS THAT CHILDREN HAVE TO BE IN SCHOOL, I HAVE TO GO BACK TO WORK, AND I DON'T WANT MY CHILDREN TO BE SICK SO I NEED TO GET SOMETHING TO TAKE CARE OF THEM.

 DR. PAPA: IF IT'S VIRAL IT WILL DO NOTHING. IT WILL DO NOTHING FOR IT,  IT WON'T HELP IN ANY WAY. THE OTHER THINGS THAT YOU WORRY ABOUT, AN ANTIBIOTIC WILL NOT HELP THAT. AND THE BIG CONCERN IS THAT THERE COULD BE SERIOUS CONSEQUENCES--A SEVERE ALLERGY, YOU CAN GET A THRUSH OR A FUNGAL INFECTION IN YOUR MOUTH.  IT CAN CAUSE DIARRHEA AND YOU WILL HAVE THE KID HOME FOR OTHER REASONS.

 DR. SALYERS: NOT ONLY THAT.  SINCE THE KID HAS BEEN EXPOSED TO THE ANTIBIOTICS AND ESPECIALLY IF IT IS DONE INAPPROPRIATELY, FOR THINGS LIKE EAR ACHES WHERE THIS KID WILL GET ANTIBIOTICS OVER AND OVER AGAIN, THAT KID COULD DEVELOP BACTERIA THAT NORMALLY LIVE IN THE BODY THAT ARE RESISTANT. A LOT OF THESE BACTERIA CAUSE INFECTIONS, SO WHAT YOU ARE DOING IS YOU'RE DOOMING THIS KID DOWN THE ROAD.

 DR. HALL:  FROM THE PEDIATRICIAN'S POINT OF VIEW, WE SEE PARENTS WHO DON'T WANT TO SEND THEIR LITTLE DARLING OUT INTO THE WORLD WITHOUT PROTECTION. AND THE ONLY THING THEY KNOW AS POTENTIAL PROTECTION, OTHER THAN PERHAPS VACCINES WHICH DON'T HELP THAT MOMENT BECAUSE THEY STILL HAVE THE DISEASE, IS AN ANTIBIOTIC. THAT'S WHAT THEY THINK.

 ORLANDO: DO THEY TAKE THEM ALL? I MEAN EVERYBODY IS ALWAYS SAYING YOU HAVE TO TAKE THE FULL COURSE, YOU HAVE TO TAKE ALL OF YOUR PILLS, AND YOU KNOW...

 DR. BETTS: HE NEVER GOT BETTER. SO IF YOU, IF YOU DON'T TAKE THE FULL COURSE IT RELAPSES RATHER THAN GETS BETTER.

 DR. SALGO: RIGHT NOW WE'VE GOT CHILD WHO HAS HAD THREE DIFFERENT ANTIBIOTICS.

 DR. BETTS: WELL HE'S ONLY HAD TWO, YOU WERE ASKING ABOUT LYME DISEASE.

 DR. SALGO: WELL HE STARTED HIM ON AN ANTIBIOTIC FOR LYME. SO THE FIRST TWO ARE SITTING IN THE REFRIGERATOR PARTLY USED AND WE ARE ON THE THIRD ONE BY NOW AS WELL.

 DR. BETTS: WAS IT DOXYCYCLINE?

 DR. SALGO: I'LL GIVE YOU DOXYCYCLINE.

 DR. BETTS: THAT ACTUALLY IS NOT TOO BAD FOR RESISTANT STAPHYLOCOCCI.

 DR. SALGO: HE HAS GIVEN THE DOXYCYCLINE WHICH IS OKAY BUT FOR THE WRONG REASON.  IS THAT PRODUCING RESISTANT BACTERIA?

 DR. BETTS: WELL I DON'T WORRY SO MUCH ABOUT THAT BECAUSE THE KID NEEDS TO BE TREATED. YOU WORRY ABOUT PRODUCING RESISTANT BACTERIA WHEN YOU GIVE AN ANTIBIOTIC THAT IS NOT NECESSARY.

 DR. SALGO: I WANT TO GO WHERE ELISSA ALMOST WENT WHICH IS THIS WHOLE THING ABOUT THE FULL COURSE BECAUSE PARENTS HEAR THIS ALL THE TIME.  WHAT'S THE PROBLEM, IF YOU ARE GIVEN AN ANTIBIOTIC, EITHER APPROPRIATELY OR INAPPROPRIATELY, YOU FEEL BETTER, THE KID FEELS BETTER, STOP THE ANTIBIOTIC, IT HAS BEEN FIVE DAYS, THE DOCTOR SAID TEN DAYS, WHAT IS THE BIG DEAL?

 DR. BETTS: WELL WITH RESPECT TO STAPHYLOCOCCI, IF YOU STOP TOO EARLY THE ORGANISM IS IN WHITE BLOOD CELLS AND IT HASN'T GONE AWAY, IT WILL RELAPSE AND THEN YOU WILL HAVE TO START ALL OVER AGAIN. AND THEREFORE IT IS NOT GOOD SENSE. ALTHOUGH SOMETIMES FIVE DAYS WILL WORK, BUT IF YOU TAKE 100 PEOPLE, ON AVERAGE FIVE DAYS ISN'T ENOUGH.

 DR. HALL: DEPENDING ON WHAT KIND OF STAPH INFECTION IT IS. 

 DR. PAPA: IT'S ALMOST LIKE YOU HAVE KILLED ENOUGH OF THEM SO YOU CAN'T SEE WHAT YOU ARE DOING, BUT THERE IS STILL ENOUGH OF THEM AROUND THAT THEY CAN COME BACK.

 DR. HALL: OR THEY CAN HIDE SUCH THAT THEY DON'T GET THE FULL DOSE OF THE ANTIBIOTIC.

 DR. SALGO: YOU HAVE TO GIVE ENOUGH ANTIBIOTICS SO THEY CAN RUN BUT THEY CAN'T HIDE.

 DR. HALL: RIGHT, AND SOME ARE MORE SENSITIVE THAN OTHERS SO WE HAVE DIFFERENT COURSES FOR DIFFERENT BUGS.

 DR. SALGO: ALL RIGHT, LOOK, AT THIS POINT IT IS REALLY IMPORTANT TO SET OUT WHAT YOU ALREADY KNOW AND WHAT YOU NEED TO KNOW. ANTIBIOTICS BECOME INEFFECTIVE MOSTLY BECAUSE THEY ARE USED INCORRECTLY WHEN YOU GIVE TOO MANY ANTIBIOTICS TO MANY PEOPLE WHO DON'T HAVE BACTERIAL INFECTIONS THAT ANTIBIOTICS TREAT, OR YOU GIVE THEM ANTIBIOTICS THAT THEY DON'T NEED, YOU GIVE THEM ANTIBIOTICS FOR TOO LONG A PERIOD OF TIME OR TOO BRIEF A PERIOD OF TIME, WHAT YOU ARE DOING IS YOU ARE SETTING SOCIETY UP AND SETTING AN INDIVIDUAL UP FOR THE RESISTANT BACTERIA TO DEVELOP AND THAT'S TROUBLE. PEOPLE JUST NEED TO KNOW THAT SOME INFECTIONS DON'T NEED ANTIBIOTICS, OTHERS NEED SPECIFIC ONES AND THE TIME TO TAKE THESE ANTIBIOTICS IS THE TIME YOU'RE ADVISED TO TAKE THESE ANTIBIOTICS - 5 DAYS, 7 DAYS, 10 DAYS. I AM GOING TO MOVE THIS CASE ALONG.

 DR. SALYERS: CAN I FIRST MAKE JUST TWO VERY BRIEF COMMENTS TO PUT THIS IN A LARGER CONTEXT?  THERE ARE TWO THINGS THAT SOCIETY HAS TO KEEP IN MIND.  ONE IS THAT WE NEED TO REMIND OURSELVES HOW MUCH OF MODERN MEDICINE RESTS ON THE CONTINUED EFFICACY OF ANTIBIOTICS. SO ANTIBIOTICS ARE NOT JUST SOME SIDE ISSUE. THERE IS SURGERY. WE ARE TALKING CANCER CHEMOTHERAPY, SOME OF THE SIDE EFFECTS OF THOSE VERY IMPORTANT THINGS THAT WE ARE DOING, WE NEED THOSE ANTIBIOTICS. SECONDLY, MANY PHARMACEUTICAL COMPANIES HAVE BEEN PULLING BACK ON OR SHUTTING DOWN THEIR ANTIBIOTIC DISCOVERY PROGRAMS SIMPLY BECAUSE ANTIBIOTICS AREN'T NEARLY AS PROFITABLE AS SOME OF THE OTHER DRUGS THAT THEY PRODUCE. AND SO THIS IS THE BROADER CONTEXT, WE HAVE GOT TO GET BEYOND JUST THINKING ABOUT THE INDIVIDUAL. YOU THINK ABOUT THE INDIVIDUAL, BUT ALSO ABOUT THIS PART.

 ORLANDO: BUT THAT IS REALLY HARD TO DO WHEN YOU HAVE A SICK CHILD, OR YOU ARE SICK YOURSELF AND YOU NEED TO GET YOUR LIFE BACK TO NORMAL.

 DR. SALYERS: WELL I AM NOT SAYING A MOTHER SHOULD DO THIS, I'M SAYING THAT WE NEED TO EDUCATE PEOPLE.

 DR. PAPA: BUT IT STARTS THERE, I MEAN IT DOES START THERE, IT'S THE ONLY WAY THAT YOU ARE GOING TO INTERFACE WITH EVERYTHING.  NOBODY IS AGAINST MAKING SURE WE DON'T HAVE SUPER BUGS. I'M SURE EVERYBODY IS LIKE YUP, I'M SURE THAT IS A GREAT IDEA, WIPE OUT THE SUPER BUGS... BUT GIVE ME MY ANTIBIOTIC.

 DR. SALGO: THE SUPER BUGS EVERYBODY IS TALKING ABOUT, SPECIFICALLY, THEN LETS GET THIS OUT ON THE TABLE, ARE ANTIBIOTIC RESISTANT BACTERIA. BACTERIA THAT HAVE SEEN ANTIBIOTICS EITHER IN YOUR KID OR SOMEBODY ELSE 'S KID AND ARE NOW EVERYWHERE AND ARE RELATIVELY UNTREATABLE. THAT'S THE SUPER BUG. AND YOU EXPECT A MOM TO GO INTO YOU AND SAY "MY KID HAS A FEVER, MY KID HAS AN EARACHE, YOU'RE TELLING ME IT'S NOT A BACTERIA SO FOR THE SAKE OF SOCIETY I AM GOING TO LEAVE MY KID SICK, DON'T GIVE ME ANTIBIOTICS."

 DR. PAPA: YOU ARE CONFUSING TWO DIFFERENT ISSUES HERE. YOUR CHILD IS SICK, YOUR CHILD IS ILL, YOUR CHILD HAS A VIRAL INFECTION, IT IS A COMPLETELY DIFFERENT BEAST. AND I THINK PART OF IT IS THAT THERE'S A SENSE THAT RIGHT THERE RIGHT NOW IT HAS TO BE ADDRESSED, AND THAT'S THE BEAUTY OF PRIMARY CARE.

 DR. SALGO: WELL LET ME JUST INTERRUPT YOU RIGHT HERE BECAUSE MY PHONE JUST RANG, MY CARD JUST POPPED UP, I KNOW WHAT BRAD'S GOT. BRAD HAS MRSA. DOCS CALL IT MERSA.  METHICILLAN RESISTANT STAPH AUREUS.  THIS IS A SUPER BUG! IT IS AN ANTIBIOTIC RESISTANT BACTERIA. NOW, ONCE AGAIN JUST FOR THE SAKE OF ALL OF US.  HOW DO YOU GET MRSA, WHERE ON EARTH DOES THIS THING COME FROM?  HOW DID THE BACTERIA LEARN TO BE RESISTANT?

 DR. SALYERS: MOST STAPHS LIVE IN YOUR NOSE.  THE NOSE AND THE SKIN. BRAD PROBABLY HAS HIS OWN STRAIN.

 DR. SALGO: COULD BRAD HAVE GOTTEN THIS FROM ANOTHER KID WHO TOOK ANTIBIOTICS?

 DR. BETTS: THAT IS EXACTLY WHAT THE INFORMATION LOOKS LIKE. INITIALLY THERE WAS A VERY SLOW INCREASE IN THE FREQUENCY OF ORGANISMS THAT WERE RESISTANT TO METHICILLAN WHICH WAS THE PRIME DRUG USED FOR YEARS TO TREAT STAPHYLOCOCCUS AND IT WAS  10%, 11%, 12% AND ALL OF A SUDDEN IT HAS JUMPED 30%, 40%, 50% PERCENT AND THE BEST INFORMATION SUGGESTS IT IS BECAUSE ONE PERSON IS TRANSMITTING IT TO ANOTHER PERSON, AND THE TRANSMISSION IS EASIER IF THAT OTHER PERSON WAS ON AN ANTIBIOTIC TO SUPPRESS THE NORMAL BACTERIA AS YOU ALLUDED TO.

 DR. SALGO: SOMEBODY ELSE'S ANTIBIOTIC TREATMENT RESULTED IN BRAD GETTING A SUPER BUG, RIGHT?

 DR. BETTS: EXACTLY.

 ORLANDO: IS THAT WHAT YOU MEAN BY SOCIETY AND YOU SHOULDN'T TAKE THEM BECAUSE OF SOCIETY?

 DR. HALL: OBVIOUSLY WHEN THIS ALL STARTED THE FOCUS WAS ON THE HOSPITAL. THAT SEEMED TO BE WHERE WE SAW THE WORST CASES, WHERE IT WAS TRANSMITTED TO MOST EASILY. BUT I THINK WHAT IS CONCERNING RIGHT NOW IS THAT IT IS OUT THERE IN THE COMMUNITY.

 DR. SALGO: IT HAS MADE THE JUMP.

 DR. HALL: YEAH, IT'S OUT THERE.

 ORLANDO: OK, WELL I'M JUST GETTING REALLY SCARED LISTENING TO THIS BECAUSE NOW A LITTLE CELLULITIS INFECTION ON A YOUNG BOY HAS TURNED INTO A SUPER BUG AND THAT IS A SCARY WORD. NOW YOU'RE SAYING THAT RESISTANT BACTERIA ARE IN THE COMMUNITY. I MEAN ARE THEY IN MY PET? ARE THEY IN MY LIVING ROOM?  I DON'T REALLY UNDERSTAND.

 DR. SALGO: CAN YOU GET THIS FROM YOUR PETS?

 DR. SALYERS: THERE ARE SOME PEOPLE WHO SUSPECT, AND I AM TRYING TO QUALIFY THIS BECAUSE RESULTS ARE NOT YET OUT, BUT SUSPECT THAT COMPANION ANIMALS CAN CARRY THE STAPH AND SOME OTHERS. BUT PROBABLY YOU GOT IT FROM ANOTHER PERSON.

 DR. SALGO: ARE WE GETTING THIS SUPER BUG STUFF BECAUSE WE ARE EATING LIVE STOCK ANTIBIOTICS EVEN IN LOW DOSES?

 DR. SALYERS: WELL THIS IS VERY CONTROVERSIAL. I THINK THE JURY IS STILL OUT ON THAT ONE. I THINK THAT IT IS CLEAR THAT THERE ARE ANTIBIOTIC RESISTANT BACTERIA THAT ARE BEING GENERATED ON THE FARM.  AND SO THE QUESTION IS: ARE THESE THE BACTERIA THAT ARE CAUSING INFECTION? I THINK MOST PEOPLE WOULD SAY THAT IT IS THE USE OF ANTIBIOTICS BY HUMANS THAT IS THE BEST.

 DR. BETTS: WELL IT DEPENDS ON THE BACTERIA. YOU CAN'T BE GENERAL. FOR EXAMPLE, IN THIS ORGANISM CALLED VANCOMYCIN RESISTANT ENTEROCOCCUS. IN FRANCE 100% OF PEOPLE ARE COLONIZED WITH VANCOMYCIN RESISTANT ENTEROCOCCUS BECAUSE ANIMAL FEED CONTAINS A VANCOMYCIN LIKE DRUG. BUT THAT IS PROBABLY NOT TRUE FOR STAPHYLOCOCCUS. SO, YOU CAN'T BE GENERAL.

 DR. SALGO: THE PROBLEM RIGHT HERE IS THAT THE GENIE IS OUT OF THE BOTTLE. THESE BUGS ARE OUT THERE. WHICH BRINGS US TO ANOTHER THING I THINK YOU REALLY NEED TO REMEMBER. JUST BECAUSE YOU ARE NOT TAKING ANTIBIOTICS, DOESN'T MEAN YOU ARE SAFE. IT DOESN'T MEAN THAT A SUPER BUG ISN'T COMING TO SEE YOU. THE USE OF ANTIBIOTICS BY EVERYBODY ELSE IN THE COMMUNITY HAS CREATED SUPER BUGS. HAS CREATED THESE RESISTANT BACTERIA, WHETHER IT IS YOUR VREF, OR BRAD'S MRSA, WHICH CAN INFECT YOU WHETHER OR NOT YOU TAKE ANTIBIOTICS. WHICH BRINGS US BACK TO THIS WHOLE QUESTION OF SOCIETY'S DEMAND FOR ANTIBIOTICS. YOU OWE IT TO YOURSELF, YOU OWE IT TO YOUR CHILDREN TO THINK VERY CAREFULLY ABOUT WHETHER YOU NEED AN ANTIBIOTIC AND LISTEN TO YOUR DOCTOR CLOSELY ABOUT WHETHER THE DISEASE THAT YOU HAVE GOT IS ANTIBIOTIC SENSITIVE OR NOT. NOW LET'S GO ON WITH THE CASE BECAUSE, THERE IS MORE. BRAD STILL WANTS TO PLAY BASKETBALL. THAT'S ALL HE REALLY WANTS TO DO.   HE'S GOTTEN NOW HIS THIRD ANTIBIOTIC. AND ALL HE REALLY WANTS TO DO IS GET BACK AND PLAY WITH THE TEAM.  THE DOCTOR HAS HAD SOME SUCCESS TREATING MRSA STAPH INFECTIONS WITH AN ANTIBIOTIC CALLED LINEZOLID. THEY ARE ALL NODDING THEIR HEADS--YES THIS IS A REASONABLE ANTIBIOTIC. SO BRAD GOES OUT ON LINEZOLID. IF YOU ARE KEEPING TRACK THIS IS ANTIBIOTIC NUMBER FOUR. THE OTHER THREE ARE IN THE FRIDGE SOMEWHERE GETTING NICE AND COOL AND WAITING FOR SOMETHING ELSE TO HAPPEN.

 DR. HALL: LIKE SOMEBODY ELSE TAKING THEM.

 DR. SALGO: WE'LL GET TO THAT. BUT FOR NOW, BRAD'S SORE GETS BETTER. THE LINEZOLID IS WORKING. BUT GUESS WHAT? BRAD DEVELOPS A RASH FROM THE KNEES DOWN. WHAT IS GOING ON NOW?

 DR. BETTS: WELL YOU DON'T KNOW WHETHER IT WAS NUMBER THREE, NUMBER TWO, OR NUMBER ONE.

 DR. SALGO: SO BRAD GOES BACK TO HIS DOCTOR AND SAYS "I'VE GOT THIS RASH" AND HIS DOCTOR IS APPROPRIATELY CONCERNED. HIS DOCTOR THINKS THAT 20% OF PEOPLE ON LINEZOLID HAVE SOME PROBLEM, WHETHER PLATELETS OR OTHERWISE- GETS A PLATELET COUNT, THE PLATELETS ARE VERY LOW. DANGEROUSLY LOW. SO DOES THIS MEAN THAT THE LINEZOLID IS POTENTIALLY LETHAL. MIGHT HAVE KILLED THIS BOY? 

 DR. BETTS: THAT PRIMARY CARE PHYSICIAN SHOULD PICK UP THE PHONE AND CALL SOMEONE WHO WORKS IN THIS AREA AND ASK HIM WHAT THE HECK IS GOING ON HERE.

 DR. SALGO: BUT DOESN'T THIS MAKE THE CASE, WHETHER IT IS ANTIBIOTIC TWO, ANTIBIOTIC ONE, LINEZOLID, THAT THERE IS NO FREE LUNCH?

 DR. BETTS: THAT'S RIGHT.

 ORLANDO: I DIDN'T KNOW ANY ANTIBIOTIC HAD ANY PARTICULAR SIDE EFFECT.  I'VE NEVER HEARD OF NOT A GOOD ANTIBIOTIC, I DIDN'T KNOW ANY ANTIBIOTIC COULD DO ANYTHING TO YOU.

 DR. PAPA: ANY DRUG CAN DO ANYTHING TO ANYBODY.

 DR. SALYERS: IT IS A RISK-BENEFIT SITUATION.  THE DECISION IS MADE IN THE CLINICAL TRIALS.  ARE THE BENEFITS OF THIS ANTIBIOTIC SUFFICIENTLY HIGHER THAN THE RISKS, WHICH ARE USUALLY PRETTY LOW?

 DR. BETTS: IN THIS CASE THOUGH, IT'S UNEQUIVOCAL THAT IF YOU WANT TO GIVE THIS KID AN ANTIBIOTIC, LINEZOLID IS AN ORAL ANTIBIOTIC THAT IS EFFECTIVE AGAINST MRSA, THERE'S A COUPLE OF OTHERS, THAT'S WHEN I SAY DOXYCYCLINE MIGHT WORK TRIMETH/SULFA MIGHT WORK, BUT THAT DRUG HAS BEEN VERY EFFECTIVE AND IT GETS IN WITHOUT GETTING AN IV, WHICH HAS ITS RISK TO TREAT THIS MRSA. SO HECK, IT'S A GOOD DRUG.

 DR. SALGO: IS ANYBODY ELSE STRUCK BY THE FACT THAT HERE IS A KID WHO SIMPLY WANTS TO PLAY BASKETBALL AND HAD, FOR LACK OF A BETTER WORD, A BOO-BOO ON HIS ARM, AND SUDDENLY HE HAS GOT A LETHAL PROBLEM POTENTIALLY WITH HIS PLATELET COUNT, ANTIBIOTICS CROWDING THE FOOD OUT OF HIS REFRIGERATOR AND HE IS STILL ON ANTIBIOTICS AND HE IS NOT PLAYING BASKETBALL YET? WHAT IS GOING ON HERE?

 ORLANDO: WAS THIS PROBLEM CAUSED BECAUSE THIS BACTERIA IS RESISTANT?

 DR. HALL: PROBABLY THE REASON IT DIDN'T GET BETTER INITIALLY IS BECAUSE OF THE RESISTANT BUGS. BUT THERE WAS NOTHING WRONG WITH GIVING THIS CHILD, I THINK, INITIALLY, DICLOXACILLAN.

 DR. PAPA: DR. HALL IS EXACTLY RIGHT. IT SHOULD HAVE WORKED AND IT DOES 90% OF THE TIME WORK.  SO IT IS AN APPROPRIATE DRUG.

 DR. SALGO: ISN'T IT FAIR TO SAY RIGHT NOW, JUST BECAUSE WE WANT TO SUM THIS UP JUST A LITTLE BIT AND PUT SOME CLOSURE ON THIS, THAT THE RESISTANT ORGANISMS OUT THERE, THE SUPER BUGS, WHETHER CAUSED BY THE OVERUSE OF ANTIBIOTICS, PROBABLY CAUSED BY THE OVERUSE OF ANTIBIOTICS, NOT ONLY ARE DANGEROUS TO YOU BUT THEY ARE DANGEROUS TO YOU MEDICALLY, THEY ARE DANGEROUS TO YOUR POCKETBOOK BECAUSE THEY ARE VERY EXPENSIVE, THEY REQUIRE YOU TO USE MORE POWERFUL ANTIBIOTICS WITH A WORSE SIDE EFFECT PROFILE--THAT IS, THE ANTIBIOTICS THEMSELVES CAN CAUSE GREAT MISCHIEF. SO WHETHER YOU DON'T WANT TO USE ANTIBIOTICS BECAUSE THEY ARE THE WRONG THING TO DO FOR THE INFECTION, YOU MAY NOT WANT TO USE ANTIBIOTICS SIMPLY BECAUSE

 THEY ARE WRONG FOR THE ENVIRONMENT AND THEY ARE WRONG FOR SOCIETY, AND THEY ARE WRONG FOR YOU, EVENTUALLY, BECAUSE THEY WILL COME BACK TO BITE YOU. WELL I AM GOING TO MOVE THE CASE ON FOR YOU, BECAUSE BRAD ACTUALLY GETS BETTER, WE'RE GOING TO LET BRAD GET WELL BECAUSE BRAD DID GET WELL. THERE ARE FIVE PARTIALLY USED ANTIBIOTIC BOTTLES NOW IN THE REFRIGERATOR. THEY ADDED THAT $100 A DOSE FOR THE LINEZOLID, FIGURED OUT THAT FOR 10 DAYS THAT COST A LOT OF MONEY, THEY MIGHT AT WELL SAVE SOME FOR LATER, AFTER ALL THIS STUFF WAS GOLD. AND FIXED HIM UP. NOW, THE NEXT TIME THE FAMILY HAS AN INFECTIOUS DISEASE, SOMETHING THAT THEY THINK IS INFECTIOUS, WHAT DO YOU THINK THEY ARE GOING TO DO? DO YOU THINK THEY ARE GONNA USE THE ANTIBIOTICS OR GO BACK TO THE DOCTOR? WHAT DO YOU THINK?

 DR. BETTS: WELL I THINK, WELL, IT'S WELL KNOWN THAT THEY WILL PICK THE ANTIBIOTICS OUT OF THE REFRIGERATOR.

DR. SALGO: IS THAT RIGHT?

 DR. BETTS:  YEAH.

 DR. SALGO: SHOULD THEY DO THAT?

 DR. BETTS: NO.

 ORLANDO:  I'M GOING TO AT LEAST CALL THE DOCTOR AND SAY, LOOK, I'VE GOT HUNDREDS OF DOLLARS WORTH OF STUFF HERE, LET ME TELL YOU THIS OVER THE PHONE, AND TELL ME WHICH ONE OF THESE YOU WANT ME TO USE.

 DR. PAPA: COMMUNICATION IS THE KEY. LOT'S OF TIMES IF PATIENTS SAY I'M JUST GONNA TAKE IT AND I CAN'T TELL YOU HOW MANY TIMES SOMEONE WILL COME IN AND SAY I HAVE THIS COLD, SINUS INFECTION, RED SPOT BLAH, BLAH, BLAH.  I'VE BEEN ON "X" ANTIBIOTIC FOR FOUR DAYS AND IT HASN'T WORKED.

 DR. SALGO: AND WITH THIS UNFORTUNATELY WE HAVE RUN OUT OF TIME. WE HAVE COVERED A LOT IN THE LAST HALF HOUR, SO WHAT I WANT TO DO IS SUMMARIZE WHAT YOU REALLY NEED TO REMEMBER FROM THIS. FIRST OF ALL ANTIBIOTICS DON'T ALWAYS WORK BECAUSE THEY ARE MISUSED, THEY ARE OVERUSED, OR THE DOSAGE THAT YOU HAVE BEEN GIVEN WAS SIMPLY NOT FINISHED. WHETHER OR NOT YOU TAKE ANTIBIOTICS, YOU ARE STILL AFFECTED BY THE USE OF ANTIBIOTICS IN SOCIETY IN OUR ENVIRONMENT. AND TO TREAT RESISTANT ORGANISMS IT REQUIRES MORE DRUGS, MORE MONEY, AND THERE ARE MORE CHANCES OF LONG-TERM HARM. ALL THE REASONS HERE FOR NOT USING ANTIBIOTICS INAPPROPRIATELY AND DOING ACTUALLY THE RIGHT THING.  I WANT TO THANK ALL OF YOU FOR BEING HERE, THIS WAS JUST TERRIFIC.  REMEMBER, TAKING CHARGE OF YOUR HEALTH MEANS BEING INFORMED AND HAVING QUALITY COMMUNICATION WITH YOUR DOCTOR.  I'M DR. PETER SALGO.  I'LL SEE YOU NEXT TIME FOR ANOTHER SECOND OPINION.

SEARCH FOR HEALTH INFORMATION AND LEARN MORE ABOUT DOCTOR/PATIENT COMMUNICATION ON THE SECOND OPINION WEB SITE.  THE ADDRESS IS PBS.ORG.

 MAJOR FUNDING FOR SECOND OPINION IS PROVIDED BY THE GUIDANT FOUNDATION.  THROUGH PHILANTHROPIC PARTNERSHIPS, THE GUIDANT FOUNDATION IS COMMITTED TO INCREASING PATIENT AWARENESS AND ACCESS TO ADVANCEMENTS IN CARDIOVASCULAR CARE, WITH ADDITIONAL SUPPORT FROM THE FOLLOWING.  THE JOSIAH MACY JR. FOUNDATION AND THE PARK FOUNDATION.

###