This is just depressing

I know I often sound hostile or dismissive of the medical profession. But it's hard not to when you read something like this recent study in Clinical and Infectious Diseases.

The most valid excuse physicians have for not prescribing the most appropriate antibiotics is that the information required is not available when it is needed. This is a real concern - a sepsis patient simply can't wait 3 days for the lab to return microbial identification and susceptibility results before beginning treatment.

But what about patients who present with wound infections - sick, certainly, but in no imminent danger of death or disablement. And what if you only need a couple of hours to get the information needed to treat effectively? And can do so while minimizing the risk of adverse events and maximizing antibiotic stewardship? This seems like a trick question, doesn't it? Of course you would seek out that information and use it to the best advantage of the patient.

If so, then you would be practicing good medicine, but you would apparently be an outlier. That's the only conclusion one can draw from the results of the CID study. Wound patients admitted to the UCLA-Olive View center were tested for the presence of MRSA or S. aureus (presumptively methicillin-sensitive) using the Cepheid GeneXpert real-time PCR test. Treating physicians had been educated on the use and interpretation of the test, and in an additional phase of the study, were contacted by a pharmacist.

The hope was that only the patients suffering from MRSA infections would be given anti-MRSA antibiotics such as vancomycin. This matters because vancomycin is probably not as effective as B-lactams, is more likely to have toxic side effects, and exposes patients to the risk of C. difficile-associated diarrhea, which kills some 14,000 Americans per year.

What the study found was that the rapid-test results had no discernible effect on physician prescribing practices: 60-70% of the non-MRSA patients received anti-MRSA antibiotics in the absence of test results, and 60-70% received them with test results. If physicians had used the test results, this number would have been 7%.

This was not a particularly large study, and it was conducted at a single institution. But still - how can this be? I appreciate that doctors are, and should be, conservative when it comes to adopting changes in practice. But the Cepheid test is not especially new - it received FDA clearance in 2008. False-negative results for MRSA are very rare, less than 1% in the literature and 0% in the CID study. So there was essentially no risk to their patients that erroneous test results would lead to ineffective treatment. These facts must have been presented to the physicians as part of the education phase of the study.

The prestige of the medical profession has always made doctors susceptible to a kind of mulish arrogance. In previous centuries and decades, this arrogance manifested itself as a resistance to improved hygiene, or in the bullying of patients. It's hard to see a refusal to follow practice guidelines when provided with timely information, as anything other than a continuation of this sordid tradition.

 

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