Posted on 12-20-2011
VETERINARIANS WILL END THE WORLD AS WE KNOW IT
Ok, maybe not all the world, just the human life that crowds the Earth at this moment….at least that is what my brother the anesthesiologist frequently says. But then, he does frequently exaggerate things a bit. It's all about antibiotics and our continuing ability to prescribe said antibiotics. He thinks that by abusing that right, veterinarians are likely to create the "superbug" that will kill us all. I'm not sure he is right, but I know lots of wildlife out there (and likely a few tree-huggers) who are cheering him on.
This article is not about the end of the world, it's about compliance, costs and common sense. It's about good medicine and good luck and the distinct difference between the two.
Yesterday I had two phone calls that brought this to my mind. The first call was about a dog with an ongoing skin condition; most likely a complication of chronic contact allergies. I had not seen the dog for 6 or 8 months and I was not absolutely sure that it was just recurrence of the "same-old, same old", but it was quite probable. Based on the owner's description of the problem and my historical notes, I was willing to re-dispense a course of antibiotics at the correct dose for 2 to 3 weeks.
That did not happen; my reasons in a moment.
The second call was about another dog who was demonstrating the signs of a urinary tract infection. I had seen the dog a couple of months ago and while I did not do much in the way of diagnostics at that time, I had noted that I felt that the dog should have a full work-up if the symptoms became a recurrent issue. The owner, understandably, was hoping to forgo the relatively expensive diagnostic process and just skip down to the antibiotics. I stood my ground on this case too, and I will try to justify that stand here so people can see some of the judgment process I go through with just about every case.
My first case, the dog with the skin infection, probably does need antibiotics. There is no doubt in my mind that the pooch is having a flair-up of his allergies and has a secondary infection. The problem I had with the whole situation is that the owner, for some bizarre reason, without so much as a free phone consultation, had seen fit to reduce the dose of the prescribed antibiotic to less than half of the correct published dose. Now, of course, by reducing the dose the owner had stretched the supply of antibiotics from a few weeks to literally months and had reduced substantially the side effects of the drug (antibiotics frequently upset tummies). This owner had also proved my brother absolutely right: using antibiotics at anything less than the appropriate dose is exactly how you create "superbugs". The low dose of the antibiotics just kills the weak and wimpy bacteria and gives the strong and robust bacteria more room to play. By reducing doses and duration of treatment you actively select for durable, pathogenic bacteria. Doctors don't just make the dose up from imagination; the doses are based on detailed research that shows the dose required to reach bactericidal blood levels for sufficient periods of time to clear the disease. Anything less and you are just setting yourself or your dog up to become a statistic in the news. If the drug really is causing your dog to feel sick, then your best course of action is to call the veterinarian and switch drugs to something that does not upset your dog's stomach. A veterinarian cannot be expected how your individual dog is going to react to a specific drug; you need to tell him or her when things are not going as predicted.
My second case, the dog with the urinary tract infection (UTI), also illustrates how we all take for granted the use of antibiotics. While I completely agree with the owner that the dog likely does have a UTI, there are many other reasons that the dog may be having problems urinating. On the other hand, the dog may have a UTI secondary to a more severe disease we don't even suspect. From my own notes I see I did a very limited work-up last time I saw the dog, probably due to financial reasons. Now we are seeing a repeat customer at the window so we need to do more than play lip service to proper medicine. Guessing at a diagnosis and getting it right is called good luck, not good medicine. Just how stupid does the doctor look if he has been treating a bladder infection for weeks when it was a bladder stone or, worse yet, bladder cancer that was actually causing the problem? Maybe we all are entertained when television's Doctor House butchers yet another patient in his "wonder medicine" process (as in "I wonder what he will do next"), but I can guarantee that real clients are not amused when things are going south quickly. In this specific case, it is clearly malpractice for me to just give in to expediency and re-dispense antibiotics based on "she's just like she was last time, Doc". Heck, we don't really know I was right last time, now do we? The dog got better in that instance, no doubt, but that might have been due to that ancient and oft prescribed medicine "tincture of time".
Now don't get me wrong. I am not one of those naysayers that are calling for the end of times all the time. Antibiotic resistance, while certainly a real problem, is not all that common in veterinary medicine. Ears infections and skin infections are the most common "resistant" infections, but mostly because they are also the most common infections period. Those two infections also tend to be caused by staphylococci bacteria, a little bug(ger) that can adapt and mutate with ease. Bladder infections (UTI) also tend to be an issue with resistance, if for no other reason than the fact they can stay hidden for quite a while and really get entrenched in the bladder. Bladder infections also are often secondary to a systemic disease such as diabetes or renal insufficiency; it's pretty hard to win against bacteria when the bug has the entire body working against the antibiotic. Bacterial resistance is not a new thing (resistant bacteria have been found in archeology digs that predate all antibiotics) and most resistance is due to the nature of the bacteria or the condition of the host rather than something wrong with the antibiotic. This does not change my opinion that we need to preserve the activity of our antibiotics by following some stringent guidelines:
1. Get the correct diagnoses
2. Use the correct antibiotic based on scientific evidence of susceptibility
3. Use the correct dose to weight and current health status
4. Use the antibiotic for long enough to completely eradicate the bacteria AND allow enough healing to prevent re-infection.
5. Recognize that all antibiotics have side effects and that the veterinarian probably has a secondary choice of antibiotics that might not result in those effects.
Let's try to work together and prove my brother wrong. When the end of the world comes, I don't want that pompous horse's hind-end to be able to say "I told you so". Don't ask me to guess at the diagnoses (I'm not Dr. House and I don't get a second take if the patient dies), don't ask me to just dispense antibiotics because it might be an infection and don't just change your prescription " just because". I know that coming to the vet costs money, but believe me when I say that I really do try to keep the client's budget under control.
Veterinary medicine is the only business I know that the business managers are always looking for some way to save the customer money. Veterinarians all know how difficult it can be to make ends meet (believe me, you should see veterinary overhead if you want to have a "breathless" moment) and we know that we are always in danger of pricing ourselves right out of our market. We economize as much as we can, but at some point the quality of our product starts to really deteriorate. When a veterinarian suggests a diagnostic plan or a treatment plan, he is usually trying to find the most effective way to help your pet, not the most profitable or the most expedient. The public needs to keep in mind that it is veterinary MEDICINE, not veterinary "used cars". I can give you good medicine or I can give you cheap medicine, but I don't believe I can give you good and cheap medicine.
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