Monthly Archives: November 2017

“Choosing Wisely Bacteriology: Ear swabs for otitis externa”

The Science of Microbiology, ,

There is plenty of scope for choosing wisely in the microbiology laboratory. The most obvious targets are actually within infectious serology, a department now essentially in the process of being superseded by molecular methods. However there are lots of opportunities within culture based bacteriology also, with an impressive proportion of superficial swabs being of low clinical value… I will try and review some of these sample types over the next few weeks.

Otitis externa is a common condition, especially in the summer when people go and bathe in rivers and lakes and get their ear canals repeatedly wet with non-sterile water…

The microbiology laboratory receives lots of ear swabs from patients with otitis externa. But in the vast majority of cases, the swab result is absolutely meaningless in terms of managing the infection.

But it is very tempting to take an ear swab nevertheless. Who wouldn’t want to take a swab to a discharging ear!

Bacteria and fungi are usually bit part players only in otitis externa. The actual condition is a vicious circle of infection of ear debris- inflammation- swelling, blockage, leading to more infection and so the cycle goes on.

Releasing the blockage by clearing the debris, along with drying the ear canal are just as effective as antimicrobial drops, if not more so.

Most otitis externa swabs grow Pseudomonas aeruginosa or Staphylococcus aureus. A few grow Candida or Aspergillus species. Others simply grow a bacterial soup! (Our lab doesn’t report more than two organisms from an ear swab)

It actually doesn’t matter that much…

And antimicrobial susceptibilities are essentially useless as well. The treatment of otitis externa is with topical agents and it is well documented that the clinical response to topical antimicrobials is poorly correlated with their in-vitro susceptibility patterns.

Mild cases of otitis externa can often be managed with acetic acid drops alone (a drying agent with some anti-bacterial activity).

More severe cases usually get drops which often contain a bit of everything; a broad spectrum anti-bacterial, an anti-fungal, and a bit of steroid to reduce the inflammation.

So ear swabs should be reserved for recalcitrant cases of otitis externa, where the clinician is at the stage of discussing the case with an ENT specialist.

For the remainder, who cares that much what the swab grows…

From a choosing wisely perspective, how do we approach this? One option is to reject all ear swabs from otitis externa patients unless the clinical details suggested recalcitrant infection. Alternatively a comment could be added to every ear swab result saying that ear swabs are not indicated for otitis externa, except in special circumstances.

Time to act…

Michael

“No Pressure”

Antimicrobial Resistance, ,

Have you ever taken yourself, or one of your children, along to a doctor and then either exaggerated the presenting symptoms in order to increase the chances of being prescribed an antibiotic?

Or have you ever directly asked the doctor to prescribe an antibiotic, either subtly or not so subtly…?

I am guilty as charged, because I am human like everyone else. However I am improving now that a large part of my job is anti-microbial stewardship!

And because doctors are human as well, they often give in to such demands, because they want the patient to leave the consultation having had a positive opinion of them, even if the antibiotic itself will make no difference to the outcome or speed of resolution of infection.

This week is World Antibiotic Awareness Week, an initiative by the World Health Organisation to make people aware of the potential dangers of overuse of antibiotics. There is plenty of useful promotional material available on their website to promote this message.

However, I believe that creating a “No pressure” culture is one of the key elements of antibiotic awareness amongst the general public. This is the concept of allowing your doctor to make an objective decision as to whether an antibiotic is required. I.e. you go to your doctor, relate the symptoms to them as honestly as possible, you do not pressurise the doctor for any particular type of treatment , and accept whatever treatment choices that the doctor makes.

As most of you are aware, antibiotics are completely futile for many of the conditions that a family doctor will see each day.

An antibiotic prescription in general practice should be the exception, not the norm.

Amidst all the various components of antimicrobial stewardship, I believe the key is reducing antibiotic usage by reducing inappropriate or unnecessary antibiotic prescriptions.

This is not just the responsibility of doctors, but of patients as well.

By all means, go to your doctor, but don’t go in the expectation that you will receive an antibiotic. If you end up getting one, so be it, but don’t push for it.

No pressure…

Michael

“Putting your job into perspective”

Confessions of a Microbiologist, ,

My baby daughter recently had open heart surgery at just two weeks of age, to repair a serious congenital heart defect (Tetralogy of Fallot). She was desperately sick in the days leading up to the surgery, and required several weeks of convalescence afterwards.

They don’t like doing open heart surgery at such a young age, but decided that this was the lesser of the evils…

On the day of the surgery she was really struggling, despite being in intensive care on maximal therapy. I never thought I would be glad to see my daughter wheeled off to theatre to be put on cardiac bypass.

Fortunately everything went well, and she is now 10 weeks old. She is doing all the things that 10 week old babies should be doing. Except for the scar on her chest, you would not even know what she has been through.

She is, quite literally, a little miracle.

Now things are getting back to normal. I am back at work, and able to think clearly again.

During the long days and nights in the neonatal intensive care unit, my microbiology job was the furthest thing from my mind.

But the whole experience has helped me put my job, and to a large extent my career into perspective.

And I am very aware that my family and I are not the only ones who have been through the emotional wringer. Most people have had major life events at some time or other; bereavements, births, severe illness, redundancy, divorce, etc., etc.

We all have our struggles…

So in future, whenever my workload is starting to feel heavy, I will think to myself “Compared to recent events in life, this is a walk in the park.”

And whenever I am asked to take on extra responsibilities, I will think to myself “I have a young baby to look after and care for. What work responsibilities can possibly be greater than that?”

And if I need to take the odd risk in order to develop and progress the microbiology department that I work in, I will think to myself “This is not a life or death situation. What is the worst that can happen…?”

Sometimes our mind plays tricks with us with regards to the challenges we face at work, to the degree that they start to become stressful and all encompassing.

When work life gets tough, then reflect on your other life, the more important one, and put your job into perspective. 

Michael