February 24, 2012 | 1:22 pm

Untreatable Gonorrhea – The Next Infectious Threat

Posted by Albert Fuchs, M.D.

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Photo by Wikipedia/CDC/Joe Millar

Our old nemesis, the clap, is in the news again this month.

Gonorrhea is the second most common sexually transmitted disease in the US, with more than 600,000 cases annually. In men it usually causes pain on urination, penile discharge, or sore throat. In women it may not cause symptoms or may cause painful urination, vaginal discharge, or sore throat. If untreated, gonorrhea can spread to the fallopian tubes, joints, and heart valves. I know that most readers simply can’t hear enough about penile discharge (especially if they’re reading this over lunch), I’ve included a microscopic image of exactly that. The gonorrhea bacteria are visible as the small dark dots.

With the discovery of penicillin in the 1940s the treatment of gonorrhea was revolutionized. But ever since that major victory gonorrhea has won several important battles. Gonorrhea developed resistance to sulfanilamide in the 1940s and to penicillins and tetracyclines in the 1980s. When I trained in internal medicine in the mid 1990s, Cipro (an antibiotic in the family called fluoroquinolones) was the preferred treatment for gonorrhea. In the 2000s some fluoroquinolone-resistant strains of gonorrhea appeared and by 2007 resistance was widespread.

Third generation cephalosporins are now the last antibiotic family to which gonorrhea is susceptible. But, as a decade ago with fluoroquinolones, sensitivity to cephalosporins is slowly decreasing, especially in the western US. Though no strain in the US has become resistant yet, a strain isolated from a patient in Japan in 2009 was highly resistant to cephalosporins.

The downward creeping cephalosporin sensitivity of gonorrhea prompted CDC researchers to sound the alarm in an editorial in the New England Journal of Medicine earlier this month. The editorial warns that if the early signs of decreasing sensitivity are analogous to what we observed with fluoroquinolones in the ‘90s, then we may be only a few years away from strains of gonorrhea that are untreatable by any antibiotics.

The authors make sound recommendations to accelerate development of new antibiotics and increase surveillance of gonorrhea antibiotic sensitivity. But it’s entirely possible that these efforts will fail, and that the only defense against gonorrhea will be from a vaccine which is not expected any time soon.

I’ve written before about the emerging problem of bacterial antibiotic resistance. Our grandchildren may study the period from the 1940s to the 2040s as the antibiotic century. Unless antibiotic development stays a step ahead of the wily microorganisms we may reach a time when sexually transmitted infections are managed the way they were a hundred years ago – promoting the use of condoms and corny public health posters encouraging men to keep their flies zipped.

Learn more:

CDC Warns Untreatable Gonorrhea is On the Way (Chicago Tribune)
Gonorrhea Could Join Growing List of Untreatable Diseases (Scientific American)
Antibiotic-Resistant Gonorrhea (Centers for Disease Control and Prevention)
The Emerging Threat of Untreatable Gonococcal Infection (New England Journal of Medicine)
Gonorrhea (U.S. National Library of Medicine)

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

February 17, 2012 | 3:47 pm

Relearning What We Knew: Antibiotics Don’t Help In Sinus Infections

Posted by Albert Fuchs, M.D.

As good as antibiotics for sinusitis

Most of us are personally familiar with the symptoms of a sinus infection – congested nose, cough, fever, pain in the forehead or cheeks, and general misery. It’s impossible not to feel sympathetic for patients with sinus infections, and it’s understandable that they want to do whatever it takes to feel better as soon as possible. And for many doctors and patients “as soon as possible” means “antibiotics”. In fact, almost one fifth of antibiotic prescriptions are given for patients with sinus infections (sinusitis).

Here’s where the story gets complicated. Doctors have known for a long time that sinus infections almost always improve even without antibiotics. Originally we thought that the reason for this was because most cases of sinusitis were caused by viruses, which are unaffected by antibiotics. It was thought that only the minority of cases of sinusitis that were caused by bacteria required antibiotics. But it turned out that even most cases of bacterial sinusitis improved on their own, with most people feeling better in ten days regardless of antibiotics.

So the prevailing teaching has long been that for acute sinusitis the best treatment is nasal decongestants and medications for the cough, pain, and fever. Only the tiny number of people who don’t improve in ten days should be prescribed antibiotics. Still, many doctors either don’t know this recommendation or acquiesce to patients’ expectations for antibiotics. I have certainly been guilty of this misuse of antibiotics many times. A sick patient pleading for antibiotics may be misguided, but he’s rarely in the mood for a lesson about the medical literature and the potential harms to society of antibiotic overuse.

Now, when you’re healthy, is a good time for that lesson, and a study in this week’s Journal of the American Medical Association is the perfect reminder. The study enrolled 166 patients with an acute sinus infection. Half were randomly assigned to receive a ten day course of amoxicillin. The other half received placebo. Both groups were also offered nasal decongestants, cough suppressants, and medicines to reduce pain and fever. Every several days, the patients were interviewed about their symptoms, their satisfaction, and any adverse effects of treatment.

You can already guess the outcome. Both groups did equally well, without any earlier resolution of symptoms for the amoxicillin group. Some doctors concede that sinusitis resolves without antibiotics, but argue that patients feel better sooner if they receive antibiotics. This study debunked that argument. Even at day three there was no difference between the two groups.

The risk of all this antibiotic use is an acceleration of the increasing prevalence of multi-antibiotic-resistant bacteria that threaten to make all our antibiotics ineffective. So the next time you see me with a terrible sinus infection, let me recommend a good nasal decongestant, and let me reassure you that there’s nothing else I can do to get you well quicker. Time is your best friend. That’s why we call you patients.

Learn more:

Got A Sinus Infection? Antibiotics Probably Won’t Help (Shots, NPR’s Health Blog)
Sinus infection? Antibiotics won’t help (CNN Health)
Antibiotics Do Nothing to Cure Sinus Infections, Study Says: Most cases resolve on their own, and use of drugs can encourage resistance, researchers say (Chicago Tribune)
Amoxicillin for Acute Rhinosinusitis (Journal of the American Medical Association)
NDM-1: No Drug Matters (my most recent post about antibiotic resistance)

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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February 10, 2012 | 6:32 pm

Tai Chi Improves Balance in Patients with Parkinson’s

Posted by Albert Fuchs, M.D.

a tai chi class

Parkinson’s disease is a progressive neurologic disorder. Parkinson’s biggest initial impact is on how patients move. Patients have tremors and have difficulty initiating movement. They walk with short shuffling steps. Balance worsens and falls are common. Parkinson’s disease is treated with medications and rarely with brain surgery. Resistance-based exercise has been shown to slow the worsening of balance and strength in patients with Parkinson’s disease, but these exercises frequently require equipment and supervision.

Tai chi is an ancient Chinese martial art. Its emphasis on slow graceful movements, balance, and attention to breathing has made it a very popular form of exercise and meditation. Researchers thought that it would be a good way to improve balance in Parkinson’s patients. A study published in this week’s New England Journal of Medicine shows they were right.

The study enrolled 195 ambulatory Parkinson’s patients to three groups. Each group attended a sixty minute exercise class twice a week for six months. One group attended tai chi classes. A second group attended resistance-based strength training classes. A third group (the control group) did stretching.

All patients had objective measures of their balance and gait and kept a log of any falls. They were followed for three months after the end of their exercise classes.

As expected, the tai chi and strength training groups had better test results than the stretching group in measures of walking and strength. But he patients who did tai chi had better balance than the other two groups and also had fewer falls. The benefits persisted even three months after the end of the classes. And there were no serious adverse effects, which would be unheard of in a trial of a medication or surgery.

This reveals an appealing opportunity for Parkinson’s patients – exercises that require no equipment, can be learned and then practiced at home without assistance, and are relatively inexpensive. Though there is no evidence generalizing this finding to other causes of balance disorder, like strokes or Alzheimer’s disease, tai chi seems to me to be a very reasonable and harmless intervention in these disorders too.

Perhaps next we will learn that Krav Maga cures gallstones.

Learn more:

Tai Chi may help Parkinson’s patients regain balance (Los Angeles Times Booster Shots)
Slow movements of tai chi helped with balance, reduced falls in Parkinson’s disease study (Washington Post)
Tai Chi and Postural Stability in Patients with Parkinson’s Disease (New England Journal of Medicine)

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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February 3, 2012 | 8:34 am

Amputations in Diabetics Decline Dramatically

Posted by Albert Fuchs, M.D.

Diabetes can lead to numerous serious complications. It is a major risk factor for stroke and heart attack. Diabetes can damage the retina and is the leading cause of new cases of blindness in the US. It can damage the kidneys and is the greatest cause of need for dialysis. It can also cause nerve damage leading to numb or painful feet.

But few potential complications evoke as much fear in my patients as foot amputations. Though many injuries and accidents lead to amputations, diabetes is the most frequent cause of nontraumatic foot amputation. Diabetes leads to limb loss through multiple mechanisms. It leads to atherosclerosis, cholesterol plaques in arteries, which limit circulation to the limbs. It leads to nerve damage which can cause wounds to go unnoticed. And it weakens the immune response so that infected wounds are very difficult to treat.

The good news this week is that amputations due to diabetes have become much less frequent. A study conducted by the Centers for Disease Control and published in Diabetes Care reviews nontraumatic lower extremity amputations in diabetics between 1996 and 2008. In those twelve years the frequency of amputation in diabetics declined by two thirds.

Many helpful trends are responsible for all those saved feet. Diabetes is typically diagnosed earlier and treated more aggressively now than in the mid 90s. Several of the medications used for diabetes now were unavailable then. Atherosclerosis treatment also continues to improve with recognition of the importance blood pressure control and of cholesterol lowering with statins. The importance of meticulous foot care by diabetic patients is better understood, and the management of diabetic wounds by multidisciplinary teams is becoming the standard of care.

So in a week in which the news appears monolithically depressing I thought I’d spread some good news. Chances are you know someone with diabetes. Chances are that he will continue to lace both of his shoes for his whole life.

Learn more:

CDC report finds large decline in lower-limb amputations among U.S. adults with diagnosed diabetes (CDC Press Release)
Lower-limb amputations have declined among diabetics (Los Angeles Times Booster Shots)
Rate of Leg, Foot Amputations Among Diabetics Drops: CDC (US News & World Report)
Declining Rates of Hospitalization for Nontraumatic Lower-Extremity Amputation in the Diabetic Population Aged 40 Years or Older (Diabetes Care)

Tangential Miscellany

Dr. Kevin Pho, the very well known physician blogger and outspoken advocate of social media in medicine, is publishing some of my posts.

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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