I’m Dealing With the Silent Fear of Infection

I saw a patient yesterday with a cough and intermittent fevers. I believe based on her history she is a low risk for COVID-19 disease. One must treat all patients as if they have COVID-19 until proven otherwise so I wore a double mask including a N95 respirator mask, a face shield and gloves.  The face shield limits your peripheral vision and fogs up easily as do your glasses. I could feel and hear my heart pounding and racing as I got close to the patient for an exam and the sweat pouring down my forehead into my eyes stinging and burning did not help.

The visit was uneventful.  I maintained my sanitary protective field, removed my protective gear afterward, as per protocol, and washed up extensively. The weather outside was stormy with torrential rain, thunder, lightening, high winds, flooding and some hail – adding to the apocalyptic climate that now exists in the patient care arena.

Yes, I began to relax some as the visit progressed but there was always this uneasiness wondering if I careful enough?   It reminded me of 1979 before we knew what the HIV virus was and what AIDS was. I was seeing a brand-new patient in the intensive care unit of Boca Raton Community Hospital. He was the editor of an internationally known tabloid published just north of Boca Raton.

Married to a French national, he had left New York to come oversee this paper and had taken ill.   I had seen many cases of this immune system destroying disease during my residency in Miami at Jackson Memorial Hospital. This obese gentleman struggling to breath had none of the risk factors for this new disease. He denied drug use or intravenous drug use. He denied being in relations with other men.  How could he possibly have this horrible new disease with none of the risk factors. His wife was testy when I questioned her alone about private and personal areas of their relationship all necessary to determine her husband’s risk of having this immune destroying disease. She was vigorous in her defense of his very ordinary, very traditional behavior.

In those days we rarely wore gloves to draw blood. It was unheard of. We rarely put on gloves to start an IV line. With this disease things were different.  I was in a paper gown, gloves, face mask, goggles and face shield as was the young pulmonary expert I was working with.  The confinement of the personal protective gear and the warmth and fogginess of your vision led to a rapid pounding heartbeat and the same sweating I was experiencing 40 years later. It calmed down some as we got into the procedure.  I was wearing scrubs then which never left the hospital locker room. I am wearing scrubs now which never leave my office. I come to work in pants, shirt and tie and change into special scrubs plus sneakers that are kept here. At the end of the day the scrubs go into a laundry bin. 

As a physician who cares for patients, I need to take this risk. As a human being over 60 years of age I realize I am high risk for developing complications and death if I catch the COVID-19 virus. I am most afraid of transmitting it to my wife, my children, my grandchildren unknowingly. I hope they have the courage to put up with my risk taking.

Should We Treat Sore Throats With Antibiotics?

How many of us have called our doctor with a scratchy throat, mildly swollen glands, congestion and overall malaise and requested an antibiotic?   “I know my body best and if I take an antibiotic I knock it out quickly.” is a common refrain.

In most cases, sore throats are due to viruses. Fewer than 10% of sore throats are caused by bacterial Group A streptococcus.  Antibiotics such as a Z-Pack (Zithromax), Penicillin or Ampicillin do not kill viruses.  If by chance a patient has a sore throat and an upper respiratory tract infection, the length of illness before recovery averages 4-7 days with or without antibiotics -whether strep is present or not.

How then did the throat culture and use of antibiotics begin and what is its rational? In the 1940’s and 1950’s when antibiotics were being introduced to the public it was determined that streptococcus pyogenes was the cause of Rheumatic Fever.  Researchers found that by administering antibiotics to patients with a strep throat they could reduce the rate of acute Rheumatic Fever from 2% to 1% (notice that even with appropriate antibiotic use we cannot prevent all the cases of Rheumatic Fever).

Applying this data in 2011 we find that there is about 1 case of Rheumatic Fever in the United States per 1 million cultured strep throats. In other words, we must prescribe one million prescriptions for antibiotics for sore throat to prevent one case of Rheumatic Fever. In turn, these antibiotics may cause 2,400 cases of allergic reactions, 50,000 cases of diarrhea and an estimated 100, 000 skin rashes.  It doesn’t make sense.

In a recent editorial article in MedPage, an online periodical supported by the University Of Pennsylvania School Of Medicine, George Lundberg M.D. presented a cogent case against throat culture use and antibiotics in sore throats and bronchitis. He suggested that “physicians should not prescribe antibiotics for sore throats….  They don’t help. They often hurt. First, do no harm!”

As an internist dealing with adult patients I am not seeing the groups most likely to catch a strep throat which is young children 2-7 years of age and their caregivers.  If patients present with fever, exudative tonsillitis and pharyngitis with large swollen cervical lymph nodes I will still culture them.  I will treat based on their immune status, general health and risk of having a significant bacterial infection. If I choose to prescribe an antibiotic I will make an adjustment based on the culture results.

Honey May Be Effective at Killing Bacteria and Thwarting Antibiotic Resistance

I have on many occasions advised my patient’s ill with an upper respiratory infection and a cough to try some tea and honey. The recommendation is based on family suggestions bridging generations plus practical experience in noting its therapeutic effect when I have a cold and cough.  Of course in today’s world of randomized double blinded objective research studies it is nice to have some evidence to back the recommendation up.

Pri-Med released a summary of a study done at the University of Wales Institute Cardiff which shows the benefits of Manuka honey.  The honey is made from the nectar collected by bees from the Manuka tree in New Zealand. This honey apparently can hamper the ability of pathogenic streptococci and pseudomonas from attaching to tissue. This is an essential step in the initiation of acute infections.

Lead author Rose Cooper additionally pointed out that Manuka honey was effective at making Methicillin Resistant Staph Aureus “more susceptible to the antibiotic Oxacillin.” Methicillin resistant staph aureus is resistant to drugs like Methicillin and Oxacillin. They do not improve or cure the infection. If you add honey, the infections are now showing a response to Oxacillin .

This is very clearly early data with more studies needed. It will not prevent me from continuing to extol the virtues of tea and honey, as well as chicken soup, as part of the treatment of a viral or bacterial upper respiratory infection.