Archive for August, 2011

The history of the recent severe tornado that struck Joplin Missouri on 5/22/11 is

well known. In the July 29,2011 MMWR–18 cases of a very unusual

severe skin infection -mucormycosis is described in Joplin residents. This

infection is usually seen only in Diabetics ,cancer patients or other

immunosuppressive conditions.13 confirmed cases ar described in the report.These

patients had all been injured in the tornado with an average of 4 wounds documented

in the ER medical charts.Medical management included surgical debridement

and removing of foreign body–wooden splinters were most common.2 of the

patients had Diabetes and none were considered immunocompromised. 10/13

required ICU admit and 5/13 (38%) died.The specific organism within the

order Mucormycete was Apophysomyces trapeziformis.This has been associated

with traumatic implantation of fungal spores.This is the first known cluster of this

fungal infection following a tornado.

In working up hundreds of consults

 since returning to Mississippi in 2002  I have

become aware of a poor but frequent medical practice widely used in

physician offices and ambulatory clinics. This is the combination of

an IM injection of an antibiotic  -usually Rocephin in high doses- 1 gram

combined with a potent steroid such as dexamethasone or Decadron.This is

spectacularly illogical and not to be found in any textbook or lecture or course. The

combination of a steroid and an antibiotic is rarely if ever indicated.

I.M. antibiotics are almost never indicated in ambulatory adults with the development of potent

well absorbed oral antibiotics.the only reasons for the use of an IM antibiotic

to an ID expert would seem to be the following:

      1.Nausea

      2.Some other reason that the GI tract cannot be used.

      3.An acute severe bacterial infection in which it is critical to get antibiotic

into the patient while they are being referred to a definitive treatment facility.

These situations are almost never seen in the charts  that I review.

There are many reasons not to use an I.M. antibiotic:

     1.They are more expensive –by an order of magnitude than oral agents.

     2.They are painful to administer.

     3.They may cause neuromuscular injury

     4.Because of the obesity of many of our patients–the drug may be injected into

fat deposits–perhaps causing fat necrosis.

It is my hope that :

1.I.M. antibiotics in office situations be restricted to the situations described above.

2.That if Rocephin is used a.Needle length be appropriate b.The dose be decreased

to 250 mg  a more appropriate dose.

3.That antibiotics never be combined with injectable steroids.There should

be no place in medicine for this as the only obvious purpose for the steroids is

to give the patient a “buzz”.

Hopefully payors will lead the way in producing the abandonment of this

most unfortunate and indefensible practice. Dr Smith