Anguish over Antibiotics

Having suffered with a bad chest cold for the last week, I figured this would be a good time to discuss the appropriate use for antibiotics in regards to upper respiratory infections.  By this, I refer to infections of the sinus (sinusitis), throat (pharyngitis), upper airways (bronchitis) or of the lung itself (pneumonia).  The common cold is usually referred to as rhino-sinusitis or infection of the nasal passages and sinus.  Over 90% of these infections are due to viruses.  The most important fact to understand is that antibiotics do not treat viral infections.  They treat bacterial infections.  There are times when it is appropriate to use them but for the most part they are to be avoided.

Now, one may ask, "What is the big deal about taking antibiotics?"  I have often heard, "I just get this twice a year and if I get my Z-pack, I do well."  However, after talking to the patient, I often come to the conclusion that their infection is likely viral.  I can assure you, that my life would be much easier if I just sent out the prescription for an antibiotic.  I have often wished I could give someone "placebocillin."  I would tell my patient to take these sugar pills twice a day for ten days and I know that chances are they will be feeling quite well by then.  There are three reasons to be wary in taking an antibiotic.  The first is a chance that you may develop an allergy to the medication.  Rarely can this be life threatening.  The second is the risk of developing diarrhea associated diarrhea, the worst of which is called, clostridium dificile colitis which is triggered by taking antibiotics and can be very difficult to clear and very serious.  The last is the risk that bacteria can develop resistance patterns due to being overexposed to antibiotics.  This is already began to be a problem.  We may not be too far away from a time when certain infections will have no available antibiotics that can be used to treat them.

What, then, are the symptoms which would suggest that antibiotics are appropriate?  First strep throat requires the use of an antibiotic.  The symptoms are fever and a sore throat.  Strep does not cause a cough. There is not much sinus involvment either. If you have a fever and a sore throat with a bad cough, that is not strep.  Bacterial sinusitis is characterized by a fever, sinus related facial pain in the prescence of yellow or green secretions.  Usually, these infections are secondary, meaning that they begin as a virus but with time (usually 10-14 days) bacteria can get trapped in the sinuses and start a new infection.  Commonly, a patient will tell me that they started with a cold, started to improve and then got worse again.  It is also important to know that colored secretions in and of themselves do not indicate a bacterial infection.  In fact, such are expected starting about 4-5 days after the beginning of a cold.

Resistant Bacteria

Bronchitis only requires antibiotics in the setting of an asthmatic, smoker or certain other lung diseases.  Such infections are quite common and can last a very long time.  Patience is the key.  If one is making gradual improvement, even if painfully slow, it is imperative to wait it out, letting our body clear the infection on its own.  Now if one developes chills, fever, pain with breathing or shortness of breath, it is time to go see your doctor and make sure pneumonia has not developed.

Lastly, pneumonia almost always requires an antibiotic.  Even if it is precipitated by a viral infection, it is common that pneumonia develops into a secondary bacterial infection.  The prime example of this is seen with influenza.  The deadly epidemic of 1918 was fueled mostly be pneumonia from staph that came after the influenza was contracted.  If you have symptoms to suggest pneumonia as listed above, it is always appropriate to be evaluated by a physician.

Holi-DAYS

The holidays are upon us.  Thanksgiving is just a few days away.  This is often the beginning of hibernation for too many of my patients.  However, I do not care for bears.  We humans have no physiologic need to store fat to make it through the long dark winter.  Remember, bears do this due to a lack of access to food during the winter.  We do not have this problem.  Now, we will, like hibernating bears, grind our metabolism down to a halt if we allow ourselves to slip into a pattern of inactivity, only getting up to forage in the refrigerator.

What are good ways of staying active in the winter time?  It will likely involve exercising indoors.  If you do not have your own treadmill, exercise bike or other equipment, consider joining a gym.  Many are relatively inexpensive.  The malls are open early for those who want to walk in them.  Put on a coat and take your walk.  Don't let the winter doldrums keep you from being active.

In regards to eating habits, this is the time of year I refer to as "the danger zone."  There will be plenty of opportunities to eat the wrong types of food.  You need to make up your mind now how you are going to respond when something really tempting crosses your path.  Many of my men patients will tell me, "if she wouldn't buy/make those cookies/cakes, I wouldn't eat them."  This is a weak excuse at best.  We must be firmly responsible for the decisions we make.  Make a resolution now and stick with it.  Don't wait until the first of the year and you've put on ten extra pounds.  Watch yourselves every day.  Get on the scale daily if you need to.  Be strong.

Lastly, I fully understand that during the holidays we are going to eat food that is not healthy.  There are three simple hints that can help keep things under control.  First, earn your calories.  Get up early on Thanksgiving and go for an extra long walk.  Play football with the kids (this may have other adverse health outcomes, though).  Go to the gym and stay longer.  If you are going to eat more, burn more.  Secondly, realize that there will be far more choices than normal.  It is all right to eat from all of them if the portions are much smaller than what you would normally take at a normal meal.  If there is something that isn't your favorite, skip it.  Don't dish it up just because it is the next item in the line.  Lastly, remember that these special days are just that..."days."  They are not holi-weeks or holi-months, they are holi-DAYS. Enjoy yourself.  Taste all the goodies.  Don't fret about feeling guilty all day but when the day is over it is OVER.  Get back on track the next day.

Colon Cancer Concerns

Colon cancer is one of the more dangerous forms of cancer, in fact it is the second leading cause of deaths among cancers.  Fortunately, it has a precancerous phase that can be detected.  These early growths can be removed, preventing this deadly disease.  Detection occurs through a procedure called a colonoscopy.  Now, I realize that contemplating a scope being inserted into the colon is not a pleasant experience.   It is not quite as bad as the imagination would suggest.  The procedure itself is done under sedation and is tolerated well.  The worse part of the test is getting cleaned out the night before.  The good news is that if the test is normal and there is no family history of colon cancer, it need not be repeated for ten years.

Now, surely, you ask, there must be a better way.  How about those virtual colonoscopies I heard about on T.V.?  This can be done, but here are the details.  The preparation is the same.  It is done by a CT scanner after dye and air have been forced up into and through the colon.  This does not feel good and no sedation is used.  If anything abnormal is detected, a full colonoscopy will need to follow so that a biopsy can be obtained.  Personally, I would rather have the better test and be done with it.  What about using those little cards to detect blood in the colon?  The problem with those is that there is a pretty high false positive rate.  It also misses many precancerous growths.  If the polyps do not happen to cause bleeding, nothing will be protected.  Is a colonoscopy really necessary?, my patients ask.  I respond that I cannot remember having diagnosed a patient with colon cancer who has been screened.  As opposed to screening for breast or prostate cancer which hopes to detect cancer at an early stage and cure it, screening for colon cancer finds growths before they have turned cancerous and thus the disease never develops in the first place.

When does screening begin?  A person at average risk should be screened beginning at age 50.  If someone has a family history of cancer or precancerous polyps in a first degree relative (parent or sibling), they should be screened starting 10 years prior to their affected relative or by age 50, whichever comes first.

Most agree that a diet high in natural vitamins and fiber decrease your risk of colon cancer.  There are, of course, found in fruits and vegetables.  Genetics play an important role as well.  Make sure you ask your family members if they have been screened and if any polyps were found.  Make sure you get screened.  Talk to your doctor about your individual risk.  It may well save your life.

The Problematic PSA

There has recently been much debate and discussion as to whether or not the PSA blood test should be used in screening for prstate cancer.  The PSA is a blood test.  It stands for "prostate specific antigen."  Protein particles in the prostate gland are released in small quantities into the blood stream and have found to be elevated in prostate cancer, a state in which prostate cells are multiplying and dividing at an accelerated rate.  Since the development and routine use of this test, the detection of prostate cancers has increased dramatically.  What is not clear, though, is whether increased detection has led to saved lives.  Let me discuss further some of the controversies that surround the issue.

First, the test itself is not a perfect test.  Cancer is not the only cause of having an elevated blood test.  A lower urinary tract infection may also elevate the test.  Some may have a low grade inflammation of the prostate gland (chronic prostatitis) that will lead to having an elevated PSA.  Recent sexual intercourse can cause transient elevations in the PSA as well.  If an abnormal result is found, it is important to repeat the test in 6-12 weeks prior to considering a prostate biopsy, a rather invasive and not so pleasant procedure.

Proper interpretation of the PSA is very important.  The test itself is not dangerous, but an elevated result may lead to a path consisting of first a biopsy and, if cancer is found, to possibly surgery, castration chemotherapy or radiation.  Any of these three may carry adverse effects ranging from urinary incontinence, urinary frequency, impotence and bloody diarrhea.  Though prostate cancer is the leading cause of cancer, it is far from the leading cause of cancer death.  Most prostate cancer is a slow growing process that most people will die with rather than from.  However, there are cases that can be more rapidly progressive and deadly.  In this form, the cancer can spread to other organs in the abdomen and into the bones.  At this stage, the cancer is quite difficult to treat.  The demise is usually slow, painful and progressive.  When looked at as a whole, the vast majority of patients will not have this deadlier version.  Some will interpret those statistics in such a way as to conclude that early detection of prostate cancer is not worth the complications attendant to its treatment.

What is really needed is a way to determine who will progress to the deadlier form of disease and who will not.  In such an instance, treatment could be safely withheld from those who do not need it but could be aggressively applied to those who do.  We do not as yet have such markers.  Strides in this area are being made in relation to breast cancer but are lacking as of yet for prostate cancer.  In the meantime, proper interpretation of the PSA test can help guide decision making.  This should be done on an individual basis between each patient and their physician.

I personally feel that it is appropriate to screen patients with a PSA level in their forties, especially if there is a family history of prostate cancer.  If in the forties, the PSA is low (below 1.0 ng/ml) waiting an additional five years to repeat the test is reasonable.  I recommend yearly testing in someone who is in their 50's.  In the 40's and 50's, an elevated test should first be repeated to make sure that it is accurate.  I am more aggressive in this age group since detection is much more likely to result in meaningful treatment.

As a patient enters their 60's and 70's, I look less at the absolute value of the test and more at how it is changing.  The PSA will rise with age just due to the fact that the prostate never quite stops growing.  If, through the years, there has been a slow gradual increase, I am not nearly so concerned as someone who suddenly has a steep spike in their value from one year to the next.  If repeat testing at a shorter interval shows progressive worsening, that is likely a sign of progressive disease and warrants consideration for a biopsy.  In a patient in his 80's or 90's, I would only use an elevated PSA if I thought there was progressive disease as manifested by symptoms of urinary blockage or evidence of cancer in the bones.

One comment.  The above discussion applies only to patients not previously known to have prostate cancer.  In a patient with known cancer, who has been treated, the PSA is a good marker of disease activity and there is no controversy as to its use.

Lastly, a word about treatment.  Hormonal based treatments definitely have symptoms of weakness, fatigue and hot flashes that likely will occur.  Radiation treatments have evolved so as to be more precise and involve less damage to other nearby organs (such as the large bowel and bladder).  In this instance there is less diarrhea, rectal bleeding and frequent urination.  Surgical techniques have changed considerably.  Many urologist have become quite proficient in the use of robotic procedures.  Since the prostate lies deep in the pelvis, former surgical techniques did not allow the surgeon to always see what was being stitched or cut, but was done by feel alone.  The robotic techniques allow for much better visualization of the area and much more precise stitching.  In the right hands, such a surgery has a very low incidence of impotence and incontinence.  Further studies are being done to determine if these better techniques can result in prolonged life without sacrificing the quality that we want.

In conclusion, using the PSA test to screen for prostate cancer is not a black and white issue.  Ask your doctor for his opinion.  Consider your options and choose the course that you feel most comfortable taking.