After-Posting Thoughts: Infectious Diseases

J. has completed 2 weeks in Infectious Diseases (ID) at TTSH, with a couple of days spent in the Communicable Diseases Centre (CDC), a brief 5-min walk from the main TTSH building. It’s been enjoyable. Earlier this year, in Canada, he attended surgical tutorials and one of the surgeons spent a brief 20min running through antibiotic classes. Since his return, J. had added to the antibiotic summary and had since found the proper prescription of antibiotics actually fun (what? is that possible?). With that basic understanding of antibiotics, he had an easier time when it came to the management of bacterial diseases (pneumonia, meningitis, etc.)

The thing about ID is that it’s a very important part, that’s often poorly understood and quite abused at times… and with that comes the frustration of being an ID physician. People must be frustrated at every discipline. The anaesthetists get upset with the high-risk patients listed for op, the renal physicians get blue letters for every patient with a raised serum creatinine, it’s not easy, to be true.

Previously, J. was complaining about his GP giving him half the dose of Klacid for half the period of time for an acute maxillary sinusitis post viral upper respiratory tract infection. The problem is that it’s a tremendously widespread problem, a combination of GPs prescribing wrong drugs, wrong doses or wrong durations of time, and know-it-all patients who decide to stop their medication.

One of the big 3 of ID, tuberculosis, is a big pain in the behind when it comes to patient compliance. Look at it this way:

  1. Patient comes in with pleuritic chest pain and haemoptysis
  2. Patient is diagnosed with tuberculosis after a CXR and a respiratory sample is obtained that is sent off for smear and culture/sensitivity.
  3. Patient is tested and found to be HIV-negative
  4. Patient is started on anti-TB medication, 3 first-line drugs that together have a treatment time of 6 months
  5. 2 weeks later, patient feels better and without consulting physicians, stops TB medication
  6. 2 months later, patient relapses and comes back with pleuritic chest pain and haemoptysis
  7. TB affecting patient is now resistant, and he now requires 9 months of therapy
  8. After being started on 2 more drugs, he feels better after 3 weeks.
  9. Patient stops taking medication because “I feel better, doc.”
  10. Patient relapses and now the TB’s resistant to Rifampicin, without which TB therapy goes to 18 months.

N.B. Every time TB therapy stops, it doesn’t just continue. It starts from scratch. Multi-Drug Resistant TB (MDR-TB) is Mycobacterium tuberculi which is resistant to rifampicin and isoniazid. XDR-TB is the same that is resistant to all first-line drugs (including pyrizinamide, ethambutol and streptomycin)

That’s an example of what happens when people think that their “personal experience” is more reliable than large-scale clinical trials and microbiological research.

The frustrations aside, J. thinks that the ID rotation has better equipped him and his classmates for life in the wards… even if some of the ID demands sound pretty tough. For instance, blood culture bottles should be filled with 10mls of blood. After sending off for aerobic and anerobic cultures x 2, that’s 40mls of blood. And what about fungal cultures, or cultures for infectious endocarditis? That’s a lot of blood to be drawn, and not every hospital has the advantage of butterfly needles with vacutainer ports.

All in all, the ID’s posting been very useful. Next up: Geriatrics.

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2 responses to this post.

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