called medicae

I gave you access. did it work?

Ha! you're a genius!

Thanks.

Well, hardly.

No, thank you.

√

Just over a third of patients presenting to the emergency department with animal bites received inappropriate treatment, a small study found.

So do you think I should go back to the doc on this?

(I don't even know how I mde that little square root thing.)

Um, has it been 72°?

I was mystified myself. I thought you knew about it.

:) no such luck

most infections will occur by 72°

That might be delayed by an inappropriate antibiotic.

But only by a few days.

Also, most people who believe they are allergic to PCN don't really have an allergy to it. So there's that.

@medica Meaning 72 hours?

@Robusto No, if she gave you the wrong abiot the first time, she'll just tut-tut you.

72° since the bite

I don't know what that means.

72 hours?

When did the cat bite you?

Last night.

and it punctured your skin in two places?

Yes.

Bled for a while. I bathed the wound in isopropyl alcohol, pretty liberally.

Well, then it has to be treated. When did you get the prescription?

This morning.

That's all good

Well, if it were me, I'd get off the clindamycin.

Also, here's a complicating factor. I have a knee replacement, so I had clindamycin on hand because I take it when I get dental cleanings.

So I took a dose of that last night.

Would you be so kind ahhhhh

lol

ok

clindamycin is good for some bacteria, but not Pasteurella

and cats deposit Pasteurella in 75% of bites.

So the treatment muxt cover that

OK, so what do you recommend I do?

yours, unfortunately, isn't so good at that

tell me about your PCN allergy a bit

Was told I had it in childhood.

Been not taking it all my life.

I think it was because of a scratch test for allergies. I have no idea what happens if I take it.

A rash, or did your throat close up, did you need to go to the hospital?

ok.

@medica No idea.

Never went to the hospital because of an allergy.

So anyway, I believe you about the pasturella. I want to know how I go back to the doc and say give me something else.

Especially because of the knee replacement. I seriously don't want that to get infected.

Well, if you have a really good relationship with your doc, tell her you read this article that some quack gave you, and it concerned you, and can she please switch you to something else?

Yes, your knee is an important consideration, you have to have prophyllaxis considering that.

Well, don't make it her fault, make it mine or yours.

Tell her you read about this and that you'd just rather be on something "stronger".

OK. I'll do that.

She can't tut-tut that too much.

But it matters what you're on.

Your knee makes a difference.

I sent you a few links, I doubt you had time to read them?

Oh, is she an orthopod? your doc?

"The first-line oral therapy is amoxicillin-clavulanate. For higher-risk infections, a first dose of antibiotic may be given intravenously (ie, ampicillin-sulbactam, ticarcillin-clavulanate, piperacillin-tazobactam, or a carbapenem)."

"Other combinations of oral therapy include cefuroxime plus clindamycin or metronidazole, a fluoroquinolone plus clindamycin or metronidazole, sulfamethoxazole and trimethoprim plus clindamycin or metronidazole, penicillin plus clindamycin or metronidazole, and amoxicillin plus clindamycin or metronidazole; a less effective alternative is azithromycin or doxycycline plus clindamycin or metronidazole."

Since you're allergic to PCN, you can ignore the first quote.

I think in your case, I might recommend a fluoroquinolone plus clindamycin.

I'm talking to them now.

The problem with cat bites is that the puncture wounds are small and they're relatively deep (esp if the cat was able to get you with both canines.)

Good, I'll stay here.

Is she an orthopod?

Because of your joint replacement, make sure they're more aggressive.

No, she's an internist but she's not my regular doctor. Only one I could get in to see on short notice at the practice.

ah

I just talked to the nurse there and she's relaying the info to the doctor, so I'm expecting a call back.

I hate to say this, but if I were your doc, it's been going on 24 hours now that the cat's bit has not been properly cared for.

Meaning I'm screwed?

I'm a very cautious doc (many aren't)

No, meaning that you maybe should get your first dose IV

That's what I would do.

The wound itself is scabbed over and clean, no pus or inflammation.

I would do it out od=f concern for your knee.

Yeah. I think she'll call me back pretty soon.

At least I hope so.

Yeah, that (20 hours) is still early

These are the stats:

amore than half of all cat bites get infected.

And it takes 72 hours to present?

75% are infected with Pasteurella multocida

Clinda doesn't cover that

it covers staph, which is the real concern for your knee

It usually blooms at 48-72°

Oh. So pasturella isn't knee-invasive or something?

No, staph is

So you're kind of covered for that

Oh. I feel like a hypochondriac now.

but you're not NO, you're not

you're just a patient with a very valid concern (your knee)

Frankly, cat bites are rarely fatal.

Yeah, the nurse didn't think it would be a big deal to get a different prescription.

Good.

@medica I am less worried about that than about my knee getting screwed up. I've gotten so healthy lately through exercise and I would HATE to lose that outlet.

The doc who ultimately treats you has to know her medicine. She has to know what works (as am I)

with both cat bites and how to prophyllax your knee

that's key

Yes.

I also don't want to wind up in the hospital for any reason. I hate hospitals.

So you should be on double-coverage

exactly

prevention is better that treatment

So here it is:

Take it for what it's worth

I would put you on a second agent

double coverage

and would give you the second agent - I would - IV.

hey, you know, my husband is also an ER doc. You want a second (third?) opinion?

IV just for your first dose

I doubt they're going to give me an IV.

that will get it into your entire system, including your joint space, very quickly.

But I'll take a third opinion. Why not?

ok, afk for a bit.

His phone is off. He must be busy.

:(

Are you close with your orthopod?

It's not my orthopod I saw.

And I haven't talked with him since my one-year checkup after the knee replacement.

"Most Pasteurella isolates are susceptible to oral antimicrobials such as amoxicillin, amoxicillin/clavulanic acid, minocycline, fluoroquinolones (ciprofloxacin, ofloxacin, levofloxacin, moxifloxacin), and trimethoprim-sulfamethoxazole. Based on in vitro susceptibility data, several antimicrobials should not be used empirically for P multocida infections, including dicloxacillin, vancomycin, cephalexin, cefaclor, cefadroxil, erythromycin, and clindamycin."

" Macrolide resistance is usually encountered with erythromycin. Other macrolides, including azithromycin, clarithromycin, and telithromycin (in order of decreasing susceptibility), retain in vitro activity against most Pasteurella strains. Aminoglycosides have poor activity against P multocida. "

That's ok, you're still his patient.

How long has it been?

Your knee, I mean.

@medica 2.5 years.

ok, here's another thing you can do (and I would) even though I'm making you feel like a hypochondriac.

The worst case scenario here is MRSA

I don't know how common it is where you live.

Well, if I have that I'm well and truly screwed.

But your orthopod will definately know how common it is where you live.

It's the USA, so I guess it's a concern everywhere.

You can (yes, it is)

He gave me vancomycin for the surgery.

You can call his office (yep, really good choice)

And I had to scrub most of my body with hibicleanse before the surgery.

ask to speak to the orthopod on call

OK

tell him about your knee replacement first, the cat bite (including the time of injury) second

and then tell him the doc put you on clindamycin

Should I wait to hear back from the first doc before doing that?

but you forgot to tell her (did she ask?) that you had a knee replacement (you old fat! haha j/k)

no

ask him what his recommendation is, and do you need anything IV at this point

Depending on how obsessive he is, he will either say no

(not obsessive)

or yes (obsessive)

If so, then you merely have to tell your ID tht he recommended blah blah and she will more or less (Much more)

have to do what he recommended.

And that is the safest way to go, I think. But hope he knows more about cat bits than she does.

ciprofloxacin

That's what she wants you to go on?

That's what she just called with, so I'm headed out to get that now.

Good. What's the first dose?

Dunno. I'll see when I get the scrip.

Thanks so much for your help. I'll be back in a little while and I'll let you know what the dosage is.

let me know. You might need to double it for the first dose. And stay on the clindamycin.

k. off you go.

OK, will do. Thanks mucho!

:)

Taking a probiotic can't hurt, but it might help. Some trials have shown that probiotics can reduce the incidence of CDAD by more than half. The problem is that no one is quite certain which mix to take.

I'd like you to consider getting a bioyogurt (live culture yoghurt with added probiotics) at least L. acidophilus and a Bifidobacterium strain. Don't drink it with Cipro, but 3 or 4 hours later is fine.

here;s one paper you can read.

ncbi.nlm.nih.gov/pmc/articles/PMC3105609

read your drug warnings included with the medicine.

I spoke with my husband who thought the cipro/clinda the best option (also sent you links to that effect).

Anyway, I think you're in good shape now, and if you have any problems, let someone know.

You can always ping me; I check the site every day (I know. Get a life, right?) except when I'm on vacation.

I'm being over-protective here because you're not my patient and I haven't done a - well, I don't know your entire medical history and the meds you might be on and all that. Also, this is who I am.

Take care, lots of fluids, bioyogurt, and tell your cat you aren't holding him ever again if he bites.

Let me know occasionally how you're doing, cuz I'll be wondering anyway.