Evidence-Based Medicine

A Chinese Proverb says, "The birds of worry and care fly over your head, this you cannot change, but that they build nests in your hair, this you can prevent."  The recent development about the heartbreaking story of the Vava'u boy has not shooed away the birds of worry amongst Tongans both locally and abroad.  It seems to have increased the flock.  The Tonga Health Ministry stated that it was a sad and deadly case of Methicillin-Resistant Staphylococcus aureus Pneumonia (MRSA-PNA). The public's reaction was predictably full of colorful languages, pain, resentment, anger, and worries.    It stirred mixed emotions, concerns, and raised a dozen questions that I haven't been able to dust off in the past few days.

The article that reported the Ministry of Health's statement did an acceptable job describing MRSA.  I am happy because that will save me from writing too much medical jargons in this post.  However, I personally feel that the article should've given appropriate information about culture-positive Pneumonia (PNA).

I have diagnosed and treated pneumonia during my many months of Internal Medicine, Family Medicine, Emergency Medicine, and Infectious Disease rotations.   A detail discussion will be too long for this post.  However, for my purpose here, I want to point out that if culture-positive pneumonia was contracted while at a Hospital, then the abbreviation is HAP.  If it was contracted from the community, then it is referred to as CAP.  These are extremely important distinctions.  It is so we can conveniently label the origin of the Pneumonia.  It also allows Healthcare providers to determine which is the appropriate antibiotics therapy and assess the mortality risks.  So keep these abbreviations in mind and they will appear later on in this post.

I also know MRSA fairly well.  I see and treat them more often than I would like.  They are just nasty and dangerous little bugs that are highly contagious.   So when I read MRSA-pneumonia, my concerns were in form of questions that I quietly asked "Did he get it at home/village?"  "Did he get it at the hospital?"  "Was he on proper isolation while he was at the hospital?"  "What was the initial antibiotic therapy?"  It is standard protocol at all hospitals (at least in the US), that any pt that is tested positive for MRSA, whether via nare-swab, sputum, wound culture, or blood culture, MUST BE IN ISOLATION.   This also means that anyone that come in close encounters with that patient will have to be properly gloved and gowned.

If you have read my previous posts, you probably picked up on it by now that midway through my post, I am always reporting some scientific research and statistics.  I love them and I love numbers.  I agree, it is probably the most boring part of my blogs.  However, it is the most important.

There is a phrase in medicine that is uttered multiple times throughout the day.  You will hear it on the Medicine Ward, Surgical Ward, ER department, Outpatient clinics, Operating Room and etc.  If you are a fan of the show DR. HOUSE, you may have heard it.  "WHAT DOES THE LITERATURE SAYS?".  (BTW I am not a fan of that show but I have seen half an episode during Medical school because one of our lecturers made us).  This practice is known in this field as "EVIDENCE-BASED MEDICINE".  I first heard about this phrase and the phrase I wrote about last time; "First, Do No Harm" at my in-laws kitchen while my wife and I were dating.  I have heard my father-in-law on multiple occasions uttered these phrases.  I didn't quite understand them then but I couldn't escape it during medical school and I can't escape it now.

Anyways, here's what some of the literatures say about culture-positive Pneumonia.  Scott T. Mitek et al.  reported in the Antimicrobial Agents and Chemistry, Oct. 2007 these statics:

a) The most common pathogens/bugs/germs in culture-positive Pneumonia is MRSA (~25%), Strep. pneumoniae (20%), P. aeruginosa (19%), MSSA (14%), and H. influenza (9%)

b) HAP (hospital acquired pneumonia) has a 68% prevalence

c) those with HAP (pneumonia)  has a death rate of ~25% and CAP (pneumonia) has a death rate of 9%.

d) they also found that getting the wrong initial antibiotics was higher for HAP (28%) versus CAP (13%)

These numbers are screaming loud and clear.  Any healthcare provider who's encountering patients with signs and symptoms consistent with culture-positive pneumonia (like our little brother from Vava'u) must ask "WHAT DOES THE LITERATURES SAY?"  These data and others alike would cause you to widen your eyes, perk up your ears, and turn on your sixth sense as a healthcare provider.  It will caution you that such condition are no small issues and must be completely worked up and treated.  It should remind you that you must put on your Sherlock Holmes persona.  Why? Because if your patient has a culture-positive Pneumonia such as MRSA-Pneumonia, 68% likely they got it from the hospital, there's a 28% chance you will give him/her the wrong antibiotics initially, and 25% chance they will die.  So, do diligence and always remember that an effective way of shooing birds of worry for both the sufferer and the healer is EVIDENCE-BASED MEDICINE!  (Unless of course you want them build a nest or you simply Don't Care.)