Friday, October 3, 2014

Ebola and the cult of vitamin R

File:FEMA - 18213 - Photograph by Robert Kaufmann taken on 10-25-2005 in Louisiana.jpgThis week saw the appearance of Ebola virus disease in a Liberian visitor to the United States. Active transmission here is not expected and public health authorities have done extensive contract tracing. Fifty individuals who were potentially exposed to the virus are being monitored and a small number are in isolation

First, a brief description of the episode. A man who had direct contact on September 15th with a woman suffering from advanced Ebola virus disease in Monrovia, Liberia, traveled to Dallas, Texas, to visit relatives. He flew from Monrovia to Brussels on the 19th of September and took a connecting flight to Washington DC before catching a final flight to Dallas, arriving on the 20th. He was screened for fever and exposure at the airport before departing Liberia; apparently, his answers to a screening questionnaire were inaccurate. After arriving in Dallas he remained asymptomatic for several days and began suffering symptoms on the 24th. On the 26th he presented to the hospital. (Note: some news accounts report the date as the 25th.) At this first visit he was evaluated, prescribed antibiotics, and sent home to the relatives with whom he was staying in Dallas. He subsequently deteriorated and was transported to the ED by ambulance on the 28th. The positive test for Ebola virus was received on the 30th.

Many details about this event are unsettling. To me, especially disappointing is that the man's travel history was not a factor in the clinical diagnosis on the 26th, although a nurse was informed that he was visiting from Liberia. The nurse entered the information into the electronic health record (EHR), following protocol, but that didn't trigger suspicion. The hospital has since clarified why: There are separate physician and nursing workflows, and patient travel history did not automatically appear in the physician's standard workflow. The doctor never saw the information.

I think it's also interesting that the man was prescribed antibiotics for what turned out to be a viral illness. In a sense, this is a familiar story: change the name of the virus and it's a scene that occurs daily in many clinics and office visits. It seems ironic that, a week after the White House released its National Strategy for Combating Antibiotic-resistant Bacteria, this physician-patient encounter resulted in the apparent inappropriate prescription of antibiotics. As the National Strategy tells us, 
. . . a growing body of evidence demonstrates that programs dedicated to improving antibiotic use, known as "antibiotic stewardship" programs, can help slow the emergence of resistance while optimizing treatment and minimizing costs. These programs help providers prescribe the right antibiotic for the right amount of time and prevent prescription of antibiotics for non-bacterial infections. It is imperative that such programs become a routine and robust component of healthcare delivery in the United States. (emphasis added)
To be fair, the man may have had a bacterial infection at the first hospital visit, in addition to the unsuspected Ebola virus infection. We don't know; it's a matter of his private health record. However, I am reminded of how a physician colleague once described the pervasive inappropriate, and often rushed, use of antibiotics,
It's a common problem. Patients present with vague complaints that are plausibly due to bacterial infection and there is a very low threshold for prescribing antibiotics. The patients often request or insist on it, and it often seems harmless to acquiesce. In fact, many doctors view prescribing them as a protection mechanism in case there is an infection or one develops. It's so common that in many clinics and EDs ceftriaxone is referred to as "vitamin R".
Perhaps the antibiotic prescription dimension of the encounter on the 26th is all too understandable.

One can hope that a thorough, transparent investigation and analysis of this entire episode can produce helpful knowledge on how to harden healthcare systems for routine healthcare as well as extraordinary events like this one. In the meantime, the CDC has produced clear guidance for evaluating patients with a history of traveling to epidemic regions.

Acknowledgement: The title is inspired from a Medscape Connect item entitled "The cult of Vitamin R", which no longer appears to be available online.

(image source: Wikipedia)

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