Facebook Share

Monday, August 27, 2007

Please tell me which P4P guidelines to use for this patient.

Anyone who reads this blog knows I rarely, in fact never, post medical issues on this business related blog. But alas, I feel I must. I have a patient I'd like to share with you who no doubt defies all P4P guidelines.

She is an 80+ year old woman with COPD and chronic bacteriuria. Now please note, I did not say urinary tract infections, which would indicate that the bacteria in her bladder causes her problems. No, she has simply bacteria in the urine, but otherwise does well. Despite her lack of symptoms, other physicians--no doubt well intentioned--had persistently started her on antibiotics for every positive culture, which happened to be on every urine specimen sent, or 6-8 times per year, for several years. By the time she came to me, she had multi-drug resistant bacteria in her bladder. Fortunately, she was not symptomatic, because if she was, we'd have had a problem.

Now she has incontinence, mild incontinence, but incontinence nonetheless. She is not particularly bothered by the problem, but she does wet the bed at night, and this bothers her caregiver, who is her daughter. Having ruled out the other usual causes of incontinence, and having tried medications to treat the problem, I have concluded that her bacteriuria is contributing, or causing, her incontinence. Since she is now symptomatic, she has, by definition, a UTI--or urinary tract infection. The urine cultures, which are catheterized cultures, show an E. coli bacteria that is susceptible to penicillin's and cephalosporins, though not to quinolones, sulfas, nitrofurantoin, or macrolides. I can use aminoglycosides, since the organism shows susceptibility to them. The patient is allergic to penicillin's and cephalosporins.

So what do I do? Well I know what to do because I have a brain and judgement and I cognate and I can have informed consent discussions with the patient and her family, all things that computers and guidelines are incapable of doing. Is the government telling me that P4P guidelines would help me treat this patient? I don't think so.

Oh, and one last thing. If you think that this patent's situation is unique or uncommon, think again. Asymptomatic bacteriuria occurs in 80% of institutionalized octogenarians. Moreover, millions of elderly woman will find themselves in a similar predicament as my patient and effective treatment requires thought and interactive discussions, not guidelines.

Thanks for listening.

The IU.