Choosing Antimicrobial Therapy: One Podiatrist's Experience

Jennifer Spector, DPM:

Welcome back to Podiatry Today Podcasts where we bring you the latest in foot and ankle medicine and surgery from leaders in the field. I'm Dr. Jennifer Spector, the Assistant Editorial Director for Podiatry Today. And in today's episode, our January Wound Care Q&A is with our clinical editor, Dr. Kazu Suzuki. Dr. Suzuki is the medical director of the Apex Wound Care Clinic in Los Angeles. He's also a member of the attending staff of Cedars-Sinai Medical Center in California. Today, Dr. Suzuki is chatting with us about his point of view and experience in antimicrobial decision-making in wound care.

Welcome Dr. Suzuki, and thank you so much for being with us today. In your practice, what's your algorithm or system that you use to choose when a patient needs any type of antimicrobial?

Kazu Suzuki, DPM:

So, I have low index of suspicion when I prescribe antimicrobial, meaning that a lot of our patients are older. My average patient in my clinic, wound clinic, is 75 years old and by definition, they're immunocompromised is how I see it. So, if they come in to see me with acute or chronic wound, with even a tiny bit of a redness around the wound, I call that infection and go ahead and treat it. That's something I've learned over my 20 years of my experience, if it looks like infection, it is an infection. The redness is just not there just for a reason.

And if I suspect any infection, even if there's no redness at all, but if the wound is completely stopped for four weeks, six weeks, two months, I think it actually deserves a short course of antimicrobial and see if it helps at all. Again, this is something, sometimes something I develop over the last 20 years as a reasonable practice.

Jennifer Spector, DPM:

When you do choose an antibiotic, how do you choose, first of all, what type of antibiotic or antimicrobial as far as a cleanser versus a topical versus oral versus IV? And then we can get into how you choose what agent specifically too.

Kazu Suzuki, DPM:

Yeah, so topical antimicrobials, I almost never use them. It just doesn't really penetrate that deep. So if the wound is infected, you need actual PO IV antibiotics, that's just kind of how my take. I do use topical antimicrobial dressings, I actually am a big believer on that. Again, I don't have really good data on that and no company that I know, that we work with have this, except the bench study. But there's a definitely bench study, let's say take any silver-based microbial dressings and they certainly have bench data to show that, "Hey, hey doctor, if you use our silver microbial and put bacteria on top, it dies within three hours," so absolutely, we do have a study on that.

This is my personal philosophy, is that chronic wound by definition has biofilms and bacteria on the surface. So it is my personal feelings that we should be using antimicrobial, let's say silver dressings to dress with as opposed to just plain sterile dressings, that's kind of what conventional wisdom calls for. Okay, so each dressing costs a dollar or $2 or more but I do not mind the expense using the antimicrobial dressing for chronic wounds. Take one example, I had this one patient, I still remember him well, I was using silver dressing on this diabetic wound once a week for a few weeks, few months.

He was getting better and better and better. Just one day I ran out of the particular silver dressings so I use the regular dressing, a kind of regular counterpart of this form dressing. And guess what? A week after that he came up with a massive infection. Now this is just example of one, but I kind of took heart of it and I felt really, really bad about that. So ever since I do continue to use antimicrobial dressing for chronic wounds.

Jennifer Spector, DPM:

So when you're deciding exactly which antimicrobial to prescribe, how do you go about doing that and what role do things like culture play in that for you?

Kazu Suzuki, DPM:

Well as first thing you want to know is antibiogram. So each hospital, each community has antibiogram, that's the annual report of the basically culture results that they grow out in their lab, each year they publish that. In my hospital, I can go through my EMR, look under culture results, look under pharmacy, and I can see the report every single year. UCLA does the same thing. And it shows more than 50% of staff that we see is MRSA, it's not MSSA, such that basically you have to use something that covers MRSA, which means I usually use Doxycycline as a first line agent.

Bactrim is second line agent, then maybe Linezolid by PO, Linezolid which is now off-brand and not too expensive, is my third line agent as a empirical oral therapy. Now, if you're treating a wound or if you're treating a wound infection, you absolutely want to take wound culture and you want to know culture and the sensitivity, that's a bottom line. I just take a wounds, debris the wound, irrigate it, take a clean swabs on the wound bottom and send it out. In two to three to four days, I usually get very reliable, very usable wound culture and sensitivity report. So I usually prescribe antibiotics.

I tell my patients, "Go ahead and start it today and come on back two to three to four days and then we'll readjust." Oftentimes we stay with the same thing. Once in a while I get surprised and I have to switch it out and that's perfectly okay. I am seeing more Doxycycline resistant MRSA in my community, which is alarming. Not a lot, but once in a while.

Jennifer Spector, DPM:

So have you had, now that it's off-brand, have you had any issues getting Linezolid for your patients when you choose that?

Kazu Suzuki, DPM:

A little bit, but not too much. I had a few insurance company that gave me a trouble, but usually not by much. And I tell my patients, "Hey, worst case scenario, just take cash." I think it costs like 60, $80 at the most, which is not bad, which is not bad alternative to sending this patient to emergency room to be admitted to get IV Vancomycin, that is the alternative. So I tell them, "Hey, do you want to go to the hospital or do you want to pay $80 and 100 times?" They're going to choose $80 and just pay cash.

Jennifer Spector, DPM:

So once you've got your plan laid out, how often do you reevaluate the use of that antibiotic? How long do you give it before you evaluate whether there's the effectiveness that you're looking for and when might you choose to change that plan?

Kazu Suzuki, DPM:

Yeah, so I usually like to see my patient in two to three to four days, in the week is a little too long, but you definitely want to see them. You definitely want to review the culture and sensitivity report with them and figure out, and then you want to see the clinical signs of improvement. So three to four days, ideally week is better than never. Sometime our patients travel this time of the year, so sometime I have to do kind of telemedicine kind of thing. But if the infections are resolving, patient should be able to feel that and see that.

Jennifer Spector, DPM:

And how do you go about deciding the duration of that antibiotic and when you choose to stop it?

Kazu Suzuki, DPM:

That's also flexible too. It's usually seven to 10 days for skin infection. That's usually enough, but you have to consider the host. I have a lot of patients with a kidney transplant. I have patients with all immunosuppressive therapy, one or the other. So in those cases, sometime I have to extend it, extend it, extend it, basically I guess extend it until the symptom goes away. Symptom being redness, swelling, pain around them.

Jennifer Spector, DPM:

And we're talking today about skin and skin structure, infection, wound infection. We're not talking about osteomyelitis because I know that's a whole separate episode we could be talking about.

Kazu Suzuki, DPM:

Yes. And of course for bone infection you have to extend it, extend conventional wisdom says six to eight weeks. Some clinicians are, "Okay, maybe more like three weeks." Traditionally osteomyelitis is a surgical disease. They're going to take them to OR and then cut out the infected bone. Now the newer study says maybe not, you could just treat them mostly with just a antibiotic, PO IV antibiotics. I go somewhere in between. If there's bone sticking out, nasty, dirty wound and like a bone melting, then I'll take them to OR to just to clean them up.

But I may be actually, speaking of which, I may be actually maybe a little less aggressive these days. And because again, our antibiotics today is so much better. Let's say when I started practicing 20 years ago and today they're probably twice of them antibiotics available now. So the choices are, more choices are definitely better.

Jennifer Spector, DPM:

Well, and I think any discussion about antibiotics would be incomplete without at least touching on the concept of antimicrobial stewardship, and doing what we can as clinicians to avoid antimicrobial resistance and adverse reactions. How do you fold that way of thinking into your practice?

Kazu Suzuki, DPM:

That is absolute stewardship is very... Do we have that in our hospital? Interesting. If you look at the nationwide, West coast tend to have better stewardship of antimicrobial so we have less resistance, but I don't want to talk bad about other parts of country, but it's absolutely important. It's not so much holding off the powerful antibiotics, but it's more about use, what's appropriate. Now there's famous phrase called Keflex reflux. The story goes, Keflex was once, Cephalexin that is, was once a wonderful antibiotics, it was great for UTI, great for pneumonia, great for skin infection. It was wonderful antibiotics, it kills everything. It was great for everything.

Today, not so much because, not be because the drug is bad, but because the bugs have changed. It's again, going back to antibiogram, it changes and it will continue to change over next 10 years, 20 years. So it's really doctor's responsibility to take a culture number one, don't neglect culture, and pay attention to antibiogram, which is readily available on the internet, and you just have to be mindful.

Jennifer Spector, DPM:

Thank you so much for sharing your decades of experience with us today, Dr. Suzuki. We really appreciate it and hope the listeners learned a lot from your experience and insights. I hope you'll join us again for future episodes of Podiatry Today Podcast, which you can find at podiatrytoday.com and on your favorite podcast platforms.