Clinical Scenario:

            A.R. is a 51-year-old Hispanic male with PMHx of uncontrolled Type 2 Diabetes Mellitus who presents to his PCP complaining of fatigue and bilateral lower extremity pain. A.R. immigrated to the United States from the Dominican Republic about two years ago with his wife and three children. He was born and raised in a rural village in the Dominican Republic where herbs are used as the primary means for managing medical conditions. A.R.’s symptoms started around 5 months ago, but he did not seek medical care until his wife insisted. Prior to this, A.R. was self-medicating by consuming a tea made of nettle, ginger, and dandelion.  He tells his PCP that he works 60 hours a week as a butcher at their local meat market, but he cannot take time off work because he needs to take care of his family. He states that it is his duty to be strong and continue “pushing forward”. A.R. speaks some English, but he is not fluent, so he prefers Spanish.

Cultural Factors:

Use of Herbal Medicine: Traditional herbal remedies are significant in Dominican culture. Medicinal knowledge is passed down from one generation to another, and it is common for villages to have traditional healers who use herbal remedies to help others manage their chronic conditions. Traditional healers possess extensive knowledge on the herbs, plants, flowers, and roots that grow on the land and are well-respected figures in their community. A.R. may have consulted a highly regarded healer from his village in the Dominican Republic about his symptoms.

Language Barrier: A.R.’s preferred language is Spanish. To effectively communicate with his PCP, interpretation services must be available to him if his PCP does not speak Spanish.

Unique Beliefs/Considerations:

Machismo: Machismo is a value which emphasizes  the importance of masculinity, strength, and responsibility as provider. A.R. admits to engaging in 60-hour work weeks to provide for his family which may have led to a delay in seeking care. There is a strong sense of pride in men who practice machismo, specifically that they must be brave and self-sufficient even when they do not feel well. A.R. expresses that he feels he must “push forward” despite his symptoms because it is his obligation to do so as a man.

Financial Situation: A.R. immigrated to the United States about two years ago. It is possible that he is working extensive hours not only to support his immediate family, but to help his family in the Dominican Republic as well. It is common in many cultures to “send money back home” to help with necessities such as food, electricity, and water. The U.S. dollar is more valuable in the Dominican Republic, and it is possible that A.R. allocates some of his money towards relatives who live there.

Areas of Potential Conflict:

Medical vs. Herbal Management: A.R. has uncontrolled T2DM and new onset fatigue and lower extremity pain. It is important to explain the benefits of lifestyle modification and possible pharmacotherapy without discounting A.R.’s beliefs on traditional medicine. Completely dismissing his cultural practices may discourage him from adhering to medical advice.

Work Demands vs. Health Needs: Because A.R. has such a strong belief in his duty to provide for his family, he may not prioritize his health. The clinician can initiate the conversation by acknowledging and even commending A.R. for his stellar work ethic then transition into the importance of resting and taking time off to recover when needed.

Machismo vs. Vulnerability: A.R. may oppose medical intervention because it opposes his machismo views.

Expected Skills:

Language Access: The clinician should offer interpreter services once A.R. confirms his preferred language. This is done to facilitate effective communication between A.R. and the medical team. Interpretation services may be provided over the phone or via video on a tablet or other smart device.

Confidentiality: The clinician should emphasize confidentiality. Confidentiality should be emphasized at the beginning of each visit.

Respect for Cultural Practices: If the clinician is not familiar with the health benefits of the herbs that A.R. is consuming, this is a great opportunity to establish rapport with the patient by asking questions and actively listening. Engaging in this manner can make A.R. feel more comfortable and he will be more agreeable to adhering to medical advice. If possible, the clinician can try to develop a treatment plan that allows A.R. to use his herbals as a supplement for disease management.

Empathy: When addressing A.R.’s health needs, the clinician should acknowledge his hard work and dedication to his family. By doing this, the clinician is addressing A.R.s cultural beliefs which strengthens the patient-provider relationship.

Collaboration: If necessary, the clinician should not hesitate to reach out to other health professionals.

Patient Education:

Type 2 Diabetes Mellitus: T2DM is an endocrine disorder in which the body’s cell become less responsive to insulin, leading to increased blood sugar levels. First-line treatment for T2DM is lifestyle modifications such as improvement in diet and exercise. Pharmacotherapy with Metformin may be initiated if lifestyle modifications are unsuccessful.

Herbal Remedies: Herbal remedies can be used as adjunct therapy to pharmacologic treatment so long as there are no interactions. Many times, patients are under the impression that taking herbal supplements in conjunction with their prescription medication is harmless. This, however, is not true. A common plant that is used for a wide variety of illnesses is St. John’s Wort. This medication possesses serotonergic properties and can induce serotonin syndrome if taken with another serotonergic drug such as citalopram. The clinician should make A.R. aware of any interactions that may arise if he initiates pharmacotherapy and wants to continue drinking herbal tea.

Importance of Seeking Timely Care: Although it is important for A.R. to provide for his family, it is equally as important to take care of himself. The clinician can suggest a treatment plan that is tailored around his work schedule and encourage him to seek care in a timely manner. 

During my rotation in Long Term Care, I was given the opportunity to engage with patients who resided in a skilled nursing facility. My days were split between working with nurse practitioners, doctors, physical therapists, and occupational therapists. In these five weeks I learned the importance of interdisciplinary education and how each member of the team plays an important role in optimizing the patient. For example, physical therapy and occupational therapy were imperative for patients who were on the subacute rehab floors. These patients were able to improve their mobility and functionality after several weeks of engaging in exercises, which allowed them to be discharged home safely. Something I struggled with during this rotation was modifying my physical exam to evaluate patients who were bed bound. Many of the patients I was assigned to were unable to turn on their own, others were unable to follow instruction due to cognitive issues. I found myself consulting my preceptors on the best way to examine my patients for the first few days. By the time my rotation ended, I felt more confident performing my physical exam, and I was able to develop a sound assessment and plan based on the clinical presentation and my findings. One thing I wanted my preceptor and colleagues to notice about my work on this rotation was my ability to interact with patients. I enjoyed talking to patients at the bedside and making sure they felt comfortable, addressing any issues they may have experienced overnight. Having these types of conversation made the rotation extremely meaningful and I gained perspective on a patient population that I did not previously have. For instance, during my internal medicine rotation, I dealt with older patients who were chronically ill and not able to converse, which was not the case for this rotation.

One of the most challenging aspects of this rotation was interacting with patients who were receiving palliative care. I learned to handle my emotions while remaining sympathetic, but it was definitely challenging. I’ve never been exposed to palliative patients before so managing them was initially difficult. I made sure to attend rounds with the palliative fellows each week to learn more about these patients and how to make their stay at the facility as comfortable as possible. Seeing how the palliative care fellows interacted with the patients taught me which strategies can be implemented to demonstrate understanding and sympathy, not only for my upcoming rotation but for the rest of my career. Prior to this rotation, I was unaware of the role and responsibilities that palliative care providers have, but this has definitely changed. The experience I gained working at a skilled nursing facility for my long term care rotation was extremely valuable to me. I know I will carry this experience with me as I go further into my career.

Article: Oral Is the New IV – Challenging Decades of Blood and Bone Infection Dogma: A Systematic Review

Citation: Wald-Dickler N, Holtom PD, Phillips MC, et al. Oral Is the New IV. Challenging Decades of Blood and Bone Infection Dogma: A Systematic Review. Am J Med. 2022;135(3):369-379.e1. doi:10.1016/j.amjmed.2021.10.007

Abstract:

Background: We sought to determine if controlled, prospective clinical data validate the long- standing belief that intravenous (IV) antibiotic therapy is required for the full duration of treatment for three invasive bacterial infections: osteomyelitis, bacteremia, and infective endocarditis.

Methods: We performed a systematic review of published, prospective, controlled trials that compared IV-only to oral stepdown regimens in the treatment of these diseases. Using the PubMed database, we identified 7 relevant randomized controlled trials (RCTs) of osteomyelitis, 9 of bacteremia, 1 including both osteomyelitis and bacteremia, and 3 of endocarditis, as well as one quasi-experimental endocarditis study. Study results were synthesized via forest plots and funnel charts (for risk of study bias), using RevMan 5.4.1 and Meta-Essentials freeware, respectively.

Results: The 21 studies demonstrated either no difference in clinical efficacy, or superiority of oral vs. IV-only antimicrobial therapy, including for mortality; in no study was IV-only treatment superior in efficacy. The frequency of catheter-related adverse events and duration of inpatient hospitalization were both greater in IV-only groups.

Discussion: Numerous prospective, controlled investigations demonstrate that oral antibiotics are at least as effective, safer, and lead to shorter hospitalizations than IV-only therapy; no contrary

Type of Study: Systematic Review

Reason:

                  I selected this article because my patient, M.C., has osteomyelitis of the RT ischium. While discussing management strategies, the attending stated that IV and PO medications are not equal in their ability to manage bone infections, specifically, PO medications are not able to penetrate the bone. I was curious about the efficacy of PO vs IV antibiotics for the treatment of osteomyelitis.

Summary:

                  There is insufficient information dictating whether IV antibiotics are superior PO antibiotics in managing blood or bone infections. Authors of this study developed a systematic review which included prospective, interventional, quasi-experimental, and randomized control trials. All other studies, including studies where the infectious agent was a non-bacterial pathogen, were excluded. Twenty randomized control trials and one quasi-experimental study met the inclusion criteria. Eight randomized control trials comprised of 1,321 patients compared IV-only vs oral therapy for osteomyelitis. Six trials compared an oral fluoroquinolone with or without oral rifamycin to IV cloxacillin.  One study compared oral bactrim w/ adjunct rifampin to IV cloxacillin. One study compared the efficacy of “standard IV regimens” to “varied oral regimens” such as fluoroquinolones, penicillins, and macrolides. The first six trials demonstrated similar success rates between the IV and oral groups. One study demonstrated “superior cure rates” for oral ofloxacin when compared to IV imipenem/cilastin. Complications associated with IVs such as local cellulitis, phlebitis, and UE DVT were also eliminated in the oral group. Based on the evidence provided in this systematic review, I believe that the patient can be managed with an oral fluoroquinolone dependent on her kidney function. She should be monitored for fluoroquinolone toxicity which can precipitate QT prolongation and potentially Torsades De Pointes as well as tendon rupture.