Monday, June 26, 2017

Strategies to limit antibiotic resistance and overuse

- Kenny Lin, MD, MPH

According to a report from the Centers for Disease Control and Prevention (CDC), more than 2 million Americans become infected with antibiotic-resistant bacteria each year, leading directly to at least 23,000 deaths and contributing indirectly to thousands more. Antibiotic resistance occurs in the community, in long-term care facilities, and in hospital settings. Another CDC report on preventing healthcare-associated infections (also discussed in this AFP article) identified six high-priority antibiotic resistance threats: carbapenem-resistant Enterobacteriaceae, methicillin-resistant Staphylococcus aureus (MRSA), extended-spectrum beta-lactamase-producing Enterobacteriaceae, vancomycin-resistant Enteroccocus, multidrug-resistant Pseudomonas, and multidrug-resistant Acinetobacter.

In a 2014 editorial, "Antibiotic resistance threats in the United States: stepping back from the brink," Dr. Steven Solomon and Kristen Oliver from the CDC identified three strategies that family physicians can use to limit antibiotic resistance: 1) Preventing infections through immunizations, standard infection control practices, and patient counseling; 2) Reporting unexpected antibiotic treatment failures and suspected resistance to local or state health departments; and 3) Prescribing antibiotics more carefully. Unfortunately, inappropriate antibiotic prescribing (also known as antibiotic overuse) is common in primary care, particularly for patients with acute viral respiratory tract infections.

Antibiotic overuse is a multifaceted problem with many potential solutions. On Sunday, July 9th at 7 PM Eastern, Dr. Jennifer Middleton (@singingpendrjen) and I (@kennylinafp) will be taking a deep dive into the evidence on the most effective strategies to curb prescribing of unnecessary antibiotics. AAFP members and paid AFP subscribers can earn 4 free continuing medical education credits by registering for the #afpcme Twitter Chat, reading three short AFP articles, and completing a post-activity assessment. We and @AFPJournal hope you can join us!

Monday, June 19, 2017

Twitter chats: 21st century CME

- Jennifer Middleton, MD, MPH

Being active on Twitter can have many advantages for family physicians. Following journals like AFP (@AFPJournal) can make it easy to keep up with the latest medical studies and news. With individual tweets limited to 140 characters, Twitter chats provide a way to explore a particular issue more in-depth and build connections among people with common interests. Increasingly, they can also be a way to increase physician knowledge and even obtain continuing medical education (CME) credit.

Typically, Twitter chats occur at a scheduled time, last for about an hour, and are moderated by one or a few members of the hosting organization. The topic for discussion is determined in advance, and the moderators usually prepare questions to ask participants throughout the hour. Participants can tweet responses to the questions - and to each other's responses - during the hour, and the conversation can be reviewed later by searching for the chat's hashtag. You can see an example of a Twitter chat here.

Several medical journals and organizations are using Twitter chats (or virtual journal clubs, as some journals prefer to call them) to engage with their members. The Annals of Family Medicine and the Society of Teachers of Family Medicine host regular Twitter chats covering a variety of clinical and educational topics pertinent to Family Medicine. In other specialties, Journal of the American Geriatrics Society, American College of Chest Physicians, Annals of Emergency Medicine, and the Society of Hospital Medicine all host or have hosted Twitter chats.

Using Twitter for medical education can have tangible benefits. Medical students who participated in Twitter activities relating to biomedical science studies had higher grades than those who did not. Medical students who participated in Twitter activities related to gross anatomy classes reported better communication with faculty, higher morale, and less anxiety. A general surgery program used a competitive Twitter microblogging project to improve their residents' in-training exam scores. An Australian research group found that online CME using Twitter and other social media platforms was perceived as more cost effective for physicians compared to attending live CME conferences.

Last year, AFP hosted its first Twitter chat, and this year, on July 9, we'll host our first Twitter chat for CME credit on the topic of antibiotic overuse. You can claim 4 hours of CME credit for participating; the chat will be 1 hour, and the additional 3 hours are allotted for the preparation time to read the articles. You can download the articles we'll be covering, learn more about the basics of a Twitter chat, and register here. If you have questions about how to get involved, you can tweet @AFPJournal or email

What benefits or barriers do you see to using Twitter for CME?

Tuesday, June 13, 2017

Start collecting community vital signs in your practice

- Kenny Lin, MD, MPH

Primary care physicians and educators are increasingly recognizing the usefulness of assessing social determinants of health (defined by the Centers for Disease Control and Prevention as conditions in the places where people live, learn, work, and play) during health care encounters. A recent National Academy of Medicine discussion paper described the Accountable Health Communities Screening Tool, developed by the Center for Medicare and Medicaid Innovation to identify and address five domains of health-related social needs: housing instability, food insecurity, transportation difficulties, utility assistance needs, and interpersonal safety. Since 2011, students at Morehouse School of Medicine and Georgia State University College of Law have participated in an interprofessional medical-legal curriculum; surveys suggested that medical students who completed the curriculum were more likely to screen for social determinants of health and refer patients to legal resources. In March, the American Academy of Family Physicians (AAFP) launched its Center for Diversity and Health Equity, whose planned activities will include

- evaluating current research on the social determinants of health and health equity;
- promoting evidence-based community and policy changes that address the social determinants of health and health equity; and
- developing practical tools and resources to equip family physicians and their teams to help patients, families, and communities.

In an editorial in the June 1 issue of American Family Physician, Drs. Lauren Hughes and Sonja Likumahuwa-Ackman add another potential dimension for action on social determinants of health by introducing the concept of "community vital signs." In contrast to data collected directly from patients, the authors write,

Community-level data are acquired from public data sources such as census reports, disease surveillance, and vital statistics records. When geocoded and linked to individual data, community-level data are called community vital signs. Community vital signs convey patients' neighborhood health risks, such as crime rates, lack of walkability, and presence of environmental toxins. ... This enhanced knowledge about where patients live, learn, work, and play can help physicians tailor recommendations and target clinical services to maximize their impact. Rather than simply recommending that a patient eat better and exercise more, care teams can connect patients to a local community garden, low-cost exercise resources (e.g., YMCA), or neighborhood walking groups.

To get started using community-level data to improve patient care and population health, family physicians can consult The Practical Playbook and the AAFP's Community Health Resource Navigator. The editorial also provides a suggested five-step process for incorporating community vital signs into clinical practice.

Monday, June 5, 2017

Making informed decisions about cancer screening

- Jennifer Middleton, MD, MPH

Debate within the medical community regarding when and how to screen for breast cancer, prostate cancer, and colorectal cancer continues. Helping patients make informed decisions about how they wish to participate in these screenings can be a challenge for busy family physicians. Two recent articles address this challenge by providing several solutions to help us help our patients make informed decisions.

The first article is a report of a large cohort study based in Virginia that examined patients' use of an online decision module regarding breast, prostate, and/or colon cancer screening. Patients were invited to view the module if they were overdue for consideration of these screenings (women aged 40-49 without a mammogram in the last 2 years, men aged 55-69 who had not had prostate cancer screening in the last 2 years, and men and women identified as overdue for colorectal cancer screening). Uptake was low; about 20% of the 11,000+ eligible patients began a module, and only 7.9% completed a module. Of that 7.9%, though, about half felt that it enabled them to have a more helpful conversation with their physician.

The second is a review of shared decision making techniques and resources in the current issue of Family Practice Management. The article reviews clinical circumstances when shared decision making is relevant and also reminds readers that shared decision making is an integral part of the United States Preventive Services Task Force's (USPSTF's) recommendations on breast cancer screening for women aged 40-49 and lung cancer screening. It describes the 6 general steps of shared decision making along with 3 tools for using shared decision making with patients: SHARE, the 5 As, and IAIS. The article also includes a table with online resource aids for patients; the first,, provides neat graphics that may make concepts like "prevalence" and "false positive" easier to discuss using lay language.

You can read about these and other controversies in the AFP Department Collection on Editorials: Controversies in Family Medicine that also includes a search engine. You can also read more about cancer screening, diagnosis, and treatment in the AFP By Topic on Cancer.

What shared decision making techniques and/or tools have you found useful?

Tuesday, May 30, 2017

CA-MRSA coverage is unnecessary for uncomplicated cellulitis

- Kenny Lin, MD, MPH

Cephalexin has long been my oral antibiotic of choice for a patient with uncomplicated cellulitis and no cephalosporin allergy. However, the increasing prevalence of skin and soft tissue infections (SSTIs) caused by community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA), often mistaken by patients and clinicians for spider bites, has raised the question of whether it makes sense to also prescribe an antibiotic such as trimethoprim/sulfamethoxazole for empiric CA-MRSA coverage for immunocompetent patients with cellulitis that is not purulent or severe enough for inpatient therapy.

A 2009 case-control study found that children with SSTIs who received empiric monotherapy with trimethoprim/sulfamethoxazole had higher rates of treatment failure than those who received beta-lactam antibiotics. Although helpful, this study did not measure outcomes in adults or in children who were prescribed more than one antibiotic. Despite the lack of evidence of benefit, national data suggest that up to 3 in 4 patients presenting to the emergency department with skin infections are prescribed antibiotics active against CA-MRSA. Potential downsides of "double coverage" include higher rates of adverse effects, cost, and increasing antibiotic resistance.

In a recent paper in JAMA, Dr. Gregory Moran and colleagues reported the results of a multicenter randomized, controlled trial of 500 adolescents and adults with diagnosed in the emergency department with cellulitis and no wound, purulent drainage, or abscess (verified by soft tissue ultrasound) who received 7 days of therapy with either cephalexin plus trimethoprim/sulfamethoxazole or cephalexin plus placebo. They found no differences in clinical cure rates in either the modified intention-to-treat or per-protocol analyses.

Based on this study's results, I will continue to restrict my use of trimethoprim/sulfamethoxazole to patients whose cellulitis fails to respond to cephalexin and patients with purulent infections. Of note, the American College of Emergency Physicians recommends against sending wound cultures or prescribing antibiotics in persons who undergo successful incision and drainage of skin and soft tissue abscesses and who have adequate medical follow-up. A 2015 AFP article provides more information on the management of SSTIs, including inpatient treatment and other special considerations.

Monday, May 22, 2017

2017 Family Medicine Day of Action #staywellsoon

- Jennifer Middleton, MD, MPH

AFP provides content on a variety of issues that may compel a larger call to social justice. Articles on caring for the homeless, victims of intimate partner violence, and ethnic minorities demonstrate our specialty's mission to care for all. Promoting breastfeedinggun safety, and oral health can help patients avoid potentially catastrophic outcomes. Our generalist's perspective can provide expertise on issues such as debated cancer screenings (breast, prostate, and lung) and unnecessary interventions (antibiotics, imaging). We are also well-suited to comment on public health issues such as obesity, opioid misuse, and even global warming.

We may recognize, however, that knowing these medical facts is only the first step to meeting our patients' and communities' needs. Sharing our perspective as family physicians is another important way that we can care for our communities.

Every year, the AAFP's Family Medicine Advocacy Summit takes a group of interested family physicians, trains them in political advocacy, and takes them to Capitol Hill to meet with their elected officials. This opportunity is undoubtedly valuable for those able to participate, but family physicians unable to make this trip now have other ways to get involved. Joining the Family Physician Action Network is a great first step; signing up will provide you with resources to be an effective advocate for your patients. An overview is available on the Family Physician Action Center website, including a primer on the legislative process and tips to maximize your engagement over social media as well as conduct an effective telephone or in-person conversation with your elected officials. Speaking up doesn't have to take a lot of time, and it can have a powerful impact. AFP's Graham Center One-Pagers Department Collection provides succinct talking points on a variety of topics.

The AAFP has also decreed tomorrow the first "Family Medicine Day of Action." You can post a "Stay Well Soon" e-postcard to your Facebook, Twitter, and/or Tumblr contacts by clicking here. AAFP's goal is to have 1000 people post with a goal of 1,000,000 views. It's an easy way to promote Family Medicine and all we have to offer our patients and communities.

Whether it's attending the Advocacy Summit, getting involved in the Action Network, or posting a #staywellsoon e-postcard, all of us can find a way to speak up. What will yours be?