Family Medicine Update

Evidence for the use of intramuscular injections in outpatient practice.

Am Fam Physician. 2009 Feb 15;79(4):297-300

Authors: Shatsky M

There are few studies comparing the outcomes of patients who are treated with oral versus intramuscular antibiotics, corticosteroids, nonsteroidal anti-inflammatory drugs, or vitamin B12. This may lead to confusion about when the intramuscular route is indicated. For example, intramuscular ceftriaxone for Neisseria gonorrhoeae infection and intramuscular penicillin G benzathine for Treponema pallidum infection are the treatments of choice. However, oral antibiotics are the treatment of choice for the outpatient treatment of pneumonia and most other outpatient bacterial infections. Oral corticosteroids are as effective as intramuscular corticosteroids and are well-tolerated by most patients. High daily doses of oral vitamin B12 with ongoing clinical surveillance appear to be as effective as intramuscular treatment. Few data support choosing intramuscular ketorolac over an oral nonsteroidal anti-inflammatory drug unless the patient is unable to tolerate an oral medication. For other indications, the intramuscular route should be considered only when the delivery of a medication must be confirmed, such as when a patient cannot tolerate an oral medication, or when compliance is uncertain.

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Evaluation of macrocytosis.

Am Fam Physician. 2009 Feb 1;79(3):203-8

Authors: Kaferle J, Strzoda CE

Macrocytosis, generally defined as a mean corpuscular volume greater than 100 fL, is frequently encountered when a complete blood count is performed. The most common etiologies are alcoholism, vitamin B12 and folate deficiencies, and medications. History and physical examination, vitamin B12 level, reticulocyte count, and a peripheral smear are helpful in delineating the underlying cause of macrocytosis. When the peripheral smear indicates megaloblastic anemia (demonstrated by macro-ovalocytes and hypersegmented neutrophils), vitamin B12 or folate deficiency is the most likely cause. When the peripheral smear is nonmegaloblastic, the reticulocyte count helps differentiate between drug or alcohol toxicity and hemolysis or hemorrhage. Of other possible etiologies, hypothyroidism, liver disease, and primary bone marrow dysplasias (including myelodysplasia and myeloproliferative disorders) are some of the more common causes.

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Antimicrobial prescribing for upper respiratory infections and its effect on return visits.

Fam Med. 2009 Mar;41(3):182-7

Authors: Li J, De A, Ketchum K, Fagnan LJ, Haxby DG, Thomas A

BACKGROUND AND OBJECTIVES: Antibiotic resistance is a growing problem that complicates the treatment of various illnesses. This study analyzes Medicaid encounter data to (1) determine antibiotic prescribing rates for common respiratory tract infections in Oregon and (2) assess the effect of receiving an antibiotic at an index visit on whether there was a return visit within 30 days. METHODS: Subjects included in this study were Medicaid patients in Oregon between 2001–2003 who were enrolled in Medicaid for a full year and were diagnosed with an upper respiratory tract infection, including bronchitis, sinusitis, acute otitis media (AOM), pharyngitis, and upper respiratory infections (URIs). Claims data were analyzed to determine receipt of an antibiotic within 3 days of the initial visit and if there was a return visit within 30 days. RESULTS: During 2001–2003, the proportion of patients receiving antibiotics for bronchitis and sinusitis decreased, from 70% to 61%, and from 78% to 74%, respectively, while antibiotic prescribing for AOM, URI, and pharyngitis changed little. After controlling for age, gender, race/ethnicity, Medicaid plan type, and location, we determined that patients who had received antibiotics during the index visit for AOM, URI, and pharyngitis were more likely to return with a respiratory tract infection during the subsequent 30 days than patients who did not receive antibiotics. CONCLUSIONS: Antibiotic prescribing among Medicaid patients in Oregon has decreased. Receiving an antibiotic does not decrease the rate of subsequent return visits.

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