#297 CRC Screening, Common Skin Complaints, and Antibiotic Pearls (TFTC #8)

September 29, 2021 | By Matthew Watto, MD

We recap the top pearls on CRC Screening, Common Skin Complaints, and Antibiotic Pearls. It’s Tales from the Curbside! (TFTC), our monthly series providing a rapid review of recent Curbsiders episodes for your spaced learning.

Note: No CME for this mini-episode but visit curbsiders.vcuhealth.org to claim credit for shows #283, #284, and #285 at curbsiders.vcuhealth.org!

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Credits

• Written, Produced, and Hosted by: Matthew Watto MD, FACP; Paul Williams MD, FACP  
• Infographics by: Elena Gibson and Beth Garbitelli
• Cover Art: Edison Jyang
• Editor: Matthew Watto MD (written materials); Clair Morgan of nodderly.com

Sponsor: ACP acponline.org/telemedicine201

Sponsor: Ten Thousand tenthousand.cc code = CURB

CME Partner: VCU Health CE

The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit. 

Show Segments

• Intro, disclaimer, guest bio
• CRC Screening
• Antibiotic Pearls
• Derm Pearls (Common Skin Complaints)
• Outro

Episode #283 CRC Screening Update

Featuring Michael Barry of the USPSTF and production and graphics by Elena Gibson

Matt’s Pearl – The rationale for a lower testing age was driven by an increase in CRC incidence for people in their 40s with an estimated 10.5% of new CRC cases in patients less than 50 years old (Siegel, 2017)

Paul’s Pearl – Like everything we do, it is important to factor in patient preference and individualize care.  There are a number of modalities that can be used, each with their own benefits and potential downsides.  For instance, while stool tests (e.g. sDNA-FIT test) are ostensibly easier due to convenience, the intervals are more frequent, and a colonoscopy is needed to follow up a positive test, which occurs ≤10% of patients.  In older patients (75-85), screening should be offered on an individual basis depending on patient preference and co-morbidities. Both Matt and Paul consider factors like the patient’s biological age, not just their chronological age.

Matt’s Pearl – The USPSTF does not favor direct visualization tests like flex sig or colonoscopy over stool based tests like FOBT, FIT testing, or sDNA-FIT testing. Any of the approved testing modalities are adequate so long as patients adhere to the screening intervals. It’s okay to switch between screening methods. 

Episode #284 Antibiotics Primer

Featuring Adi Shah and production and graphics by Nora Taranto and Beth Garbitelli

Matt’s Pearl – Ask yourself a series of questions before prescribing antibiotics (infectious vs noninfectious, previous antibiotic (abx) exposure, site of infection, bugs to cover, tests to order before giving antibiotics, and finally is source control needed). Paul likes to ask “What has worked before?”. This all serves as a form of stewardship and can help prevent cognitive errors (expert opinion). 

Paul’s Pearl – 

We discussed duration at length, so it’s probably worth once again mentioning the ACP Best Practice Advice for abx duration (Lee, 2021):

1. Clinicians should limit antibiotic treatment duration to 5 days when managing patients with COPD exacerbations and acute uncomplicated bronchitis who have clinical signs of a bacterial infection (presence of increased sputum purulence in addition to increased dyspnea, and/or increased sputum volume).
2. Clinicians should prescribe antibiotics for community-acquired pneumonia for a minimum of 5 days. Extension of therapy after 5 days of antibiotics should be guided by validated measures of clinical stability, which include resolution of vital sign abnormalities, ability to eat, and normal mentation.
3. In women with uncomplicated bacterial cystitis, clinicians should prescribe short-course antibiotics with either nitrofurantoin for 5 days, trimethoprim-sulfamethoxazole (TMP–SMZ) for 3 days, or fosfomycin as a single dose. In men and women with uncomplicated pyelonephritis, clinicians should prescribe short-course therapy either with fluoroquinolones (5 to 7 days) or TMP–SMZ (14 days) based on antibiotic susceptibility.
4. In patients with nonpurulent cellulitis, clinicians should use a 5- to 6-day course of antibiotics active against streptococci, particularly for patients able to self-monitor and who have close follow-up with primary care.  Per IDSA – “Treatment recommendations include a cephalosporin, penicillin, or clindamycin, except for patients whose cellulitis is associated with penetrating trauma or who have evidence of MRSA infection elsewhere, nasal colonization with MRSA, injection drug use, or systemic inflammatory response syndrome”

Matt’s Pearl – Three to five days for community-acquired PNA and 7 days of TMP-SMX for uncomplicated pyelonephritis were suggested by #medtwitter when we asked for feedback (see Shorter Is Better site by Brad Spellberg). This is all evolving so stay tuned.

Paul’s Pearl –  I appreciated Dr. Shah’s pet peeves/pitfalls to avoid:

1. Pip-tazo covers anaerobes, so no need to add metronidazole
2. You also don’t need metronidazole for aspiration coverage (IDSA, 2019)
3. Daptomycin does not treat pneumonia, since it’s broken down by surfactant
4. Check the QT interval with fluoroquinolones and azithromycin
5. Hospitalized patients who can tolerate appropriate oral antibiotics should receive them

Episode #285 Common Skin Complaints in Primary Care

Featuring Helena Pasieka and production and graphics by Maddie “Mad Dog” Morgan, Edison Jyang

Matt’s Pearl – Onychomycosis is famously difficult to treat and recurrence rates are high. Urea 40% cream can help achieve an adequate cosmetic and/or mechanical result (i.e. debulk the nail so the patient can paint them, or just fit in shoes again) —John Hopkins Abx Guide. Apply it to the nail daily…until the nail kind of melts away (expert opinion)! Note: Some sources recommend protecting the surrounding skin with tape (John Hopkins Abx Guide). 

Paul’s Pearl – Acrochordons (skin tags)

These are papules (raised) and have a stalk, and are located in areas of friction/areas of skin touching skin (intertriginous areas). They are often skin-toned or hyperpigmented. Skin tags can get inflamed, thrombosed, and become symptomatic. When symptomatic (i.e. necklace gets caught, razor knicks it, gets inflamed/traumatized), removal can be covered by insurance when documented appropriately. Per expert opinion, consider sending rapidly growing or symptomatic skin tags to pathology, or if the stalk is >4mm. Dr. Pasieka and her colleagues sometimes find unexpected malignancies!

Removal of skin tags depends on the diameter of the stalk. Expert opinion: a thin stalk can be removed with liquid nitrogen, but it is important to note that this treatment in darker skin tones could kill melanocytes and cause hypopigmentation. It can also be removed by a straight blade or iris scissors.

Matt’s Pearl – Diagnose tinea versicolor with the “fluff test”. Place index fingers over a spot and swipe them apart to raise the “furfuraceous scale”. Use ketoconazole shampoo as a body wash for treatment. Wait 5-10 minutes before rinsing. Use daily for 1-4 weeks (John Hopkins Abx Guide). Maintenance therapy should be less frequent (i.e. weekly, not daily). Note: In the past dermatologists would tell patients to take oral ketoconazole and then exercise vigorously two hours later to improve drug delivery to the skin! Hepatotoxicity has ended this practice (John Hopkins Abx Guide)

Paul’s Pearl – Pruritis with or without rash

Dr. Pasieka breaks down pruritus into two separate buckets 1) with and 2) without a rash. For older patients, without a rash pruritus presentation is often multifactorial. The threshold for chronic pruritus is 6 weeks. Common clinical presentation includes “itchiness” all over the body and in the winter months. Pruritus can be caused by comorbidities, showering routines, or medications such as statins, opioids, aspirin, and chemotherapy/immunotherapy (e.g. PD-1 inhibitors) drugs.

Check LDH in older patients (looking for lymphoma). Xerosis is the most common cause. Use jarred stuff instead of stuff out of pumps (expert opinion).

Goal

Listeners will review tops pearls from recent curbsiders episodes

Learning objectives

After listening to this episode listeners will…

1. Implement the latest CRC screening recommendations
2. Build a framework to approach antibiotic use
3. Discuss common derm complaints in primary care

Disclosures

The Curbsiders report no relevant financial disclosures. 

Citation

Williams PN, Watto MF. “#297 CRC Screening, Common Skin Complaints, and Antibiotic Pearls (TFTC #8)”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list Final publishing date September 29, 2021.