Clinical Practice Points
Prescribing antibiotics for acute respiratory infections contributes to overuse. This
study evaluated the sources of variation in practice and found that veterans with
acute respiratory infections often received antibiotics, regardless of patient, provider,
Use this study to:
- Review treatment guidelines for acute respiratory illnesses (e.g., bronchitis and
sinusitis). Use the information in ACP Smart Medicine: Acute Bronchitis and Acute Rhinosinusitis to ask your learners when antibiotics are indicated for acute respiratory infections.
Which antibiotics should be used when necessary?
- Ask why a physician might prescribe an antibiotic when not indicated.
- Role-play conversations with a patient with an acute respiratory infection who requests
– and expects –a prescription for an antibiotic that is not required.
Ask your learners to explain why they are not prescribing antibiotics. How will they
explain the risks of antibiotic use when not required? What will they tell the patient
they will do to manage their symptoms? Is it useful to discuss the societal harms
of antibiotic overuse with a patient, or to focus only on the risks of harms to the
This report describes the clinical characteristics and management of a cluster of
patients with EVD, including two health care providers who acquired the disease while
providing care to an infected patient.
Use this report to:
- Invite someone from your hospital's administration to discuss your disaster preparedness
plan. While most hospitals would not be expected to manage a domestic Ebola outbreak,
large-scale biologic or traumatic disasters are a possibility.
- Ask your learners how they would feel if asked to care for a patient with a highly
contagious disease. Would they care for a patient with a disease whose communicability
is not yet well understood? Discuss the ethical dilemmas with your learners surrounding
the care of the patients in the article. How can they balance dedication to a patient
and self- protection?
This is the first description of the clinical and laboratory features of a series
of patients with BMD, a newly recognized tick-borne infection. The findings suggest
that BMD should be part of the differential diagnosis of febrile patients from areas
where deer tick–transmitted infections are endemic.
Use this study to:
- Start a teaching session with a multiple-choice question. We've provided one below.
- Compare the presentations and therapies of various tick-borne illnesses in the United
States. Use the information in a recent In the Clinic: Lyme Disease to discuss how to prevent tick bites, and the differential diagnosis of tick-borne–related
- How will this case series inform your learners' diagnostic and treatment choices for
patients with exposures in the Northeast US? How will they counsel patients regarding
this (and other tick-borne) illnesses? Use the accompanying editorial to help frame the discussion.
This research study examined the association between sexual orientation identity and
human papillomavirus (HPV) vaccination among U.S. women and girls, and found that
adolescent and young adult lesbians may be less likely to initiate HPV vaccination
than their heterosexual counterparts. The position paper offers recommendations on
how to reduce health disparities for lesbian, gay, bisexual, and transgender (LGBT)
persons in the health care system.
Use these papers to:
- Review the risk factors for HPV transmission and indications for the HPV vaccine.
- Ask your learners why there might be disparities in the utilization of HPV vaccination.
In what other areas are there disparities in health care according to sexual orientation
identity? These are reviewed in the ACP Position paper.
- Review the positions of the ACP. Do your learners agree with them?
- Ask your learners whether they believe personal religious or cultural beliefs have
a place in the practice of medicine. Where might a physician's personal beliefs appropriately
inform his or her practice of medicine, and where might it be wrong? What if those
beliefs hold that being lesbian, gay, bisexual, or transgender is “wrong”?
How would your learners respond to a colleague who objected to participating in care
that his or her religious beliefs deem to be “wrong”?
A 22-year-old man is evaluated for a skin eruption on his leg. The patient lives in
Virginia and is active outdoors. One week ago, he found a black tick on his lower
leg, which his roommate removed with a tweezers. Yesterday he developed diffuse myalgia,
neck stiffness, and fatigue. These symptoms have persisted, and today he notes erythema
at the site of the previously attached tick.
On physical examination, temperature is 38.1 °C (100.6 °F); other vital
signs are normal. There is no nuchal rigidity. Skin findings are shown in the image
Which of the following is the most appropriate initial management?
A. Borrelia burgdorferi polymerase chain reaction on skin biopsy specimen
B. Empiric intravenous ceftriaxone
C. Empiric oral doxycycline
D. Serologic testing for Lyme disease
C. Empiric oral doxycycline
Empiric oral doxycycline is the recommended treatment for erythema migrans regardless
of the cause.
Manage a patient with an erythema migrans skin lesion.
The skin lesion shown is consistent with erythema migrans, and oral doxycycline should
be started immediately. Erythema migrans may be due to either early localized Lyme
disease or Southern tick–associated rash illness. Although these two infections
are caused by specific tick vectors with relatively distinct geographic distributions,
both ticks are endemic to Virginia. Geographic location is therefore of little value
in differentiating between these two syndromes in this patient. However, empiric doxycycline
is the recommended treatment for erythema migrans regardless of the cause. Treatment
should be given based on the clinical finding of an expansile, target-like skin lesion,
particularly at the site of a known tick attachment.
Borrelia burgdorferi polymerase chain reaction testing is not indicated. Although B. burgdorferi may be amplified from erythema migrans skin biopsy specimens if the diagnosis is
uncertain, this study is generally not needed because the presence of the characteristic
erythema migrans rash, such as is seen in this patient, dictates treatment.
Intravenous ceftriaxone is reserved for patients with cardiac or neurologic manifestations
of disseminated Lyme disease.
Serologic testing for B. burgdorferi is not recommended because false-negative antibody assay results may occur in patients
with early localized Lyme disease and would be negative in patients with Southern
tick–associated rash illness.
Stonehouse A, Studdiford JS, Henry CA. An update on the diagnosis and treatment of
early Lyme disease: “focusing on the bull's eye, you may miss the mark”.
J Emerg Med. 2010;39(5):e147-151. PMID: 17945460
This question was derived from MKSAP® 16, the latest edition of the Medical Knowledge Self-Assessment Program.