Does asking screening questions increase risk?
My hospital uses the Columbia-Suicide Severity Rating Scale (C-SSRS) to screen all patients for suicide risk at admission. I'm not comfortable asking a potentially suicidal patient about thoughts of suicide or self-harm. Couldn't those questions trigger the patient to make a plan and then act on it?—W.S., N.C.
No. Multiple studies have shown that discussing suicide with depressed individuals doesn't increase suicidal ideation. In a major review of published literature on this issue, researchers concluded, “Our findings suggest acknowledging and talking about suicide may in fact reduce rather than increase suicidal ideation, and may lead to improvements in mental health in treatment-seeking populations.”1
The evidence-based C-SSRS has been endorsed or adopted by many professional organizations, including The Joint Commission, the CDC, and the World Health Organization, and is considered the gold standard for suicide risk screening. Many versions of this short, user-friendly tool have been developed for various patient populations and settings, including primary care settings, schools, the military, corrections facilities, and the community. Training and use of the tool are free for healthcare professionals and members of the public alike. Learn more about it at http://cssrs.columbia.edu.
1. Dazzi T, Gribble R, Wessely S, Fear NT. Does asking about suicide and related behaviours induce suicidal ideation? What is the evidence. Psychol Med. 2014;44(16):3361–3363.
Are antibiotics indicated for prophylaxis?
A patient at the clinic where I work plans to travel in Central America next month. He's concerned about developing traveler's diarrhea and asked the provider to prescribe an antibiotic for prophylaxis. When the provider declined to do so, the patient was very upset and claimed that another provider had prescribed prophylactic antibiotics for him in the past. Has something changed?—K.D., PA.
Research on antibiotic-mediated disruption of the microbiome and colonization with resistant organisms has raised concerns about travelers acquiring antibiotic-resistant organisms and possibly spreading resistance globally. As a result, the CDC endorsed new guidelines late last year to prevent the overuse of antibiotics to prevent traveler's diarrhea.1 Under these guidelines, antibiotics shouldn't be prescribed routinely for healthy travelers, although they may be considered for travelers at high risk for complications from traveler's diarrhea, such as those with severe cardiac or renal disease who would be seriously compromised by dehydration.2
Providers can consider prescribing bismuth subsalicylate, unless contraindicated, for any traveler to prevent travelers' diarrhea. If prophylactic antibiotics are indicated, rifaximin is the drug of choice. Fluoroquinolones aren't recommended for prophylaxis of travelers' diarrhea due to the risk of antibiotic resistance and the potential for harm to the central and peripheral nervous system, tendons, muscles, and joints.1,2
Remind patients traveling to high-risk areas that they can protect themselves with common-sense measures such as avoiding food or drink containing untreated water, eating only cooked food served hot, and keeping their hands clean. For more tips from the CDC, refer them to https://wwwnc.cdc.gov/travel/page/travelers-diarrhea.
1. Riddle MS, Connor BA, Beeching NJ, et al Guidelines for the prevention and treatment of travelers' diarrhea: a graded expert panel report. J Travel Med. 2017;24(suppl 1):S57–S74.
LaRoque R, Harris JB. Traveler's diarrhea: microbiology, epidemiology, and prevention. UpToDate. 2018. http://www.uptodate.com.
Weighing the evidence for nonoperative treatment
My otherwise healthy adult patient was admitted to the hospital for treatment of nonperforated appendicitis. The surgeon strongly recommends an appendectomy, but the patient is opposed to surgery and wants to be treated medically with antibiotics only. Is this a viable option?—D.P., CALIF.
Also called simple or uncomplicated appendicitis, nonperforated appendicitis is an acute appendicitis without clinical or radiographic signs of perforation such as an inflammatory mass, phlegmon, or abscess.1 In 2016, the European Association of Endoscopic Surgery released consensus guidelines on the treatment of appendicitis based on an extensive review of the evidence and current practice.2 While acknowledging a body of research supporting nonoperative treatment of nonperforated appendicitis, the expert panel cited concerns about the risk of recurrent appendicitis, missing an underlying malignancy, and progression to complicated appendicitis. In addition, the available evidence doesn't establish whether patients who recover following supportive, nonoperative therapy might also recover without antibiotics.3 The expert panel concluded, “Until higher qualitative evidence has been obtained regarding the potential benefits of initial nonoperative management of acute appendicitis and the potential long-term effects have been investigated appropriately, appendectomy remains the gold standard in acute uncomplicated appendicitis.”2 However, nonoperative treatment could be an alternative to immediate surgery for certain patients with nonemergent, uncomplicated appendicitis, such as those with a history of surgical complications and those who refuse to consent to surgery.1
Smink D, Soybel DI. Management of acute appendicitis in adults. UpToDate. 2018. http://www.uptodate.com.
2. Gorter RR, Eker HH, Gorter-Stam MA, et al Diagnosis and management of acute appendicitis. EAES consensus development conference 2015. Surg Endosc. 2016;30(11):4668–4690.
3. Park HC, Kim MJ, Lee BH. Randomized clinical trial of antibiotic therapy for uncomplicated appendicitis. Br J Surg. 2017;104(13):1785–1790.