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At Jail Medicine we discuss all aspects of medicines practiced in today's jails, prisons and juvenile facilities. One of the greatest concepts I have run across since I finished school is the Number Needed to Treat (abbreviated NNT).
Since it is influenza season and time for us to get our flu shots (I got mine yesterday), I thought it would be a great time to see how beneficial the flu vaccine is.
This entry was posted in Drug Evaluations, Infectious Disease, Influenza, Medical Practice and tagged correctional medicine, evidence based medicine, infectious disease, Influenza, inmates, jails, prisons on October 15, 2014 by Jeffery Keller MD. As you probably know, Sovaldi (sofosbuvir) is an important new treatment for Hepatitis C infection that was released this last December and has been aggressively marketed by its maker, Gilead, ever since. This price has placed prison systems in a no-win situation–and not just prisons, but also Medicaid, insurance companies, and HMOs. This entry was posted in Drug Evaluations, Gastroenterology, Infectious Disease, Medical Economics and tagged correctional medicine, evidence based medicine, hepatitis, Hepatitis C, inmates, jail medicine, jails, Pharmacy, prisons, Sovaldi on March 20, 2014 by Jeffery Keller MD. This entry was posted in Dermatology, Drug Evaluations, Infectious Disease, Medical Economics, Practice Management, Uncategorized and tagged correctional medicine, evidence based medicine, Herpes simplex, jail medicine, pharmacy practice, prisons, Rash on February 28, 2014 by Jeffery Keller MD. In the first article, entitled We Will Soon Be in a Post-Antibiotic Era, CDC researchers predict that the end of the antibiotic era is coming quickly. This entry was posted in Drug Evaluations, Infectious Disease, Medical Practice and tagged Antibiotic resistance, Center for Disease Control and Prevention, correctional medicine, evidence based medicine, inmates, jail medicine, jails, Methicillin-resistant Staphylococcus aureus, prisons, Staphylococcus aureus on October 17, 2013 by Jeffery Keller MD.
Over the weekend, my family and I went to see the “Mummies” exhibition at the local museum. The theory of the Fecal Veneer states that the whole world is covered with a thin layer of, well, shit (Sorry!
People interact with their environment and hence with the Fecal Veneer mainly with their hands. The bottom line here is that hands contaminated by the Fecal Veneer are the source of many common illnesses. I suspect that most of us remember to clean our hands often when we are working around patients. What is the dirtiest surface that people touch all of the time without cleaning their hands afterward (including you, probably)? Hint: this surface is handled by hundreds, maybe thousands, of people and usually is never cleaned. This entry was posted in Infectious Disease, Influenza and tagged cleanliness, correctional medicine, Escherichia coli, evidence based medicine, Fecal Veneer, Hand washing, infectious disease, jail medicine on May 31, 2013 by Jeffery Keller MD.
This entry was posted in Dermatology, Infectious Disease, Medical Practice, Procedures and tagged Abscess, correctional medicine, evidence based medicine, Incision and drainage, inmates, jail medicine, jails, MRSA, prisons on December 9, 2012 by Jeffery Keller MD.
This article was generated by the CDC and is about the increasing incidence of drug resistance of Neiseria gonorrhoeae, as well as the CDC’s newest recommendations for the treatment of gonorrhea. This entry was posted in Infectious Disease, Medical Practice and tagged CDC, Ceftriaxone, correctional medicine, evidence based medicine, gonorrhea, jail medicine, jails, Penicillin, prisons on October 23, 2012 by Jeffery Keller MD.


This entry was posted in Infectious Disease, Inmate issues, Medical Economics, Medical Practice and tagged chlamydia, correctional medicine, evidence based medicine, gonorrhea, inmates, jail medicine, jails, pharmacy practice, prisons, sensitivity, specificity, STDs on September 4, 2012 by Jeffery Keller MD. I am going to answer your questions with my opinions on these topics and invite others to answer also via comments.
Apply mupiricin (Bactroban) 2% ointment to both nostrils (where MRSA tends to hang out in carriers) twice a day for ten days. Rifampin 600 mg po BID for five days in addition to your primary MRSA drug, whether Bactrim or Doxycycline—don’t prescribe rifampin alone. We are talking here about typical young healthy patients.  Patients who have chronic health problems or are immunocompromised must be approached differently. This entry was posted in Dermatology, Infectious Disease and tagged antibiotics, correctional medicine, dental infections, inmates, jail medicine, jails, MRSA, prisons on July 31, 2012 by Jeffery Keller MD.
Antibacterial drugs and the risk of community-associated methicillin-resistant Staphylococcus aureus in children. This is a great study done in England, where a database of medical treatment for the whole country is available for research (unlike in the US).
Not surprisingly, they found that a child who is prescribed an antibiotic does, in fact, have an increased risk of a subsequent MRSA infection. If you receive one antibiotic prescription, your risk of MRSA infection within the next 6 months more than doubles. The CDC has published excellent guidelines on the proper use of antibiotics for sore throats, bronchitis and sinusitis. The more important message is that inappropriate antibiotic prescribing harms your patients. This entry was posted in Drug Evaluations, Infectious Disease, Medical Economics, Medical Practice and tagged correctional medicine, evidence based medicine, inmates, jail medicine, jails, MRSA, pharmacy practice, prisons on July 24, 2012 by Jeffery Keller MD. NNT was never taught back when I went to medical school (we had barely given up The Four Humors!).
The problem is that Gilead is charging an unheard of, jaw-dropping, $1,000.00 per pill for Sovaldi. On one hand, Sovaldi is a good drug that, in fact, represents a significant advance in Hepatitis C treatment. Antibiotic resistance is developing so rapidly now, that it is only a matter of time until antibiotics just don’t work anymore. One display invited participants to feel squares of leather that were said to feel like mummy skin.
I was taught to wash my hands after each and every contact with a patient—up to 40-50 times a day sometimes.
There is a large body of literature that says antibiotics should not be routinely prescribed for MRSA abscesses as long as they can be fully drained and as long as the patient is otherwise healthy and there is no accompanying cellulitis.  This patient is healthy and I see no cellulitis surrounding the abscess, so I am not going to use antibiotics. Make your best guess, maybe based on a picture the nurses send you if you are not right there, and re-evaluate as needed tomorrow or the next day.  You will pick correctly 95% of the time.


If you receive two antibiotic prescriptions within 150 days, your risk of MRSA more than triples.
All drugs help some people, harm some people (with adverse side effects) and make no difference one way or another in some people.
This translates into a MINIMUM of $84,000.00 for Sovaldi alone for the simplest course of Hep C treatment.
As I watched the family of six ahead of me all caress the leather, I wondered how many hundreds of people had fondled this exhibit. In other words, like every other surface, we people are covered with a fecal veneer–but it is thickest on our hands. They deposit these secretions on their hands, which in turn deposit the infectious secretions on something they touch, like a doorknob. By cleaning our hands, we accomplish two ends—we make it less likely that we ourselves will become infected by pathogens in the Fecal Veneer and we also will be less likely to transmit pathogens to others. This much washing can cause skin breakdown in the form of rashes and cracked skin that I used to get especially on my knuckles. If we kill all of the microbes that can be killed by our antibiotics, then of course the only ones left will be those that cannot be killed by antibiotics, in other words, that are resistant. Someone else touches the doorknob, gets the infected goobers on their hands and then transfers the virus into their mouths, say, when they eat. Here is a study that showed that significant hand contamination occurred 13% of the time despite surgical gloves. There is even a fabulous website devoted to this where you can look up the NNT and its corollary, the Number Needed to Harm (NNH) for all sorts of drugs and treatments (found here). In some places, the fecal veneer is thick—like the gas station public restroom I was in recently that must have last been cleaned when it was built.
Since the Fecal Veneer does not just include feces, but any and all human secretions, you can also find viruses, MRSA and all sorts of other nasty things.
Instead, if influenza is transmitted through the air, it occurs like this: an infected person coughs or sneezes and launches a mucous goober through the air.
There has been some great recent research into the beneficial effects of our personal bacterial colonies, such as this report on the  Human Biome Project. This can and does occur (which is why you should cough and sneeze into your elbow), but it is more likely that the mucous bomb will land on some surface, like a desk top. However, even more likely than this aerial bombardment would be that the ill person coughs or sneezes infected mucous onto his hands, which touch something (like a doorknob), which you then touch with your hand, and those dirty hands then transfer the virus to your mouth when you eat.



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