Why do doctors/hospitals in Thailand not run wbc count or strep tests b4 prescribing antibiotics?

[farang000999]

It seems like these are rather inexpensive tests to quantify if the patient has a viral or bacterial infection.

[lopburi3]

Because antibiotics are often being prescribed as prophylactics rather than treatment would be the logical reason - not that it is always the case - most patients probably are more happy to leave with a pill than a get well soon wish.

[dragonfly94]

I have had antibiotics offered here for everything from bronchitis and stomach pain, to a skin rash, I normally decline if I have doubts. How some here got to be Dr's and pharmacists I'll never understand, many are ignorant.

Edited March 22, 2015 by dragonfly94

[AyG]

wbc count won't tell you if an infection is viral or bacterial. A strep test will only pick up streptococcus. A negative test doesn't mean the infection is necessarily viral.

The doctor is basically covering all bases:

- If the condition is viral, there's probably nothing you can do about it, but antibiotics won't do any harm if taken correctly.

- If the condition is bacterial, then antibiotics will probably help.

[robblok]

wbc count won't tell you if an infection is viral or bacterial. A strep test will only pick up streptococcus. A negative test doesn't mean the infection is necessarily viral.

The doctor is basically covering all bases:

- If the condition is viral, there's probably nothing you can do about it, but antibiotics won't do any harm if taken correctly.

- If the condition is bacterial, then antibiotics will probably help.

I am not so sure antibiotics dont do harm.. they are quite a powerful medicine and kill the healthy bacteria too.

[manarak]

I think that the OP actually wanted to reference the CRP test (C-reactive protein).

CRP will react to all bacteria and not to viruses, with the exception of adenoviruses.

The test takes less than 5 minutes and can also be done with a machine (I don't remember the pricing).

[AyG]

I think that the OP actually wanted to reference the CRP test (C-reactive protein).

CRP will react to all bacteria and not to viruses, with the exception of adenoviruses.

Are you sure about that? I understood that it was a general test for detecting inflammation within the body - inflammation which can be from a multitude of causes, including viral infection.

[AyG]

Just one other point: viral infections can lower the body's resistance to bacterial infections, so some doctors might consider it a good idea to help the body fight any potential opportunistic infection by prescribing antibiotics.

[Sheryl]

Actually, a WBC differential (if the WBC is elevated) will indeed help distinguish between a viral and bacterial infection.

There are several factors that go into the overuse (and indeed, there is overuse) of antibiotics by thai doctors:

1 - Thai doctors seem partial to use of antibiotics prophylactically and will knowingly give them for viral infections to prevent bacterial super-infection. While that can occur, prevailing medical thought is that the risks of overuse of antibiotics outweighs this and that antibiotics should not usually be so used, but this has not made its way into Thai practice.

2 - Patients are assumed to expect/want antibiotics and multiple medications in general, so it is also done not to "disappoint" the patient. (This also explains why every visit seems to result in no less than 3 drugs, at least some of them unnecessary). This assumption is in fact true as regards Thai patients, who tend to equate the amount and potency of medication given to the quality of care.

3 - Thai doctors tend to assume patients have no understanding of their condition and cannot be relied upon to keep follow up appointments. While how to explain things to patients in layman's terms is a big part of medical education i nthe West (and an even bigger part of nursing education), this does nto seem to be the case in Thailand and many Thai doctors have no idea how to explain something in non-technical terms. This is a big factor in a lot of Thai medical behavior, including for example recommending hysterectomies to women with cervical dysplasia when a "wait and see" approach would be preferred (they assume she will not come back for follow up, so safer to operate). Of course this belief is a self-fulfilling prophecy in not explaining the rationale for treatment or nature of the problem (since patients are assumed to be incapable of understanding), does indeed make it likely patients will fail to follow advice given. People do not, in fact, do things that don't make sense to them, even though "doctor says so".

4 - Cultures take a few days to get the results. See #3 above - the patient may not return for the result and treatment. And #1 above - patients will be unhappy to be just tested and told to come back, they'll want immediate treatment. In addition, the delay in starting treatment can sometimes have adverse consequences. Even in the West, doctors will often start treatment without a culture and then use the C&S results to determine whether to continue it, especially if the patient is acutely uncomfortable and/or clinical signs strongly suggest a bacterial infection. With some very common problems that are almost always bacterial and usually due to just a few bacteria (e.g. UTIs in women) it is accepted even in the West to treat empirically first and do a C&S only if the patient fails to improve.

5 - Doctors working out of private offices/small clinics often lack lab facilities. Where this is true, there is a marked tendency not to order tests even when clearly necessary. It seems to be considered a "loss of face" to send the patient elsewhere, and they'll try to fit the treatment to the facilities available to them. (This is also true of Vetinarians....my local Vet for years was spaying and neutering with no lab work. Now that he has a lab, he checks the RBCs and platlets first as is correct practice).

All that said, you should always take the initiative in (1) clearly telling the doctor you do not want any medications that are not absolutely necessary (this will be a complete surprise to doctors unused to farang patients); (2) asking about getting a CBC and (if applicable) culture done -- in fact, insisiting on a culture in certain cases such as a suspected wound infection; and (3) in general asking for an explanation of the treatment being given. If the doctor does not react well to all this -- change doctors.

These problems are much rarer in doctors who trained in the West.

[manarak]

I think that the OP actually wanted to reference the CRP test (C-reactive protein).

CRP will react to all bacteria and not to viruses, with the exception of adenoviruses.

Are you sure about that? I understood that it was a general test for detecting inflammation within the body - inflammation which can be from a multitude of causes, including viral infection.

Viral infections causer lower CRP levels than bacteria.

My comment about "reaction" was related to the defined positive threshold, at over 40mg/l, if associated with possible symptoms of a bacterial infection, there's an approximately 90% chance for a bacterial infection to be present.

http://www.ncbi.nlm.nih.gov/pubmed/8511515

http://labtestsonline.org/understanding/analytes/crp/tab/test/

[PMNL]

CBC is the initial step of checking bacterial or viral infection. Strep rapid test is not widely available, so not being offered mostly because of that reason. Culture for bacteria takes normally 2-3 days to long to wait so most Drs overlook on the option as it does not give any information to the treatment option on the visit.

CRP is not used as indicator to deferential between bacterial or viral. It is used as a follow up marker for inflammation.

Sheryl answered all the questions very clearly.

Edited March 22, 2015 by PMNL

[manarak]

CRP is not used as indicator to deferential between bacterial or viral. It is used as a follow up marker for inflammation.

Quite pretentious of you to issue a blanket statement about how CRP tests are used.

There is enough litterature out there that point out other possible uses.

Some doctors do use it because the test is cheap and quick, the test can be done on-premise, it yields good results and allows for earlier antibiotics prescription with 90% accuracy.

[PMNL]

CRP is not used as indicator to deferential between bacterial or viral. It is used as a follow up marker for inflammation.

Quite pretentious of you to issue a blanket statement about how CRP tests are used.

There is enough litterature out there that point out other possible uses.

Some doctors do use it because the test is cheap and quick, the test can be done on-premise, it yields good results and allows for earlier antibiotics prescription with 90% accuracy.

I guess Google answer it all. I haven't seen any dr use the CRP by itself as a screening test for bacterial infection both Thais and westerners. CBC and CRP sometimes are requested especially in orthopedic infectious type of infection.

They use CRP and ESR to follow up infection.

Well this is not just a personal observation thus believe as you wish sir.

[NickJ]

Better safe than sorry....not just thai docs. How many people have been prescribed anti biotics in your own country? How many have you had a c reactive test? .......In clinical practice sickness will hit in waves and thats what is looked at. And again better safe than sorry.......also viral infections and bacterial infections are often present at the same time. ......

[arjunadawn]

wbc count won't tell you if an infection is viral or bacterial. A strep test will only pick up streptococcus. A negative test doesn't mean the infection is necessarily viral.

The doctor is basically covering all bases:

- If the condition is viral, there's probably nothing you can do about it, but antibiotics won't do any harm if taken correctly.

- If the condition is bacterial, then antibiotics will probably help.

A CBC complete blood count with differential will tell you if an infection is viral or bacterial. Its the outside normal ranges of for neutrophils or lymphocytes. It will certainly steer you correctly but no doc should treat the lab test alone, they should clinically treat the patient. The cost is more and for many practicing clinic medicine for many years they are usually proven correct. The fact is, viral and bacterial look alike, at certain times. But there are differences. Many docs argue that even if they are wrong no harm can be done because it could later prevent secondary opportunistic infections from bacterial. This is true, but poor medicine. Moreover, widespread overuse of AB reduced the efficacy of the AB in the future- yes, they learn to become resistant.A patient can become resistant, develop super-infection, have diarrhea, candidiasis of the vagina, and other problems if treated improperly.

As Staph and strep are very common; ruling these out can suggest other differential diagnoses to consider, but there are other common bacterial pneumonia which will not respond to the drugs use for staph and strep. In military medicine they use "shotgun" therapy- kill everything, early, and get the person back up and functioning. This template has serious reconstructions to a much larger audience of millions. Lastly, if viral, increasingly there are zinc and interferon aids that can shorten the span or virulence of the virus, so a good doctor does matter.

[manarak]

CRP is not used as indicator to deferential between bacterial or viral. It is used as a follow up marker for inflammation.

Quite pretentious of you to issue a blanket statement about how CRP tests are used.

There is enough litterature out there that point out other possible uses.

Some doctors do use it because the test is cheap and quick, the test can be done on-premise, it yields good results and allows for earlier antibiotics prescription with 90% accuracy.

I guess Google answer it all. I haven't seen any dr use the CRP by itself as a screening test for bacterial infection both Thais and westerners. CBC and CRP sometimes are requested especially in orthopedic infectious type of infection.

They use CRP and ESR to follow up infection.

Well this is not just a personal observation thus believe as you wish sir.

I believe in proven science.

Maybe this is an age-related issue, most papers on CRP as an indicator for bacterial infections have been published after 2000.

[scoutman360]

I will go against the grain here and disagree with the overall premise and consensus on this thread. I have had the same treatment from U.S. doctors, who have given me antibiotics for every office visit without even a single test. Thailand, no different. There was a recent documentary about the over-use of antibiotics, and a U.S. doctor interviewed said that the medical profession has been trained and instructed that patients are "customers". And the customer satisfaction is more important. Customers are not satisfied if a doctor sends them home with nothing.

[PMNL]

Meant to say they use CRP and ESR to follow up inflammation not infection in my previous post, could not edit.

In RA / Psoriasis arthritic/ other autoimmune arthritis CRP is being used for follow to see how the inflammation is being responded by the prescribed meds.

A knowledge of more than 5 years medical is considered very old. Not to say correct or not!

Last year the recommendation for blood thinner ( anti platelets) in heart patients with PCI (stent) was 6 months, the year before was 12 months and this year there are studies, suggesting the longer the better so my point is if one try to offer any medical advise / suggestion to others please be sensible and be reliable. If not so, better not to mis inform others.

I don't intend to attack anyone in particular just read a lot of poor advises from dr Google on here and I am feeling sorry for those who genuinely seek sound advise.

[farang000999]

i can't find anything online that suggests that doctors are using CRP tests to distinguish between viral and bacterial infections.

In my experience in the USA, at this point it seems standard to get a WBC differential done at the beginning of a doctor visit when you are sick with an upper respiritory infection.

[farang000999]

so to increase the good bacteria in your gut that may have been killed by antibiotics you are supposed to eat fermented foods. Does cooking these fermented foods eliminate the bacteria? Like, Kimchi soup (cooked) or miso soup (cooked) or saurkraut (cooked)?

[l4ml4m]

On 3/22/2015 at 2:20 PM, Sheryl said:

Actually, a WBC differential (if the WBC is elevated) will indeed help distinguish between a viral and bacterial infection.

There are several factors that go into the overuse (and indeed, there is overuse) of antibiotics by thai doctors:

1 - Thai doctors seem partial to use of antibiotics prophylactically and will knowingly give them for viral infections to prevent bacterial super-infection. While that can occur, prevailing medical thought is that the risks of overuse of antibiotics outweighs this and that antibiotics should not usually be so used, but this has not made its way into Thai practice.

2 - Patients are assumed to expect/want antibiotics and multiple medications in general, so it is also done not to "disappoint" the patient. (This also explains why every visit seems to result in no less than 3 drugs, at least some of them unnecessary). This assumption is in fact true as regards Thai patients, who tend to equate the amount and potency of medication given to the quality of care.

3 - Thai doctors tend to assume patients have no understanding of their condition and cannot be relied upon to keep follow up appointments. While how to explain things to patients in layman's terms is a big part of medical education i nthe West (and an even bigger part of nursing education), this does nto seem to be the case in Thailand and many Thai doctors have no idea how to explain something in non-technical terms. This is a big factor in a lot of Thai medical behavior, including for example recommending hysterectomies to women with cervical dysplasia when a "wait and see" approach would be preferred (they assume she will not come back for follow up, so safer to operate). Of course this belief is a self-fulfilling prophecy in not explaining the rationale for treatment or nature of the problem (since patients are assumed to be incapable of understanding), does indeed make it likely patients will fail to follow advice given. People do not, in fact, do things that don't make sense to them, even though "doctor says so".

4 - Cultures take a few days to get the results. See #3 above - the patient may not return for the result and treatment. And #1 above - patients will be unhappy to be just tested and told to come back, they'll want immediate treatment. In addition, the delay in starting treatment can sometimes have adverse consequences. Even in the West, doctors will often start treatment without a culture and then use the C&S results to determine whether to continue it, especially if the patient is acutely uncomfortable and/or clinical signs strongly suggest a bacterial infection. With some very common problems that are almost always bacterial and usually due to just a few bacteria (e.g. UTIs in women) it is accepted even in the West to treat empirically first and do a C&S only if the patient fails to improve.

5 - Doctors working out of private offices/small clinics often lack lab facilities. Where this is true, there is a marked tendency not to order tests even when clearly necessary. It seems to be considered a "loss of face" to send the patient elsewhere, and they'll try to fit the treatment to the facilities available to them. (This is also true of Vetinarians....my local Vet for years was spaying and neutering with no lab work. Now that he has a lab, he checks the RBCs and platlets first as is correct practice).

All that said, you should always take the initiative in (1) clearly telling the doctor you do not want any medications that are not absolutely necessary (this will be a complete surprise to doctors unused to farang patients); (2) asking about getting a CBC and (if applicable) culture done -- in fact, insisiting on a culture in certain cases such as a suspected wound infection; and (3) in general asking for an explanation of the treatment being given. If the doctor does not react well to all this -- change doctors.

These problems are much rarer in doctors who trained in the West.

 

 

Really clear explanation ! Thank you !

 

For example in case of tonsillitis, it seems that they always give antibiotics without trying to know if it's viral. Is it the case at any hospital, even private ?

 

Thank you.

 

 

[Sheryl]

22 minutes ago, l4ml4m said:

 

 

Really clear explanation ! Thank you !

 

For example in case of tonsillitis, it seems that they always give antibiotics without trying to know if it's viral. Is it the case at any hospital, even private ?

 

Thank you.

 

 

Especially private.

 

But you as patient (or parent of patient) can insist on a throat swab for culture.

 

A CBC will also help determine if a bacterial rather than viral infection is present (though it will not identify which bacteria).

 

Because tonsillitis is often due to streptococcal bacteria and this, if untreated, can cause serious heart and kidney complications, even when a throat swab is taken they may start antibiotics pending the results.

[BritManToo]

On 3/22/2015 at 7:41 AM, farang000999 said:

It seems like these are rather inexpensive tests to quantify if the patient has a viral or bacterial infection.

Cost of antibiotics 20bht, cost of doctor consultation 60bht.

So more cost effective to give antibiotics, and avoid the extra cost of the test and a second doctors consultation.

 

Most people just buy the antibiotics from a pharmacy or supermarket, you don't really need the doctor in the way.