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Letters to the Editor

Doxycycline and Community-Acquired Pneumonia

TO THE EDITOR: King and Pippin¹ hesitate to make doxycycline (Vibramycin) their first choice for outpatient treatment of community-acquired pneumonia in spite of their praise for its low cost and easy dosing schedule. Their only stated reason for reservation is that Streptococcus pneumoniae "resistance to this agent is increasing."

The authors' two references on this point offer no evidence for their assertion. One is a primary research paper which does not mention doxycycline.² The other is a review article by Mandell³ which contains a statement similar to the one made by Drs. King and Pippin. The reference given for this claim in the Mandell article is a 1973 paper by Gopalakrishna and Lerner.⁴ These authors serially tested for tetracycline resistance in one hospital over the course of 31 months; they did not report similar testing for doxycycline. The data presented do not allow the reader to determine the prevalence of doxycycline resistance at any point in time, let alone ascertain that the rate of resistance had increased during the study.

Perhaps Drs. King and Pippin have made the common error of assuming that tetracycline resistance, which is indeed common for S. pneumoniae, implies doxycycline resistance as well. This is not true.⁵

Doxycycline is consistently active against all common typical and atypical bacterial causes of pneumonia, is inexpensive, offers twice-daily dosing, has a favorable side-effect profile, and achieves unusually high penetration into lung tissue and especially into alveolar macrophages.^5,6 Doxycycline is, in short, a nearly ideal antibiotic for initial outpatient treatment of community-acquired pneumonia in adults.

ROBERT J. WOOLLEY, M.D.
University of Minnesota
Boynton Health Service
410 Church St. S.E.
Minneapolis, MN 55455

REFERENCES

1. King DE, Pippin HJ Jr. Community-acquired pneumonia in adults: initial antibiotic therapy. Am Fam Physician 1997;56:544-50.
2. Jorgensen JH, Doern GV, Maher LA, Howell AW, Redding JS. Antimicrobial resistance among respiratory isolates of Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus pneumoniae in the United States. Antimicrob Agents Chemother 1990;34:2075-80.
3. Mandell LA. Antibiotics for pneumonia therapy. Med Clin North Am 1994;78:997-1014.
4. Gopalakrishna KV, Lerner PI. Tetracycline-resistant pneumococci: increasing incidence and cross resistance to newer tetracyclines. Am Rev Respir Dis 1973;108:1007-10.
5. Shea KW, Cunha BA, Ueno Y, Abumustafa F, Qadri SM. Doxycycline activity against Streptococcus pneumoniae [Letter]. Chest 1995;108:1775-6.
6. Cunha BA. Community-acquired pneumonia. Cost-effective antimicrobial therapy [Published erratum appears in Postgrad Med 1996;99(5):51]. Postgrad Med 1996;99(1):109-22.

IN REPLY: We wish to apologize to the readers of American Family Physician for incorrectly referencing our comments concerning doxycycline resistance. We intended to reference items 13 and 19 rather than items 13 and 16.

Dr. Woolley wonders why we hesitate to make doxycycline our first choice for outpatient treatment of community-acquired pneumonia. The article we intended to cite¹ indicates that doxycycline resistance is a class effect, since both doxycycline and tetracycline resistance are plasmid-mediated. The article referenced by Dr. Woolley² is a letter to the editor pointing out in vitro data which demonstrate 21 percent intermediate and full resistance to tetracycline (for S. pneumoniae) and 16 percent intermediate and full resistance to doxycycline. In vivo clinical experience with doxycycline in pneumonia is very limited. In contrast, the American Thoracic Society guidelines show erythromycin (Ery-Tab) to be a very cost-effective choice.³ In addition, erythromycin has more reliable activity against Legionella pneumophila than doxycycline. Further clinical in vivo research with doxycycline may uphold Dr. Woolley's position; until then, we feel that erythromycin is still the first choice for initial antibiotic therapy of uncomplicated community-acquired pneumonia.

DANA E. KING, M.D.
H. JOEL PIPPIN, PHARM. D.
Family Practice Center
East Carolina University School of Medicine
600 Moye Blvd.
Greenville, NC 27858-4354

REFERENCES

1. Smilack JD, Wilson WR, Cockerill FR III. Tetracyclines, chloramphenicol, erythromycin, clindamycin, and metronidazole. Mayo Clin Proc 1991; 66:1270-80.
2. Shea KW, Cunha BA, Ueno Y, Abumustafa F, Qadri SM. Doxycycline activity against Streptococcus pneumoniae [Letter]. Chest 1995;108:1775-6.
3. Gleason PP, Kapoor WN, Stone RA, Lave JR, Obrosky DS, Schulz R, et al. Medical outcomes and antimicrobial costs with the use of the American Thoracic Society guidelines for outpatients with community-acquired pneumonia. JAMA 1997;278:32-9.

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Physician-Assisted Suicide
and 'Moral Neutrality'

TO THE EDITOR: I wish to discuss the editorial by Drs. Brody and Vandekieft,¹ which pleads that physicians approach a patient's request for assisted suicide from a morally neutral stance in order to discuss it thoroughly, and reach an agreement that strengthens the physician-patient relationship. To support this opinion, the authors cite "Quill's paradox," which says that most patients given a means for suicide will not use it, but instead will find the option of personal deliverance merely a comforting idea. I wish to question several of the authors' assumptions.

First, some have pointed out that rational suicide is a cultural phenomenon, most popular in the well-educated affluent Caucasian community.^2,3 For the most part, however, requests for suicide and suicide attempts are not unencumbered and rational, but are due to psychiatric depression.⁴

Second, Quill is quite well-known as a major promoter of assisted suicide;⁵ his "law" is most undoubtedly based on anecdotal experience. However, Hendin, a psychiatrist and the executive director of the American Suicide Foundation, warns that "a doctor who suggests euthanasia as an option to a patient ... or relatives who respond too readily to a patient's mention of euthanasia send a powerful message that they believe that the patient should not continue to live. In such cases, we are not dealing with autonomy or the patient's right to die, but with ... their right to influence the ending of a life that has become a burden, or that they think is not worth living ... "⁶

Indeed, a poll of dying patients confirms that assisted suicide is rarely wished for, except in those patients where clinical depression is present.⁷ As for strengthening the physician-patient relationship, it should be noted that in the same poll, a small but significant percentage of patients said they would actually change physicians if they knew their physician were in favor of euthanasia.⁷

Third, the authors' insistence that physicians who hold a moral position condemn a patient's actions is ridiculous. Most physicians encourage their patients to discuss their fears, hopes and darkest impulses. It is our duty to listen, to understand and to advise our patients of their options, including that option which we feel is best.

I suspect that what the authors are actually proposing is something a bit different: that assisted suicide should be considered a purely private issue, in the same way that Roe vs. Wade has made abortion an absolutely private matter in which physicians, family members, religious leaders and legislatures have no right to interfere with a woman's private choice. This would, of course, effectively silence any public debate over or opposition to euthanasia. However, the editorial takes this further than Roe vs. Wade, which does not assume physician neutrality, but views the physician involved as a moral agent who brings his medical and psychiatric knowledge to a woman's decision.

As physicians, we cannot and should not ignore the societal aspects of euthanasia, especially since the law would position us as enforcers of such a public policy. When medical societies have been morally neutral on this subject, the public interprets this silence as support for such a policy. Approval of any suicide is a dangerous public policy, for it encourages more suicides among the depressed, and in the case of physician-assisted suicide, leads to the idea that some lives are not worth living and are better off dead.

An example of how easily a discussion concerning assisted suicide for the competent can turn into approval of unwanted active euthanasia for the handicapped can be seen in the editorial; although it is intended as discussion of requested rational suicide, it begins with an anecdote in which active euthanasia is requested not by a patient but by a relative of a disabled person because the caretaker feels the patient is a burden. If good and honorable men such as the authors have accidentally become confused at the difference between such requests and a patient's presumably rational desire for suicide, how much will this confusion spread in a community where not all are such good and honorable men?

NANCY K. O'CONNOR. M.D.
P.O. Box 308
Red Lake, MN 56671-0308

REFERENCES

1. Brody H, Vandekieft GK. Physician-assisted suicide: a very personal issue [Editorial]. Am Fam Physician 1997;55:2421-7.
2. New York State Task Force on Life and the Law. When death is sought: assisted suicide and euthanasia in the medical context. New York: New York State Task Force on Life and the Law, 1994:122-5.
3. Gianelli DM. Hemlock leaders reveal strategy in campaign for suicide aid. Am Med News 1996; 39:3.
4. Conwell Y, Caine ED. Rational suicide and the right to die. Reality and myth. N Engl J Med 1991;325: 1100-3.
5. Quill TE. Death and dignity. A case of individualized decision making. N Engl J Med 1991;324: 691-4.
6. Hendin H. Seduced by death: doctors, patients, and the Dutch cure. New York: W.W. Norton, 1997:157.
7. Emanuel EJ, Fairclough DL, Daniels ER, Clarridge BR. Euthanasia and physician-assisted suicide: attitudes and experiences of oncology patients, oncologists, and the public. Lancet 1996;347:1805-10.

IN REPLY: Dr. O'Connor has offered a number of thoughtful comments on physician-assisted suicide. Rather than reply point by point, we would rather view her letter as helpful warning of ways in which our original editorial is open to misunderstanding. These misunderstandings highlight the need for open, deliberative dialogue on this complex and controversial topic.

Our central point was that assisted suicide is a "hot button" topic for many if not most family physicians, and the immediate emotional reaction to a patient's raising this issue might work against the optimal therapeutic process. Fortunately, we argued, the supportive and compassionate approach to the patient will differ little, regardless of whether the physician is morally in support of or opposed to physician-assisted suicide. The first task in either case is to determine what has caused the patient to seek such a "solution" and then to explore alternative ways of dealing with the suffering.

We assumed in framing our recommendations that the physician would have a strong moral stance on the subject of suicide assistance, and so we had no intention of calling for "moral neutrality." Moral neutrality and a compassionate, inquiring, nonjudgmental attitude toward the patient are two very different things. In calling assisted suicide a "very personal" issue, we meant to address its emotional impact on the physician, rather than to suggest that it should be seen as a purely private transaction for purposes of public policy.

We applaud Dr. O'Connor for her own compassion and capability, which allow her "to listen, to understand and to advise" even if the patient requests an option she finds morally repugnant. As she admits in another context, not all physicians are equally capable and farsighted, else we would have had no reason to write the editorial. But we are aware of anecdotal reports in which reactions from physicians and health care providers were much less compassionate. We have, for instance, heard of hospice programs which will work to disenroll a patient once the patient has shown an interest in requesting physician-assisted suicide. Family physicians will, we hope, aspire to do better.

Finally, Dr. O'Connor notes that one of the case vignettes we used to begin the editorial involved an ambiguous request for assistance, where the intended "victim" of the "suicide" might have been a relative rather than the one making the request. We did not, and assumed that the reader would not, confuse such a statement with a request from a supposedly competent patient himself. Instead we included that vignette to illustrate the various ways that the issue of physician-assisted suicide might insert itself into the daily work of the family physician, pressing every "hot button" in the process.

HOWARD BRODY, M.D., PH. D.
GREGG K. VANDEKIEFT, M.D.
Department of Family Practice
Michigan State University College of Human Medicine
B-100 Clinical Center
East Lansing, MI 48824-1315

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Guidelines for Opportunistic Infections in HIV

TO THE EDITOR: In our July 1997 article¹ on opportunistic infections and psychosocial stress in persons with human immunodeficiency virus (HIV), Dr. Gebhardt and I described the current U.S. Public Health Service and the Infectious Disease Society of America (USPHC/IDSA) guidelines. Our article also mentioned that the new guidelines were soon to be forthcoming. The updated guidelines were recently published.² The following are the most significant changes:

(1) Prophylaxis for Mycobacterium avium complex (MAC) has moved from a B rating to an A ("standard of care") rating. This means that, like prophylaxis for Pneumocystis carinii pneumonia, toxoplasmosis and Mycobacterium tuberculosis, MAC prophylaxis should always be offered when clinical and staging criteria are met.

(2) Vaccination against Streptococcus pneumoniae in adults with a CD4⁺ count greater than 200 per mm³ (200 3 10⁶ per L) has moved from a B rating to an A ("standard of care") rating. Thus, all adults in this category should receive pneumococcal vaccine polyvalent (Pneumovax).

The USPHC/IDSA guidelines also now emphasize (as we did in our article) the need to base initiating or continuing prophylaxis on the lowest (not necessarily the current) CD4⁺ cell count.

SUSAN LOUISA MONTAUK, M.D.
Department of Family Medicine
University of Cincinnati
P.O. Box 670582
Cincinnati, OH 45267

REFERENCES

1. Montauk SL, Gebhardt B. Opportunistic infections and psychosocial stress in HIV. Am Fam Physician 1997;56:87-96.
2. USPHC/IDSA Prevention of Opportunistic Infections Working Group. 1997 USPHC/IDSA guidelines for the prevention of opportunistic infections in persons infected with human immunodeficiency virus. MMWR Morb Mortal Wkly Rep 1997;46(No. RR-12):1-46. *

The editors of AFP welcome input concerning topics of current medical interest and feedback in response to articles and other material published in AFP. Send letters to Jay Siwek, M.D., Editor, American Family Physician, 8880 Ward Pkwy., Kansas City, MO 64114; fax: 816-333-0303; e-mail: afplet@aafp.org. Please include your complete address, telephone number and fax number. Letters should be double-spaced, fewer than 500 words and limited to one table or figure and six references. Letters submitted for publication in AFP must not be submitted to any other publication. Letters pertaining to AFP subject matter must be received within two months of publication. Any financial associations or other possible conflicts of interest must be disclosed at time of submission. Submission of a letter constitutes transfer of copyright to the American Academy of Family Physicians. The editors reserve the right to edit correspondence to meet style and space requirements.

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