As internists, our comfort zones are more often confined to our own selves and our immediate families, and our own medical practice, be it general internal medicine or any of its subspecialties. The Philippine College of Physicians, hence, challenges its members to go beyond their comfort zones and extend beyond the concerns of self, family, or private practice, and be involved in the concerns of the community, nation and beyond. While there is an increasing burden of chronic illness and complexity of medical care, there is also an astounding development in the field of information and communication technology that has blurred geographic borders, enabling us to coordinate care across various settings and health care providers. While disparities in healthcare access among various groups continue to exist, the Filipino internist is given the chance to reaffirm his own relevance by becoming part of the solution to this inequity.

The PCP also urges its members to practice medicine beyond medicine – to scrutinize the nature and effects of the patient’s illness, to understand the complexity of clinical judgments and the ethical dimensions of physician–patient, physician-physician and physician-industry encounters, and to utilize the multifaceted dimensions of health to further improve patient care.

We therefore envision the PCP 2010 Annual Convention to be a venue wherein we, as Filipino internists, may explore our own territories, examine our own follies and strengths, and rediscover our own relevance. We will be redefining ourselves and our profession – beyond our traditional roles as clinicians, beyond the biomedical definition of health, beyond geographic boundaries, all within the bounds of medical ethics, all for the improvement of our patients’ welfare.  http://www.pcp.org.ph

>>>Complete list here

1. The most effective preventive measure is the avoidance of high-risk exposure (i.e. wading in floods and contaminated water, contact with animal body fluids).
2. If high risk exposure is unavoidable, appropriate protective measures include wearing boots, goggles, overalls, and rubber gloves.
3. Pre-exposure antibiotic prophylaxis is NOT ROUTINELY RECOMMENDED. However, in those individuals who intend to visit highly endemic areas AND get exposed, pre-exposure prophylaxis may be considered.

Pre-exposure prophylaxis regimen for non-pregnant, non-lactating adult: Doxycycline 2 capsules of 100 mg/ capsule once weekly, to begin 1 to 2 days before exposure and continuing through the period of exposure Currently, there is NO recommended pre-exposure prophylaxis that is safe for pregnant and lactating women.

B. Post-Exposure Measures

1. Antibiotic prophylaxis in the prevention of leptospirosis is NOT 100% effective.
2. Factors that may affect prophylactic effectiveness include the quality of the drug, timing of intake of the antibiotic, drug interaction, the presence or absence of skin wounds, and degree and extent of exposure.
3. Antibiotic prophylaxis of leptospirosis may be achieved by administration of doxycycline depending on the risk category of exposure.
1. LOW RISK is defined as those individuals with a single history of wading in flood or contaminated water but with absence of wounds, cuts or open lesions of the skin.

2. Doxycycline (hydrochloride or hyclate) at 2 capsules of 100 mg/capsule single dose within 24 to 72 hours of exposure. MODERATE RISK is defined as those individuals with a single history of wading in flood or contaminated water and the presence of wounds, cuts, or open lesions of the skin, OR accidental ingestion of contaminated water.

3. Doxycycline (hydrochloride or hyclate) at 2 capsules of 100 mg/capsule once a day for 3-5 days to be started immediately within 24 to 72 hours of exposure. HIGH RISK is defined as those individuals with continuous exposure (i.e., those with more than a single exposure; those exposed for several days, e.g., residents in flooded areas, rescuers and relief workers). People who wade in flooded or contaminated water everyday – with or without wounds, cuts or open lesions of the skin; those who swim in flooded water and ingest contaminated water are also considered high risk.

Doxycycline (hydrochloride or hyclate) at 2 capsules of 100 mg/capsule once weekly until the end of exposure
4. The use of such prophylaxis REQUIRES PRIOR CONSULT WITH A PHYSICIAN. It should not be taken unless prescribed and fully explained by a physician, including common side-effects and contraindications.
5. SINCE ANTIBIOTIC PROPHYLAXIS IS NOT 100% EFFECTIVE, INDIVIDUALS SHOULD CONTINUE TO MONITOR THEMSELVES FOR FEVER AND OTHER FLU-LIKE SYMPTOMS.

C. Algorithm on the Risk Category and Prophylactic Regimen

ANNEX
Doxycycline8-10

Contraindications

* Do not use this medication if you are pregnant. It could cause harm to the unborn baby, including permanent discoloration of the teeth later in life.
* Do not take this medication without telling your doctor if you are breast-feeding a baby. Doxycycline passes into breast milk and may affect bone and tooth development in a nursing baby.
* Do not give doxycycline to a child younger than 8 years old. Doxycycline can cause permanent yellowing or graying of the teeth, and it can affect a child’s growth
* Do not use this medication if you are allergic to doxycycline, or to similar medicines such as demeclocycline, minocycline, or tetracycline.

Precautions

* Before taking doxycycline, tell your doctor if you have liver or kidney disease. You may not be able to take doxycycline, or you may need a dose adjustment or special tests during treatment
* Doxycycline can make birth control pills less effective. Use a second method of birth control while you are taking doxycycline to keep from getting pregnant.
* Avoid exposure to sunlight or artificial UV rays (sunlamps or tanning beds). Doxycycline can make your skin more sensitive to sunlight and sunburn may result. Use a sunscreen (minimum SPF 15) and wear protective clothing if you must be out in the sun.
* Do not take iron supplements, multivitamins, calcium supplements, antacids, or laxatives within 2 hours before or after taking doxycycline
* Store this medication at room temperature away from moisture and heat
* Throw away any unused doxycycline when it expires or when it is no longer needed. Do not take any doxycycline after the expiration date printed on the bottle. Expired doxycycline can cause a dangerous syndrome resulting in damage to the kidneys.

Drug Interactions

* Drug interactions: antacids; minerals such as iron, zinc, calcium, magnesium, and over-the-counter vitamin and mineral supplements cholesterol-lowering medications such as cholestyramine or colestipol; isotretinoin; tretinoin; product that contains bismuth subsalicylate; warfarin; penicillin antibiotic such as amoxicillin, penicillin, dicloxacillin, oxacillin (Bactocill), and others.

Adverse Reactions

* Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat.
* Antibiotic medicines can cause diarrhea, which may be a sign of a new infection. If you have diarrhea that is watery or has blood in it, call your doctor. Do not use any medicine to stop the diarrhea unless your doctor has told you to.

Other alarming side effects:

* severe headache, dizziness, blurred vision; fever, chills, body aches, flu symptoms; severe blistering, peeling, and red skin rash; urinating less than usual or not at all; pale or yellowed skin, dark colored urine, fever, confusion or weakness; severe pain in your upper stomach spreading to your back, nausea and vomiting, fast heart rate; loss of appetite, jaundice (yellowing of the skin or eyes); or easy bruising or bleeding, unusual weakness.

Less serious side effects may include:

* swollen tongue, trouble swallowing; mild nausea, vomiting, diarrhea, or stomach upset; white patches or sores inside your mouth or on your lips; sores or swelling in your rectal or genital area; or vaginal itching or discharge.

How to Reduce Doxycycline Side Effects

* Ensure that your physician is aware of all medications and over-the-counter vitamin supplements or herbal remedies that you are taking. Antacids and certain vitamins and minerals are known to interfere with doxycycline absorption.
* Take doxycycline with food or following a meal. If you have taken doxycycline on an empty stomach before and gotten away with it, the next time may be different. Doxycycline induced nausea is quite unpleasant and more serious stomach irritation can occur.
* Don’t lie down for an hour following doxycycline intake to prevent one of the most formidable doxycycline side effects, esophageal damage. If reclined, the medication may dissolve in the esophagus instead of the stomach. If this doxycycline side effect occurs, a patient may gag on something as innocuous as sips of water. Treatment may take days for this condition to abate, depending on the extent of the irritation or damage.
* Avoid, if possible, taking doxycycline along with other medications that are known to bother the stomach. Space out the medications accordingly and add more food intake if needed. Pain medications and NSAIDs (e.g., ibuprofen) combined with doxycycline may cause significant stomach distress.
* Talk to your physician about the benefits of acid reducers, rather than antacids, as these may be helpful in reducing or eliminating some doxycycline side effects.
* Discuss any recommended treatments for yeast infection should these occur. Some patients find lactobacillus helpful in preventing yeast infections. This healthy bacteria is found in some foods, including yogurt and cheese. It is also available as a supplement in capsule form.
* Take doxycycline 100 mg capsule BID if 200 mg OD is not tolerated.

References

1. San Lazaro Hospital Guideline on Prophylaxis for Leptospirosis 2009
2. DOH- Health Emergency Management Staff Manual on Treatment Protocols of Common Communicable Diseases and other Ailments During Emergencies and Disasters
3. Mandell’s Principles and Practice of Infectious Diseases 2005 6th ed chapter 237:2789-2795
4. Mandell’s Principles and Practice of Infectious Diseases 2009 7th ed
5. New England Journal of Medicine Feb 23, 1984 Volume 310 (8):497-500
6. Int J Antimicrob Agents 2000 Feb; 13 (4): 249-55. Randomized controlled trial of doxycycline prophylaxis against leptospirosis in an endemic area
7. Revista do Instituto de Medicina Tropical de Sao Paulo 1998; 40: 59-61. Use of doxycycline for leptospirosis after high-risk exposure in Sao Paulo, Brazil
8. http://health.yahoo.com/infectiousdisease
medications/doxycycline/healthwised00037a1.html#d00037a1-drugs
9. http://www.drugs.com/pro/doxycycline.html.
10. http://www.ehow.com/how_2165217_avoid-doxycycline-side-effects.html?ref=fuel&utm_source=yahoo&utm_medium=ssp&utm_campaign=yssp_art

Task Force Committee
Marissa M. Alejandria, MD
Rhona G. Bergantin, MD
Manolito L. Chua, MD
Raul P. Destura, MD
Raquel Victoria M. Ecarma, MD
Ma. Cecilia S. Montalban, MD
Mario M. Panaligan, MD
Minette O. Rosario, MD
Paul Salandanan, MD
Rontgene M. Solante, MD
Maria Fe R. Tayzon, MD
Dionisio M. Tiu, MD
Catherine Yu, MD

The North Luzon chapter under the leadership of Dr. Manny Bautista had met
with his team to have an accurate assessment of the impact of the recent
disaster on the prospect of holding the PCP mid-year convention in Baguio
as scheduled. They have wisely deemed it prudent and appropriate to cancel
the mid-year convention that they had earnestly prepared for. At this
time, focus has to be put on the on-going relief operations.
The Board of Regents  agrees with their assessment of the situation and
has approved the recommendation to cancel the 2009 mid-year convention in
Baguio. The recommendation to cancel the convention is thus carried out.

Meanwhile, the people of north Luzon need help. We will be figuring out in
the next few days the best way to help. We are one with the people of
North Luzon – especially our colleagues there – and we intend to help
where help can make a difference. Their preparations in Baguio to welcome
us next week during the scheduled convention need not go to waste. The
comfort and relaxation that we would have enjoyed, we definitely wouldn’t
mind giving up in exchange for the comfort and relief of our unfortunate
brothers and sisters who have lost a lot more in the last few days.

The recent disasters have taught us important lessons; we have become more
sensitive to the misfortune of others. We should also learn one important
thing: WE ARE LEADERS. WHAT WE HAVE HAD IN THE LAST FEW DAYS ARE
OPPORTUNITIES TO LEAD.

Kudos to all!

Eugene Ramos