Thursday 26th March 1992   Portmere Hospital 16:57

“Good afternoon, Dr Delany.”
“Good afternoon, Dr Dennis. It’s nice to see you. Why are you wearing your school uniform? It’s far too small!”
“It’s not mine. It’s Dennis’. I got up late this morning and I was trying to get dressed in a hurry in the dark. I think Daphne must have laid our clothes out on the wrong chairs last night.”
“Have you been in work like that all day?”
“Yes . . . by the time I realised, morning surgery had already started. I have had no time to go home and get changed.”
“Has Dennis been to school in your clothes?”
“No, he refused to go.”

“Anyway, I’ve come about these results.”
“You’ve come in about the results?” Dr Delaney looked surprised. “Couldn’t you have ‘phoned?”
“I did ring. I rang at half past eight but you hadn’t arrived at work. At ten o’clock, you were busy in the lab. I just missed you at quarter to twelve and then, at one o’clock, you were on your lunch break. At half past two you were in the weekly pathology meeting. At twenty to four, you had popped out to get some paracetamol. I thought the easiest thing would be to come up and try to catch you.”

“So, this is Mrs Dorothy Baxter,” my Dad continued holding up the laboratory report. “Her date of birth is 14th June 1936. I saw her on Monday. She had been unwell for 3 or 4 days with pyelonephritis.”
“Pyelonephritis, Dr Dennis? Don’t you mean cystitis?”
“No, pyelonephritis.”
“Perhaps you mean cystitis with a bit of muscular back pain?”
“No. Mrs Baxter had been quite poorly. She had a high temperature and shivering. She had been feeling sick and vomited twice. She had a severe pain coming from the right kidney and radiating into the right groin. She was having to go to the toilet very frequently and, when she did so, there was a severe, burning sensation. I must say, she looked quite unwell when I saw her.”
“Mmmm . . .” Dr Delaney still did not sound convinced.
“I prescribed Ciprofloxacin. It is one of the antibiotics you recommend for pyelonephritis.”
“Yes, we do, if it is pyelonephritis.”
“I wrote PYELONEPHRITIS on the form in capital letters.”
“The laboratory tests confirm that she does have a urinary tract infection. You have tested 3 antibiotics against the infection. The first antibiotic was trimethoprim. Unfortunately, Mrs Baxter is allergic to trimethoprim.”
“Allergic? Are you talking about a proper allergy or do you mean that she has had side effects when she has taken trimethoprim in the past?”
“No, she is allergic. I prescribed it last year and she came out with a severe, itchy rash. She also had swollen eyes and swollen lips.”
“That’s unusual with trimethoprim.”
“Yes, it’s unusual. It is the first case I have seen for about 10 years. The next antibiotic was nitrofurantoin.”
“A good, old fashioned choice.”
“Mrs Baxter has renal impairment so we can’t use it for her.”
“Renal impairment. . . that’s unfortunate.”
“The third antibiotic is amoxicillin. According to your sensitivity tests, amoxicillin will not work for this particular infection.”
“It’s resistant.”
“I am not sure why you have included it in the results though.”
“It is one of our three standard antibiotics. We always do,” Dr Delaney explained.
“Yes . . . but you haven’t put ciprofloxacin on the list. That’s the one I prescribed. I don’t know whether it will work or not.” My Dad looked slightly flustered.
“Is she feeling better?”
“She is a bit better but she is not fully recovered.”
“Has she improved as much as you would expect with an antibiotic that is working effectively?”
“Not quite.”
“As you know, Dr Dennis, ciprofloxacin is one of those antibiotics that we prefer you not to prescribe. Although it is extremely effective, it’s expensive and has got some rather unpleasant side effects. It also appears to be particularly good at encouraging bacteria to develop resistance.”
“It doesn’t look as if we’ve got much choice in this situation,” my Dad said.

“A group of us,” Dr Delaney explained, “all the consultant microbiologists in Wales in fact, got together and agreed that we would keep the sensitivities of some antibiotics hidden. Ciprofloxacin is one of those. We felt that these would help us discourage family doctors from prescribing these particular antibiotics.”
“In some ways,” my Dad said, “I agree with your sentiments but it can be a bit of a nuisance when you are treating a patient with pyelonephritis.”
“You only need to make a quick ‘phone call to the lab.”
“Listen,” my Dad said, looking at his watch, “I suppose that the thing I need to know is whether Ciprofloxacin is the correct antibiotic for Mrs Baxter.”

“Let me have a look, Dr Dennis.” Dr Delaney took the microbiology form from my Dad. He held it up to the light. “It is actually written on the form. It’s just that we use invisible ink for those special antibiotics.” Dr Delaney took a JIF lemon out of his pockets and squirted a fine spray of lemon juice onto the form. “Look . . . there we are . . . this particular infection is sensitive to ciprofloxacin. It should work a treat.”
“Thank you, Dr Delaney.” My Dad took the form back and off he went.

Hidden sensitivities.
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