I am thrilled to have Dr. Alan Schroeder, my brilliant mentor and friend, contribute a guest post here this week. He tackles an important question that many parents face- does my child really need antibiotics for this illness- and clearly outlines why we must carefully consider the answer.
Does your child really NEED those antibiotics?
by Alan Schroeder, MD
As a pediatric intensive care physician, I am able to witness the miracles of antibiotics firsthand. Thanks to antibiotics, a child with a life-threatening infection can go from being on death’s doorstep to giving me a high-five or an ear-to-ear grin in a relatively short period of time. Antibiotics save lives, irrefutably. They can be considered one of public health’s major victories in the 20th century.
But like so many interventions in health care, there can be too much of a good thing, and antibiotics are a perfect example. In fact, just as the introduction of antibiotics can be considered a major public health victory, the escalating problem of antibiotic resistance can be considered a major public health threat. Antibiotics have been overused, and bacteria have gotten smarter as a result. Increasing numbers of potentially lethal bacteria are emerging that are tough to kill because they are resistant to so many antibiotics. The more antibiotics we use, the more these vicious bugs thrive.
What is driving antibiotic overuse? Antibiotics have been a victim of their own success. Because we have drugs that can kill bacteria, we mistakenly believe that bacterial infections always need antibiotics (they don’t). We also aren’t very good at figuring out whether a given infection is truly caused by a bacteria (most aren’t). Infections are frustrating – our children are miserable, they’re up all night, they can’t go to school, and we can’t go to work. Plus, the fact that they could get even sicker is scary. So it’s natural to want to do something – anything – to make them better, and if there’s even a chance it could be a bacterial infection, why not treat with antibiotics? From the doctor’s perspective, we want to help too. And, we want to keep our customers happy. As we hear often, it’s much easier to write a prescription for a Z-pack (a common antibiotic) than it is to take the time to explain why antibiotics can be harmful and why viruses don’t need antibiotics.
Aside from the problem of antibiotic resistance, antibiotics have other serious consequences. They can cause diarrhea and/or vomiting, and severe allergic reactions. Associations between antibiotic exposure and chronic diseases such as asthma, diabetes, and obesity are increasingly described (note that these are associations and do not prove causation). Another under-appreciated consequence of prescribing antibiotics for viral infections is that many viruses cause rashes. When that rash appears, it is often attributed to the antibiotic. This is probably why most reported antibiotic allergies are not true allergies when formally tested. Once a child is labeled as having an antibiotic allergy, it makes it much more difficult to choose an appropriate antibiotic if one is truly needed in the future, and stronger antibiotics may be prescribed.
Here are some areas where we can combat antibiotic overuse:
1.) Ear infections. First, what looks like an ear infection to one physician may look like a normal ear to another. The ear drum can be hard to see, especially in a cranky child who resists the exam, or if there’s a lot of wax. So, make sure it’s a real infection. Second, most ear infections go away on their own. In one of the largest studies on the treatment of ear infections, 80% of the children treated with antibiotics were completely better by 7 days vs 75% who received a placebo. The American Academy of Pediatrics does not recommend antibiotics for all ear infections, just severe ones. This means you don’t necessarily need to rush your child into the doctor if you think he or she has an ear infection – consider trying some pain relief first.
2.) Cough and colds. Viral upper respiratory infections are probably the most common scenario where unnecessary antibiotics are prescribed. As tempting as it seems to take antibiotics, they don’t help and may make things worse. And be aware that if you take your child to his or her doctor, the doctor may get the impression that you are there because you want a prescription, so be sure to voice your concerns about antibiotics.
3.) Strep throat. The routine use of antibiotics to treat strep throat has not necessarily been motivated by a desire to make kids feel better (they aren’t great at doing that), but rather to prevent a complication called rheumatic fever. However, rheumatic fever is much less common now, so the probability of having a serious allergic reaction to the antibiotic is substantially higher than the probability of getting rheumatic fever without the antibiotic. While there may be other reasons to treat strep throat (namely, your child can go back to school sooner), similar to ear infections, there is no need to rush your child to the doctor when he or she complains of a sore throat.
4.) Antibiotics in meat. Even if your child has never taken antibiotics, if they eat meat they’ve probably been exposed to antibiotics on multiple occasions. California has recently enacted legislation to forbid animals from being raised with antibiotics. Hopefully, other states will follow. In the meantime, it’s worth spending a few extra bucks on antibiotic-free meats (or limiting meats altogether) if you can afford it.
There are multiple efforts underway to combat antibiotic overuse.The CDC’s Get Smart about Antibiotics Week is coming up in mid-November. Similarly, working with the Lown Institute during their Right Care Action Week, we recently led an initiative to promote antibiotic stewardship, and have had nearly 300 pediatric healthcare providers sign a pledge committing to this topic. Still, 300 committed pediatric providers is not enough! We all need to work together to make sure that antibiotics are provided to the kids who really need them, but avoided in those who don’t.
Dr. Schroeder is the medical director of the Pediatric Intensive Care Unit and Chief of Inpatient Pediatric Services at Santa Clara Valley Medical Center in San Jose, California, and a clinical associate professor of pediatrics (affiliate) at the Stanford University School of Medicine. His research interests focus on identifying areas where we can “safely do less” in healthcare. Follow him on twitter @safelydoingless