This is part three of my question and answer session for the A Musing Maralee blog. Today I focus on antibiotic use and touch on overprescribing.
The original article can be found here. Andy Smith, MD wrote a related article on antibiotics found here.
When do we need antibiotics? Are they over prescribed? What should a parent do if they are concerned they are being unnecessarily prescribed antibiotics for their child?
Antibiotics are a powerful class of medications designed to kill off bacteria that have invaded the body. They are useful medications that can rapidly change the tide of a worsening infection. In the strictest sense, antibiotics are only used when the invading bacteria are not being sufficiently killed off by the body’s typical defense mechanisms thereby causing significant risk to the individual’s health.
This indication for using antibiotics is not as simple as some would like to think. For instance, ear infections in children may commonly be a bacterial infection that would dramatically improve with antibiotics. Different countries and cultures have different levels at which their healthcare community typically prescribes antibiotic help. In the United States, we have a low threshold for pain and suffering in our children and the standard for treatment is much sooner than the Northern European countries. The trade off is more antibiotic use but less complications from untreated infections.
The advice I give my patients is that I use antibiotics only when I feel they have a bacterial infection that their body cannot clear adequately enough on its own. Sometimes the evidence is very clear and sometimes it becomes a decision based on experience.
It’s important to note that there is a difference between an antibiotic and an antiviral medication. Antibiotics only attack bacteria and they do so largely by killing them. After a day or two of antibiotics there are fewer bacteria. The reduction is rather dramatic, honestly. Antiviral medications don’t work that way. They tend to stop the virus from replicating itself within the body. So if there are 100,000 copies of the virus present when the antiviral medication is started that number begins to stagnate. It only declines when the body begins to appropriately process and attack the infection. This is why antibiotics often have impressive effects in the first 48hrs while antivirals don’t.
I think antibiotics get over prescribed because physicians often assume the worst and patients often expect the best. Patients expect to heal more quickly than they really will and when that doesn’t happen they come in asking for something to make it better. Physicians are all too eager to help because as a group we want to “do something” to help our patients. If more antibiotics had annoying (but not harmful) side effects like turning your hair purple fewer people would over prescribe them. Even today a parent said to me about their child “But she can’t be sick, we’re going to be out of town in three days. Can’t you do something?” There is great pressure from many sides to over prescribe.
Parents who think they are being prescribed antibiotics unnecessarily should ask a few simple questions. Where, specifically, is the infection? Which bacteria is likely causing the infection? What do we gain by starting the antibiotic today? What do we risk by waiting to start the antibiotic? I would welcome any parent asking me these questions because they are the ones going through my mind each time I write out my prescription therapy. I need to be able to answer them well before deciding on the best course.
Here is the next post in the series I did for A Musing Maralee’s blog. I answer some of her reader questions concerning the common cold and influenza infections. You can find the original blog post here.
What is the biggest mistake you see parents making in treating the common cold or flu?
If a child has a cold, when would it be necessary to see a doctor? If they have the flu, when would it be necessary?
What are the pros and cons of cold medicine for children?
The common cold and influenza are both caused by viral infections of the respiratory tract. That’s about where the similarities end. The common cold is caused by over 200 different strains of viruses while influenza only has a couple predominant strains each year. The common cold causes a runny nose, congestion, a sore throat, cough, and often a mild fever. Influenza on the other hand can be devastating. It causes a violent infection of the upper respiratory tract (the nose and throat) as well as usually infecting the lower respiratory tract (the trachea, bronchi, and lungs). Fevers up to 104F are typical. The common cold hits its stride during the fall and winter months but can be a problem all year long. Influenza tends to come in mini-epidemics for individual communities. January through mid February is the peak season for my town.
The biggest mistake I see parents making in treating the common cold or influenza is seeking medical care at the wrong time. For most of the year when a child gets a fever and has a runny nose or sore throat that’s just a symptom of the common cold. A lot of TLC and chicken noodle soup will help them along until the body clears that infection in about 7-10 days. No amount of medication will change that time frame. If the common cold infection causes enough disruption in the body’s normal defenses, bacteria that are always around trying to invade will take the opportunity to set up shop. A new fever, new pain, and focusing of symptoms to the affected spot would be an indication that something different is occurring. This could be fluid build up in the middle ears, the sinuses, and even just the nose. Bacteria grow and cause an ear infection, a sinusitis, or a rhinitis. Medical attention would be a good idea at that time.
During influenza season a new pronounced fever (>102F) especially if there is a known exposure should prompt an evaluation right away. After about 48-72 hours of symptoms antiviral medications that help limit influenza’s spread don’t work. The person just has to ride it out at that point which is often a two week process.
I classify the common cold as a ‘desert island disease’. If you have the common cold and are stuck on a desert island, then you are still stuck on a desert island. No matter what you do or what medicine you take you will get better. That is often not the case for influenza which sadly has claimed the lives of several people in my town already this year.
In choosing medications or therapies to help with the common cold we should pick options with low possibility of side effects. Since the cure will come from ourselves we need to realize that nothing we do is strictly necessary to get better. That will happen anyway.
That being said I like using medications for specific symptoms. If I have a congested cough then I’ll take an expectorant. If I have nasal congestion I’ll take a decongestant. There are many preparations available for multisymptom treatment. I don’t like those as much but that’s just my personal preference. Since these drugs are not curative and can have side effects if used too much, I try to take as little as possible to obtain some relief and for as short a time as possible. Less really is more in these situations.
Generally you should avoid cold medications in children under two years of age. They don’t really work anyway at that age and aren’t necessary for getting better either. We all want to make our kids feel good but we don’t want to put them at unnecessary risk however slight it may be.
Fever and pain treatment are amazingly helpful in keeping kids feeling better while their body does its job. Acetaminophen (Tylenol) and ibuprofen (Advil, Motrin) are useful medications to relieve these aches and pains from infections and are good fever reducers. Remember not to use ibuprofen in children under six months of age.
I was recently asked by Maralee Bradley, host of a great blog on adopting, parenting, and fostering children entitled A Musing Maralee, to answer some of her reader generated questions on fevers, the common cold, and influenza. I’ve had the privilege to do this before for her on a series of questions regarding vaccinations. It was a great experience for me and her audience asked some really fantastic questions. You can find those posts starting here. Years ago I had the opportunity to work with Maralee and her husband, Brian, in caring for their son. They have since moved, grown their household with more wonderful children, and continue to ask challenging questions of me.
The original post from her website is at Ask the Pediatrician: What should I know about fevers? I’ll repost the future Q&A’s as they get posted on her site.
What is a fever? When does it become a problem? How should I treat it?
We use body temperature as one of many tools to help understand how sick a person is. Any number on a thermometer, in and of itself, doesn’t provoke a certain diagnosis or a specific set of therapies. It only tells us information we then use to help decide why the person has an atypical body temperature and if anything needs to be done.
Core body temperatures fluctuate during the day and often reach their peak in the late afternoon. A healthy adult might reasonably be measured at 99-100°F between 4-5pm. Women attempting to time ovulation know their body temperatures change over the course of their menstrual cycle. It all has to do with what temperature is appropriate for the situation. One of the most critically ill children I ever cared for in the emergency room had a core body temperature of 94°F. He had a brain infection that was so severe he couldn’t even maintain a normal body temperature. While people are individual in what their body temperature normally runs this doesn’t change how we define a fever. People who really are sick enough to manifest a fever still get about 100.4°F.
So when do we worry about a rising body temperature? In infants we have to be more diligent because they lack many of the other signs and abilities we rely on in older children and adults to help point out the cause. An infant may be cranky or sleepy as a sign of their infection but lots of infants are occasionally extra fussy or take long naps. Unusual body temperatures help us tell the difference.
An infant less than 3 months old who develops a body temperature above 100.4°F should be evaluated by a physician in a matter of hours. They are at much higher risk of serious infections such as meningitis, urinary tract infections, and bacterial infections of the blood stream. As such, we must be all the more diligent to prove their fever isn’t of great concern. Hours matter in these situations so I often advise my patients who call in the middle of the night to seek emergency care if their infant has a fever. We must prove their health as the risk of fatal infection is so great.
In older children we move the ‘worry point’ to 102°F. When children under three years of age but older than three months develop a fever they often display more evidence of why the fever occurs and if we need to try and fix it. They can report ear pain or sore throat. They may be potty trained and then suddenly develop accidents because of an urinary tract infection. They stop eating and complain of belly pain with appendicitis. In these situations we are able to focus in on the cause of their over all problem of which fever is simply one manifestation. I typically recommend to parents that children under three years of age be evaluated by a physician as soon as possible. Often the next day in the office is just fine as long as there are no other red flag symptoms like shortness of breath or uncontrolled abdominal pain. Emergency care may still be necessary. When in doubt contact your physician for advice on what to do for your particular situation.
As to everyone older than three years of age, it all depends on the circumstances. For instance, we are currently in the mini-epidemic of our seasonal influenza infections. In this case, anyone with a fever and symptoms at all suggestive of influenza ought to be evaluated. Early diagnosis and therapy can make a big difference in influenza outcomes. However, most of the year when otherwise healthy people have a modest fever such as 101 F, I recommend a watchful waiting approach. Respiratory tract infections typically are self-cured in seven days or so and other more serious infections will manifest with other symptoms that will help guide our diagnosis and therapy options.
A word on how to take an accurate temperature. What we want to know is what the temperature inside the body is. Rectal temperatures are by far the most accurate and it is what I recommend to parents caring for infants. As children age, oral temperatures are very good as children can hold the thermometer under their tongue consistently. Remember not to eat or drink anything for about 5-10mins prior as that can alter the result. If your kids are asleep it doesn’t matter what their temperature is really. I certainly wouldn’t wake them up to test it. Under arm or axillary temperatures are pretty good also. Lots of people suggest adding a degree to those readings. I’ve never seen good data to show that should be done so I always just ask parents how they took the temperature.
Ear thermometers and forehead thermometers seem like a great idea but I’ve seen many inaccurate readings. I once saw a healthy, playful 5 year old boy with ear pain who was reported to have a temperature of 108°F! Turns out the ear they checked the temperature in was infected. His body didn’t have a fever but his ear sure did.
So once you’ve found a fever and appropriate therapy is underway, whether that’s letting to body do its thing or using proper medication to kill off an invading pathogen, the question becomes “Should we reduce the fever?” I think the answer really depends on the person. Many kids can run around and play normally with all manner of fevers while others of us tend to feel really run down. I would say treat a fever when, after you know what’s causing it, you need it to go away. I don’t know of any real advantage to leaving the fever just for the fever’s sake. Sure many bacteria grow best in normal body temperatures so changing that might slow them down. In my experience though the body is so fantastic at doing what it needs to do that the body temperature doesn’t play the deciding factor.
If you are a patient at Trinity then feel free to drop us an email or call us. Together we can decide how and when to treat a fever.
Sleep – at its best it’s a wonderfully refreshing period where we physically and emotionally get reset for another day. But for an estimated 70 million Americans, one of the over 80 different sleep disorders intrudes on their ability to get a good night’s sleep. Everything from sleep apnea to restless leg syndrome to simple insomnia is included on the list. For our purposes today, we want to look under the covers at insomnia, defined as difficulty initiating or maintaining sleep resulting in daytime impairment.
About 10% of the population would fit the criteria for some level of chronic insomnia, hence the 60 million prescriptions yearly for sleep aids. And this doesn’t include the raft of over-the-counter sleep meds that fly off the shelves.
So is insomnia such a big deal? Well, yes, it is tied into several serious illnesses. Those with insomnia are twice as likely to have congestive heart failure, five times as likely to have anxiety or depression, and have increased rates of diabetes, obesity, motor vehicle accidents, infections, and have impaired memory, thought, and work and school performance. Of course some of these are effects of the insomnia and some are causes.
How much sleep do we really need? The average person needs 7 to 9 hours of good quality sleep. But the average American gets 6.9 hours, leading to a lot of sleep deprivation and all the baggage that comes with it. Some individuals are in bed long enough but don’t wake up refreshed and rested. This often indicates a poor quality of sleep, either through frequent awakenings, sleep apnea or some other sleep disorder that intrudes on the benefits of their sleep.
What are some of the causes of insomnia? For some, it is a built-in condition with a nearly life-long pattern of poor sleep-wake cycles. But there are a number of factors that can worsen the problem. Not surprisingly, children with smart phones, televisions or computers in their bedrooms are generally found to have poorer sleep patterns than those who do not. Certain medications, such as decongestants or corticosteroids can cause insomnia. Even meds that are used to induce sleep, such as antihistamines, can cause an opposite effect in a percentage of individuals, causing prolonged wakefulness.
So, to cut to the chase, what can you do if you notice that you are not sleeping well? Perhaps you awaken unrefreshed and have some daytime sleepiness. First, tune up your sleep habits. In general:
- avoid daytime napping
- avoid caffeinated drinks after lunch
- get some physical exercise or exertion in (preferably early in the day)
- try to go to bed at approximately the same time daily
- don’t watch TV or read in bed
- give yourself a set amount of time (perhaps 20 minutes) to fall asleep
- if you don’t fall asleep in the set time, get out of bed and read in a chair until you feel you may be tired enough to sleep. Then get back into bed and give yourself 20 minutes again.
If after 1-2 weeks of this approach you aren’t seeing good results, you may benefit from consulting your physician. Certain medications may be an issue, or health issues such as hyperthyroidism, anxiety or depression.
If other issues are ruled out and the problem is persisting, prescription sleep aids can be considered as well as something called cognitive behavioral therapy, though this can be harder to access. Sleep meds include everything from the well-known Ambien (zolpidem) to sedating anti-depressants such as trazodone, antihistamines such as diphenhydramine (Benadryl), to benzodiazepines such as temazepam (Restoril), and even stronger, less-often-needed meds such as Seroquel. Incidentally, it was recently found that for females the 10 mg. dose of Ambien was associated with a 30% higher incidence of motor vehicle accidents the next morning. This led to the recommendation that women limit their Ambien dose to 5 mg, especially if they will be driving the next morning.
Over-the-counter meds such as Tylenol PM and Advil PM often use the sedating antihistamine, diphenhydramine, which leaves many with some left over morning grogginess. Melatonin has been found to be mildly effective in shift workers, but not very effective for typical insomnia. And the list goes on.
The bottom line is that there are pros and cons to each treatment option, including the option of just trying to ignore this problem and not treat it. So if insomnia is plaguing your nights, it’s worth some attention. Good sleep and good health tend to go together.
Andrew Smith, MD is board-certified in Family Medicine and practices at 1503 East Lamar Alexander Parkway, Maryville. Contact him at 982-0835