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.
“It’s the most wonderful time of the year…” So states one of the frequently-heard Christmas songs. And in many ways, it can be wonderful. At the same time, from a health perspective, it’s a time to take a few extra precautions. You may notice a few extra sniffles and coughs around you. Some are more serious than others. Let’s take a few moments and look at this hairy beast called influenza, or the flu.
For most people, the flu is just a big unpleasant nuisance. But it is estimated that over 20,000 people die from the flu each year in the U.S., mostly the very young and the very old.
Far more lethal strains emerge periodically. These deadly strains produced 3 global pandemics in the last century. The worst one, called the Spanish flu, occurred in 1918 and killed an estimated 20-50 million persons world-wide, with 549,000 deaths in the United States alone. So the flu can be a huge deadly deal.
Flu symptoms are typically some combination of sore throat, congestion, cough, fever, fatigue, body aches, and headache. It is very contagious from airborne droplets and close contact and is most contagious from the day before symptoms start to a couple days after they have begun. It usually takes 1-4 days between being infected and starting to show symptoms.
Right now our area of east Tennessee is showing a substantial spike in flu illness, which is a little earlier than the typical January-February peak of illness we usually see. Also, there have been some strains of flu that actually tend to hit young and middle-aged adults the hardest.
The good news is that virtually all of the strains currently circulating are included in this year’s flu vaccine. Sometimes the makers of the vaccine guess right and sometimes they get fooled; this year they seem to have nailed it. By the way, the new quadrivalent flu vaccine (that has four instead of three strains that it covers) only offers a very slight additional advantage as the fourth viral strain has barely showed up.
The other good news is that there is almost no resistance to the commonly used antiviral medicines, Tamiflu and Relenza. However these medicines need to be started within 48-72 hours of the onset of symptoms to get much benefit; the sooner the better.
So, what’s the best approach for traversing this precarious time of the year? First of all, if you or your kids haven’t gotten the flu shot (or nasal spray where appropriate), it’s not too late, and I’d strongly recommend it, especially this year when its coverage is so good. But don’t delay, as mentioned, the wave of flu is currently breaking over east Tennessee and it takes about two weeks to achieve good immunity after vaccination.
By the way, the flu shot has no live virus so it can’t give you the flu. Nationwide, the flu shot and spray prevent hundreds of thousands of cases of flu. Of course there are other flu-like illnesses that the flu shot won’t protect against, but your odds of getting the actual flu are greatly reduced. Also, when you get a flu shot you protect those around you who you could otherwise infect if you got the flu.
OK, what if you start getting symptoms of the flu? If the symptoms are bad, this is a time where you don’t want to just wait and see for a few days. The sooner you get in and get diagnosed and specifically treated, the greater your benefit from one of the antiviral meds, if this is indicated. Beyond this, rest, fluids and ibuprofen or acetaminophen can be helpful for substantial fever or pain. I’m a bit of a minimalist with multi-symptom over-the-counter meds since none of them directly fight the virus and some have a lot of potential for side effects, especially in younger children. Occasionally they can give a bit of relief if some symptom is particularly obnoxious.
So, as another Christmas song proclaims, “You better watch out…” We’re in the first wave of the flu season and we want this to be a wonderful rather than a miserable time of the year. In the meantime, and on a deeper level, “Do not be afraid; for behold, I bring you good news of great joy which will be for all the people; for today in the city of David there has been born for you a Savior, who is Christ the Lord.” Blessings!
Andrew Smith, MD is board-certified in Family Medicine and practices at 1503 East Lamar Alexander Parkway, Maryville. Contact him at 982-0835