Are They Wonder Drugs?
by Warren P. Silberstein, M.D. Have you ever thought, "My child has a fever. He must need an antibiotic!" or "My child's cold won't go away. The mucus is green. He's got to have an antibiotic to get better"? If you have, you're not alone. Fevers and colds are the most common reasons for parents to bring their children to a pediatrician. Many parents bring their sick child to the pediatrician thinking they need a prescription. If they don't get one they feel like the doctor didn't take them seriously and that they didn't receive good care.
When I walk into the room to see a patient here are a few of the opening lines I dread:
These parents all believe that antibiotics are the wonder drug necessary to cure their child's illness. They came to my office for the prescription they think they need. If they don't get the prescription they will be worried. They may be angry or feel cheated. They'll call me back the next day or even in the middle of the night to tell me their child is still sick or the fever is higher, and they want to know if I'll change my mind and give them the prescription now. Many physicians faced with the pressure to prescribe antibiotics will just do it. They figure that the parents will just find another doctor who is willing to prescribe the antibiotic anyway. They also figure that it's safer to prescribe the antibiotic because just in case an antibiotic is necessary, they're covered. And they figure it won't do any harm.
- "I thought I'd come get an antibiotic and nip this illness in the bud."
- "He's had the fever for three days already. Don't you think he needs an antibiotic?"
- "I don't bring my child in for every little sniffle, doctor. I think he needs an antibiotic."
- "My child always needs an antibiotic when he gets sick."
- "The fever is so high. That means infection. He needs an antibiotic!"
- "The mucus is green. That means infection. He needs an antibiotic!"
- "He always ends up needing an antibiotic when he gets sick. Can't you just give it to me now?"
The problem is that inappropriate use and overuse of antibiotics does do harm. There are many good reasons to not prescribe antibiotics unless they are clearly needed.
Some definitions to help you understand the above statement and the rest of the discussion. A broad spectrum antibiotic is one that can kill many different types of bacteria. A broad spectrum antibiotic is useful for treating infections that might be caused by many different types of bacteria such as ear infections. A narrow spectrum antibiotic is one that kills only a small variety of germs. Many people refer to a broader spectrum antibiotic as a stronger antibiotic, but spectrum and strength are not exactly the same. If an organism is sensitive to narrow spectrum antibiotic like penicillin using a broader spectrum antibiotic will not result in any better cure. If a patient is large he may require a larger dose or strength (500 mg. instead of 250 mg.). It is always best to treat with the narrowest spectrum antibiotic that will do the job and to save the broadest spectrum antibiotics for serious infections and infections that haven't responded to narrow spectrum antibiotics.
- Most uncomplicated virus infections get better within a few days. By prescribing antibiotics for these infections doctors increase parental demands for antibiotics. When the child gets better parents assume he is better because of the antibiotic since they haven't had an opportunity to see that children recover from these infections without medication.
- All medicines have side effects. When an antibiotic is used where it won't help, the patient risks experiencing these side effects without any potential benefit. Most of the side effects of antibiotics are just a nuisance, but some can be serious.
- When antibiotics are used without establishing a diagnosis there is a possibility that a more serious infection will be masked rather than cured. This can make it harder to come to the correct diagnosis and treatment down the road.
- Prescribing antibiotics at the first sign of illness before the diagnosis is established doesn't give children any opportunity to develop any immunity to infectious bacteria. Except for serious infections like meningitis and sepsis there is no risk in delaying antibiotic treatment for 24 hours.
- Some infections, especially gastroenteritis, may be aggravated by antibiotics. Treatment of bacterial gastroenteritis requires an accurate diagnosis in order to choose the correct antibiotic. Treatment of Salmonella infections with antibiotics can make the patient a chronic carrier. Antibiotics can lead to an intestinal infection called necrotizing enterocolitis which then requires treatment with a different antibiotic.
- Overuse of antibiotics, especially broad spectrum antibiotics, has encouraged the development of resistant strains of bacteria. Years ago all pneumococcal infections (a germ that causes pneumonia) could be treated with plain penicillin. Now there are strains of pneumococcus that are resistant to all antibiotics except vancomycin. How long will it be until we are facing infections with bacteria that are resistant to all antibiotics known to mankind?
Since most of us grew up with antibiotics we tend to take them for granted. It's hard to believe that antibiotics have only been around for 60 - 70 years. I grew up with antibiotics, but my parents didn't. Penicillin was discovered in 1928 and wasn't widely used clinically until the 1940's. Sulfonamides first came into use in the 1930's. Before that there were very few effective antimicrobials. Antibiotics have gone a long way in preventing deaths from serious infections like meningitis and blood poisoning, and they help to prevent complications like rheumatic fever from Strep throat and mastoiditis from ear infections. But people did get better before there were antibiotics. Their immune systems fought the infections. Now, less than 60 years after penicillin made its debut, we are facing a crisis because of bacteria that are resistant to multiple antibiotics. To deal with this, some physicians are advocating shorter courses of antibiotics for some infections. In England they have tried treating some
ear infections without antibiotics. As a result the incidence of mastoiditis has gone up, but since many of the infections don't require treatment, most of the kids get better.
The following information includes the facts that patients should know about antibiotics and the principles that doctors should follow in prescribing antibiotics:
The principles above apply to the average healthy patient. There are some conditions that require chronic antibiotic treatment such as immune deficiency syndromes, patients without spleens, rheumatic fever, cystic fibrosis, etc. If your doctor has prescribed antibiotics for you and you think that you may be on a broader spectrum antibiotic than you need or an unnecessary antibiotic, discuss it with your doctor. Do discontinue any medication prescribed by your doctor without discussing it with him. If you disagree with your doctor's advice, seek another opinion. Don't try to be your own doctor.
- Antibiotics have no effect on fever. Fever resolves with antibiotics when the infection being treated can be cured by the antibiotic.
- Virus infections cannot be treated with antibiotics. Antibiotics have no effect on viruses. Antibiotics kill bacteria. That is all antibiotics do.
- Upper respiratory infections like colds and flu are caused by viruses. Antibiotics do not help and should not be used for treating them.
- Discolored mucus does not necessarily mean bacterial infection. When mucus dries in the nose it becomes thickened and discolored. Your doctor can tell by his examination and sometimes some tests if there is a sinus infection.
- Most sore throats are caused by viruses. Strep throat cannot be diagnosed accurately by the appearance. Your doctor should do a throat culture or Rapid Strep Test in order to diagnose Strep and avoid prescribing unnecessary antibiotics.
- Strep throat responds to penicillin. Penicillin allergic patients should be treated with erythromycin. Unless your doctor has a good reason for choosing other antibiotics he should not prescribe broader spectrum antibiotics for treating Strep throat. Overuse of broad spectrum antibiotics encourages the development of resistant strains in the environment which will render the broad spectrum antibiotics useless in the near future.
- Children do not become resistant to antibiotics. Only bacteria do. There is no such thing as a child who does not respond to amoxicillin since the amoxicillin is working on the infection and not the child. Children don't harbor resistant organisms in their ears or throats since they don't have any pathogenic organisms in their ears or throats between infections. Even though a child may sometimes require more than one course of antibiotics to treat an infection it should never be routine to start with the newest, broadest spectrum antibiotics since that will hasten the development of resistant organisms. Use of these antibiotics should be reserved for unresponsive infections and recurrent infection in children recently treated with antibiotics.
- Always complete any course of antibiotics prescribed. Early discontinuation of antibiotics has a risk of relapse of infection, and since the relapse will occur with the germs that were more resistant to the antibiotic, there is a greater likelihood of selecting and encouraging the development of resistant strains of bacteria by stopping treatment prematurely. If you experience a problem with the medication call your doctor.
- For the reasons mentioned above and the fact that viruses don't respond to antibiotics, don't self medicate with antibiotics for a few days when you are sick. You should not have leftover antibiotics. Antibiotics should only be taken under the direction of a physician and the full course should be taken as prescribed.