Posted tagged ‘viral infections’

Fighting back the superbugs

September 9, 2011

The Pediatric Insider

© 2011 Roy Benaroch, MD

Antibiotics are not wonderdrugs that can treat any illness. They can only treat certain  bacterial infections, and each antibiotic has a different “spectrum” of bacteria that it can kill effectively. Every time bacteria are exposed to any antibiotic, there’s the potential for the bacteria to become resistant. We had once thought that infectious diseases were a thing of the past, but it’s become clear that at least for now the germs are winning. Currently, hospitals are swarming with resistant C difficile; in some parts of the world gonorrhea is now resistant to all antibiotics; and the emergence of the resistant staph MRSA has completely changed our approach to common skin boils and abscesses.

All of this is our own fault. We’re hosing down our kids, our hospitals, our farm animals, and our planet with antibiotics.

So which patients really benefit from antibiotics? Take this fun quiz to find out!

  • A 15 year old with a sore throat.
  • A 12 year old with a cough.
  • A 30 year old with bronchitis.
  • A 10 year old with 7 days of nasal congestion that’s turned green.
  • An 8 year old with an ear infection.
  • A 6 month old with a fever.

The answer: none of them. None of these patients is likely to benefit from antibiotics; in fact, antibiotics are more likely to make them sick with side effects (like diarrhea), possible allergic reactions, and resistant bacterial overgrowth.

There are caveats, of course: some of these patients might need antibiotics. A child with a sore throat should have antibiotics if a strep test proves that it’s a bacterial infection (most sore throats are viral, and a doctor can’t reliably tell the difference without an objective test.) Almost all cough illnesses are viral, including bronchitis, unless the lungs have been damaged by years of cigarettes or other problems. Cold viruses will cause green snot—that doesn’t mean there are bacteria—and most cold virus illnesses will last 7-10 days. Most ear infections in children past age 2 will resolve on their own without antibiotics, and if symptoms are fairly mild it’s very reasonable to “wait and see” before prescribing. A 6 month old does need a good evaluation to see what’s causing the fever, but in the developed world among immunized children most fevers are caused by viral infections that have to run their course.

In an evidence-based, good medical practice antibiotic prescribing should be the rare exception. Unfortunately, that’s just not what’s happening in the real world. 50% of inpatient antibiotics are unnecessary; for typical outpatient prescribing, it’s been estimated that 75% of antibiotics are not needed.

Why are so many antibiotics being prescribed?

In some instances there is a genuine knowledge gap. Some physicians were trained in an era when the effect of antibiotic overprescribing were less-well understood. But honestly, as physicians we’re hearing about this issue constantly. It’s not a believable excuse anymore.

There is a perception that patients will demand antibiotics. While it’s true that some patients will not leave happy without a prescription, most people prefer a good, honest assessment and a plan that will help them feel better. Of course, discussing other treatments and why an antibiotic will do more harm than good takes time… which brings us to what I think is the most significant reason for antibiotic over-prescribing: it’s quicker. And in an odious way, it’s better for business to prescribe than yak about why you’re not prescribing.

That’s right: market forces, for now, seem to favor the docs who whip out the pad and give patients a prescription. It’s quicker, so those docs can see more patients and bill more encounters. And it makes a careful and thoughtful history and physical exam less necessary—hell, I’m going to put ‘em on antibiotics anyway, so why do I need to clear the wax out of those ears? And it creates repeat business, because the patients of these doctors quickly learn that they need to come in for a prescription for every illness.

I will tell you: I personally know pediatricians right here in my community who see twice as many patients as I see in a day and who essentially always prescribe antibiotics. And their patients love them, because they think they’re getting good care. They’ve been trained with certain expectations, they’re happy to get antibiotics, and their doc is  making plenty of money. Meanwhile, the germs get smarter. The resistant bacteria spread to other children. Your child may end up with a resistant infection, even if you’ve been careful about antibiotic overuse. Resistant bacteria affect the whole community, not just the patient on the unnecessary antibiotics.

What can parents do about this?

  • Prevention is better than cure. Prevent common illnesses with good hand washing and common sense. Keep your children up-to-date on vaccines (including a yearly influenza vaccine.) Any illness prevented is one less potential antibiotic course. Breastfeeding and avoiding cigarette smoke also help prevent many childhood infections.
  • Make sure your pediatrician knows you’re not one of those parents who wants antibiotics. If you’re getting the impression that your doc is quick-to-prescribe, change doctors to someone who uses good careful judgment.
  • If you do have an antibiotic prescription, follow the directions. Take it for the full course. Do not hoard antibiotics or start them on your own without very specific instructions from a qualified health provider.
  • Avoid going to urgent-care clinics, ERs, or quickie health clinics in retail stores. Because they don’t have long term follow-up, these sorts of places are more likely to knee-jerk prescribe (remember: what’s good for their business isn’t necessarily good for your health.)

For now, the bugs are winning: they’re defeating our antibiotics quicker than new ones can be discovered. It’s a problem that’s mostly self-inflicted. Indiscriminate use of these medications (in humans and in agriculture) is the best way to make sure that they won’t work when we need them. The germs are patient, and have been around a long time. Are we smart enough to stay ahead of the race?