The Parent’s [Long-Overdue] Guide to Antibiotics

Responsible antibiotic use is an ever-increasing challenge. While antibiotics are some of the most important medications that we have, they are also vastly over-requested and over-prescribed. Often, patients (or parents) have decided before they walk into the doctor’s office that antibiotics are necessary. I know that because I’ve done it. Before my medical training, there were multiple times when I demanded requested antibiotics for what I’m now certain were viral infections. And it seemed like they worked–because during the 7 days I was taking them, the virus ran its course, and I started feeling better. Sadly, none of my doctors took the time to educate me about my misconceptions. Perhaps I was a “difficult” patient, or maybe it was just easier to write the prescription. Either way, they didn’t do me any favors.

What is an antibiotic?

Antibiotics are drugs designed to kill bacteria or to keep them from reproducing, but they aren’t the only chemicals that do this. Disinfectants also kill bacteria, but because they are unsafe for topical or internal use in people, their utility is limited to sanitizing objects or surfaces. A great example is bleach, which kills bacteria almost universally, but causes significant harm to humans as well. Antiseptics are slightly different, in that they are safe for topical use, but shouldn’t be ingested. These are substances like alcohol, chlorhexidine, or other chemicals used to clean the skin prior to needle sticks or surgical procedures. While alcohol does a fantastic job killing bacteria on the surface of the skin, drinking enough to treat pneumonia would challenge even the most seasoned sailor. In contrast, antibiotics are designed to treat bacterial infections while causing minimal harm to your own body–an important distinction when evaluating claims about alternative treatments that may kill bacteria in petri dishes, but have no benefit at all when taken internally.

History of antibiotics:

On the grand canvas of medical history, antibiotics are a relatively new addition. In fact, the Germ Theory of Medicine (the concept that diseases are caused by infectious organisms invisible to the naked eye) didn’t really catch on until the 19th century. And it wasn’t until the 1930’s that medications to combat these microbes became available. The first antibiotics were sulfa compounds and penicillin. These early medications played a huge role in treating wounded soldiers in World War II, and we have seen millions of lives preserved by an explosion of new and improved antibiotics over the past 80 years.

How antibiotics work:

Depending on how you divide them up, there are now somewhere around 15-20 different classes of antibiotics, most of which contain several similar drugs. Each class works in a unique way to kill bacteria or stop them from reproducing. Some work by destroying the bacterial cell wall; others target the machinery responsible for producing DNA or proteins, which are necessary for reproduction. The “mechanism of action” of each antibiotic is what determines how effective it will be against a particular microbe–if it has any effect at all. This is why a particular antibiotic may work very well for one infection, while having no activity at all against another. (I won’t go into details here; it’s an entire course in medical school. If you’re interested in reading more, the book Clinical Microbiology Made Ridiculously Simple is a great introduction.)

Antibiotic resistance:

Here’s the big problem: bacteria are programmed to survive and reproduce. This is their sole mission, and they have become quite good at it. Random mutations or swapping of genetic material allows bacteria to develop resistance to antibiotics. It’s evolution on a microscopic scale, and on a terrifying timeline. This artificial selection allows resistant bacteria to survive and reproduce, rendering useless many drugs that were enormously effective just a decade or two ago.

Bacteria began developing resistance to penicillin back in the 1940’s, but it wasn’t until relatively recently that this problem began to draw significant attention. Today, methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus, and multi-drug-resistant tuberculosis are just a handful of the “superbugs” we’re dealing with. Carbapenem-resistant Enterobacteriaceae recently made the news when it was linked to two deaths at UCLA caused by contaminated endoscopes. These organisms are responsible for about 25,000 deaths every year in the US. And I just read this morning that, in several countries, gonorrhea has become an untreatable condition. Antibiotic resistance is no joke.

Factors driving antibiotic-resistance include unnecessary use of antibiotics, use of inappropriately “broad-spectrum” antibiotics (more on this later), and partially-treated infections caused by stopping an antibiotic too early.  But while doctors play a huge role in breeding resistant bacteria, we can’t take all the credit. The agricultural industry helps us out quite a bit through the indiscriminate use of antibiotics in animals raised for food. They use even more than we do.

Choosing an antibiotic (or two…or three):

One challenge of deciding which antibiotic to use is that we’re typically not sure exactly what we’re treating. In most circumstances, we use what is called “empiric therapy,” meaning that we make an educated guess about the most likely culprits, and choose a drug that tends to kill them. For instance, we know that the majority of ear infections in children are caused by Streptococcus pneumoniae (followed by Haemophilus influenzae and Moraxella catarrhalis). So when we diagnose a child with an ear infection, we choose a reasonable antibiotic and hope for the best. The same goes for pneumonia, urinary tract infections, skin abscesses, or any other bacterial infection. Occasionally we’re wrong, and we have to switch to a different medication.

When our initial choice doesn’t work, we will often transition to a different antibiotic. Most people (doctors included) think of this as a stair-step approach, with each subsequent antibiotic being “stronger” than the first. But “stronger” doesn’t really apply quite as directly here as it does with, say, pain medication. The goal of antibiotics is to kill bacteria, and dead is dead. When an antibiotic fails, the next one is usually chosen either for “broader” coverage (meaning that it targets more types of bacteria), or to circumvent resistance by using a different class of medication.

IV antibiotics are often considered “stronger” as well, but that’s not necessarily the case, either. While it’s true that some of our broadest-spectrum antibiotics are available only in IV form, other IV medications are no more effective than their oral counterparts. One distinct advantage to IV antibiotics–especially in pediatrics–is that kids can’t spit them out. So while oral medications are perfectly fine for most situations, IV antibiotics are sometimes the best (or only) option to treat a particular infection.

In some cases, it’s important for us to know exactly what bacterium is causing an infection. We can get this information by taking a sample for culture and trying to grow the bacteria in the lab. Once we’ve figured out exactly which bacteria is causing the infection, we try to narrow our coverage back down so we don’t promote more resistance. The ideal antibiotic is the one that can get to the infected area and kill the responsible organism with the least possible collateral damage.

How long should infections be treated?

Once we find an antibiotic that seems to be working, we have to decide how long to continue it. Many common infections are treated for 7-10 days–a period that was originally derived from strep throat studies, but has traditionally been applied to other infections as well. However, there is compelling evidence for several infections that shorter courses are equally effective, while causing fewer complications. Because this is an area of emerging research, it’s best to let your doctor make the call and avoid stopping antibiotics early; the complications of “not enough” are often more severe than those of “too much.” Life-threatening or deep-seated infections, or unusual infections like tuberculosis, can require much longer courses–on the order of several months.

Which infections should be treated?

Sometimes, we aren’t sure if an infection is bacterial or not–it’s not always easy to tell. In these cases (assuming the child isn’t extremely ill), a watch-and-wait approach is almost always appropriate. Re-evaluating in a couple days is a reasonable approach to most minor illnesses, and things that require treatment tend to get worse, not better. Antibiotics don’t treat viral infections, and even bacterial infections will often resolve on their own. Strep throat and ear infections are examples of common illnesses that are almost always treated with antibiotics, often unnecessarily. Just because we can do something doesn’t mean that we should.

Cold-type symptoms are almost always caused by viruses, but viral infections may create a set-up for bacterial infections like pneumonia or ear infections. If your child has had a viral illness for a few days and starts getting worse instead of better, it could be a sign of one of these complications. A fever lasting 5 days or longer deserves a doctor’s visit (but still may not need antibiotics). Fever in an infant less than 2 months old, difficulty breathing, dehydration, and lethargy are reasons for urgent evaluation. Beyond that, any time you are concerned about your child’s health, give your doctor a call–they should be happy to help. Don’t expect them to call in antibiotics without seeing your child; this is typically bad practice, as it’s quite difficult to know whether or not they are needed, or if there may be something even more serious going on.

Antibiotics to prevent infections:

In certain circumstances, we give antibiotics to prevent infections. This isn’t something we do for the average child, but for those with chronic conditions that predispose them to bacterial infections, it can be quite effective. For most of these situations, there are clear, evidence-based guidelines about when this prophylaxis should be started and which antibiotics should be used.

How much is too much?

Some children have frequent infections that require so many courses of antibiotics that it’s generally considered better to take another approach. Common examples are ear infections and strep throat, both of which can be treated with surgical procedures as well as medications. Because surgery isn’t without complications, there are published guidelines to help determine when these procedures may be justified. The general rule for ear tubes is 3 ear infections in 6 months, or 4 in a year. For removing tonsils because of strep throat, it’s even more strict: 7 episodes in a year, 5 each year for 2 years, or 3 each year for 3 years. It should go without saying, but it’s important that these infections be accurately diagnosed. Sadly, that’s not always the case.

Do people become immune to antibiotics?

It’s important to remember that antibiotics don’t treat people, or even diseases; they treat bacteria. Unlike most medications, which are intended to interact with the cells in your body, antibiotics are designed to affect only bacteria. Because of this, their effectiveness relies not on the patient or the disease, but on the specific organism causing the infection. For this reason, people don’t grow “immune” or “tolerant” to antibiotics, but the bacteria that live on or within them certainly may. For people with chronic medical problems who receive frequent antibiotics, this is a very real problem.

Side effects vs. allergic reactions:

Like any medical treatment, antibiotics have a risk of side effects. These can vary from mild to life-threatening. (Fortunately, the life-threatening ones are rare). Specific side effects depend on the medication, but upset stomach and diarrhea are very common; this is often a result of the antibiotics killing off beneficial bacteria as well. Giving probiotics or yogurt to replenish these living organisms (the “good guys”) can be helpful.

Rashes are also very common, especially with amoxicillin. These are not always dangerous, but are worth a call to your doctor. There’s a chance that the rash could be caused by the infection itself, or that it could be a sign of an allergic reaction or another serious condition.

Another mild, but frequently distressing, side effect is red stools caused by cefdinir (Omnicef). I’ve seen it at work, but I’ve also had a few distressed calls from friends (one of whom was on the way to the ER). It’s not blood–just a pigment from the medication passing through. Nothing to worry about.

Life-threatening allergic reactions (anaphylaxis) are infrequent, but they do happen. Symptoms include rash, vomiting, cough or difficulty breathing, and swelling of the face, mouth, or throat. These reactions would need emergent medical attention, and if you have an Epi-pen…well, this seems like a pretty good time to use it.

Conclusion:

I realize that much of what I’ve said may sound like I’m bashing antibiotics. I’m not. I prescribe them frequently, and I’ve cared for numerous patients that would be dead without them. What I am saying is that, like any other medical treatment, we have to balance their benefits against their risks (both direct and indirect). We should avoid them when possible and use them judiciously when necessary.

All this leads to an interesting question–how should parents discuss this topic with their child’s doctor? Probably the most important step is to avoid insisting on antibiotics. As physicians, we struggle to balance good patient care with the ever-increasing demands on our time. If it’s obvious when a mom walks in the door that she isn’t leaving without a prescription, many of us will forego the discussion; it takes a lot less time to write the prescription than to explain why it isn’t necessary.

Another challenge we face is that we want to do something; after all, that’s why you brought your child in. Often, that “something” could be as simple as listening to your story, doing a physical exam, and reassuring you that no antibiotic treatment is necessary (you know, the “just a virus” talk). But we often perceive pressure from parents–whether it’s real or not–to prescribe medications, even when we know it isn’t necessary.

On the other hand, many doctors over-prescribe without any external pressure at all. If you find yourself in this situation, it’s certainly ok to ask (in a non-confrontational way) whether antibiotics are truly necessary. If your doctor is offended by this question or unable to communicate his reasoning, consider finding a new one. One of the best things you can do for your child’s health is to find a pediatrician whose treatment philosophy aligns well with yours, and whose judgment you trust.

As always, your comments are welcomed (even if you happen to disagree). I'll get back to you as soon as I can. Please try to keep it civil--I reserve the right to delete comments that are offensive or off-topic.

5 thoughts on “The Parent’s [Long-Overdue] Guide to Antibiotics

  1. I find it interesting that you say strep throat does not always need to be treated with antibiotics. While it will get better on it’s own, traditional teaching is to treat to avoid the possible (albeit uncommon) Rheumatic heart disease complication. Do you not agree with that?

    • Exactly–I think that’s an area where “traditional teaching” could use a tune-up. Antibiotics can help shorten the duration of symptoms from strep throat by 12-24 hours. But the real reason we give them is to prevent rheumatic fever. Except it’s not a very good reason.

      The studies about strep treatment and rheumatic heart disease were done 70 years ago in a young adult population. Best case, treating with antibiotics reduces rheumatic heart disease by 50% (doesn’t eliminate it). Cutting the risk in half sounds great, until you translate this from relative risk into absolute risk, factoring in the insanely low number of people who actually get rheumatic fever.

      With the number antibiotic prescriptions that are written for strep throat (and the adverse effects/cost/resistance that come with them), I just don’t think the math adds up. David Newman makes a great case for not treating adults here. As far as kids go, I’ve written on this topic specifically in a previous post. It’s not that I think strep throat should never be treated…I just think it doesn’t need to be automatic. I think informing parents about the remote (1 in millions) chance of rheumatic heart disease vs the relatively common diarrhea/rashes/allergic reactions with antibiotics, and then letting them decide is a perfectly acceptable approach. Another consideration is that if you’re not planning to treat, there’s no point in testing either.

      Would love to hear your thoughts. Thanks for reading!
      -Chad

      • I had a chance to read your strep article and did find it very intriguing. Interestingly, many years ago I stopped doing back up cultures after a negative rapid strep after seing the statistics on the likelihood of the rapid strep missing a case of strep, AND that particular strep strain being one that caused RHD. It is almost non existent. Then I started working in a practice where everyone did do the cultures, and I felt (although it may not have been true) that it seemed weird to everyone that I did not. So I started again. At the very least I will stop doing that. How does it go over with parents when you tell them that you do think it is strep, but that you do not recommend antibiotics? And what percentage of the time do you not treat strep? At times I have a hard enough time convincing parents that their kid doesn’t need the antibiotics for what is clearly a viral infection (of course I do not give them- and have some negative Yelp reviews and insurance satisfaction ratings to prove it. sigh).

        And do not even get me started on the ED and urgent care doctors who do call it strep and treat without testing!

        Very interesting reads– I will share them both with my practice partner (who is also my husband).

        Michelle

        • Michelle–glad you found it informative…or at least thought-provoking.

          If I feel that a patient is more likely to have viral pharyngitis than strep, I usually don’t test at all. If the story sounds like strep, I discuss with the parent that strep typically resolves on its own, and the reason we have traditionally treated it is not to fix symptoms, but because of concerns about extremely rare complications. I explain that antibiotics have complications, too, and that these are more common than RHD. If they decide that they would want treatment, I send the RST–and if it’s negative and I don’t believe it, I’ll sometimes send a backup Cx. If I wasn’t really convinced (like the nurse already did the RST before I walked in the room, but it sounds viral), I don’t bother with the Cx. And I NEVER treat without a positive test. I think the chance that the few that I miss will have complications that could have been prevented by treatment is remote.

          I don’t typically run into the situation of having a positive test and not treating because if the parent and I both agree not to treat, I don’t test (there’s no reason to). The percentage of parents that make that call really depends on your patient population. Education level, anxiety, desire to avoid unnecessary intervention, etc. all factor in. But I have had numerous parents who were thankful that I offered them the choice and explained the reasoning behind it.

          It takes more time than just treating, but I think it’s good medicine. Too bad online reviews don’t always reflect true quality.
          -Chad

          • Noted this article was a couple months ago, but I am intrigued.. I agree with much of your thinking absolutely. However, I guess my child was the one in millions who was just diagnosed with Sydenhams Chorea/rheumatic fever. So while a clinician I tend to follow and trust your logic wholeheartedly, but as a mother with a son that has now been suffering for 7 months with neuropsychiatric symptoms related to rheumatic fever I rethink ALL of this every minute of the day.. Why didn’t I push for antibiotics earlier.. Because of the same rationale you presented.. Even though my gut told me mercilessly he just needed the right dosing of antibiotics.. I am curious with changes in tonsillectomy guidelines etc. Is it possible that we may see RF on the rise because of this? I have never once had a positive throat culture or treated my child for strep until his illness in Feb and in now eradicating him for strep found his tonsils after removal were full of strep. We are lucky so far, his cardiac echo seems ok, we presented purely with Sydenhams chorea and high fever and progressed psychiatrically over months. He just attended the first 2 full weeks of school since this began in Feb. His improvements came about with high dose antibiotics and prednisone, but now we wait and hope we can spare his heart on low dose antibiotics until he is 21…

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