Last week, we discussed how to take care of a sick child. Susie came in with a fever, cough, and runny nose, and we talked about the importance of treating the fever and keeping her hydrated. But gosh darnit, you want her illness to go away, for her to be able to go back to school or daycare, and so on. So, you demand a medication to make things go away. An antibiotic. Your pediatrician refuses, saying that it's not indicated.
Look, I understand why you want your child to feel better. You hate seeing them sick. I get it. Really, I do.
But antibiotic use with diseases like the one above is such an issue that the American Academy of Pediatrics has made it #1 on their list of 5 things pediatricians and parents need to discuss.
Let's take a step back a moment. As a kid, you certainly learned about germs. The germ theory of disease, that is, that germs cause disease, has been around since the mid-1800s. It is the reason that when you go into surgery now, any member of the staff touching your open wound is 'sterile', and the reason we wash our hands when going into and coming out of patient rooms. The reason you probably tell your children to wash their hands before dinner, and Lysol every surface in the house if you have a bad illness spread through.
There are four major types of 'germs': bacteria, viruses, parasites, and fungi. Bacteria causes diseases like strep throat (which is caused by a streptococcal bacteria), some pneumonias (infections of the lung), and some other, rarer infections of the brain, sinuses, and intestines. Parasites include malaria and pin worms. Fungi cause diseases like athlete's foot, yeast infections, and ringworm. Viruses can cause any number of different diseases, so many that we don't always know about them. The common cold is caused by a group of viruses called rhinoviruses. Herpes, chicken pox, the flu, cervical cancer, and any number of other respiratory or stomach bugs are also caused by viruses.
Statistically, you are more likely to come in with a disease caused by a virus than one caused by any of the other groups of germs. Antibiotics are not effective against viruses. We do have some medicines that are effective against some viruses; for instance, cold sores caused by the herpes virus can be treated with acyclovir to shorten the course of disease and the flu can be treated early on with Tamiflu (though it really doesn't help). But amoxicillin won't make your cold go away.
As with fevers, showing up to your doctor within the first few days of an upper respiratory infection (a cold) doesn't tell us a whole lot. It could be bacterial, but it is much more likely to be a virus. And if antibiotics aren't going to help you, then the risk of them doing harm outweighs the benefit. Any antibiotic, but particularly the penicillins, can cause life-threatening allergic reactions, or more mild side effects such as diarrhea and vomiting. Why chance it if you don't need it?
So when should you get antibiotics? The American Academy of Family Practitioners recommends antibiotic use for upper respiratory infections only if the symptoms have lasted 10 days. Viruses generally go away after 5-7 days (though the cough may last up to 2-3 weeks), but if you continue to have fevers, runny nose, etc after that period, or if you start to feel better and suddenly get worse, you're much more likely to have a bacterial infection. Note that the color of the snot or mucus has no bearing on whether or not it is bacterial or viral. Unless it's clear, then it's more likely to be allergic in nature, rather than infectious.
What about other things?
Ear infections should generally be treated, but the physician should see a bulging, red, and pus-filled ear-drum. An ear drum that just has fluid behind it is not a sign of a middle ear infection, and antibiotics should not be given in those cases. You can see some examples of what ear drums look like here.
Bronchitis (chest colds) should probably be evaluated by a physician, but generally follows the same concept as upper respiratory infections: no antibiotics until 10 days into the course, or if you get better and take a turn for the worse. There is one important exception: if a child has coughing spells so severe that he/she vomits at the end, or has a "whoop" trying to breathe during the spell, he or she should be seen, as these are indications of Pertussis, which can be life-threatening in very young children. There is an antibiotic treatment for it, but often once the coughing starts, the antibiotic is no longer effective.
There is some current debate over whether or not strep throat needs to be treated. Antibiotics do not shorten the course of strep throat. The reason we give them is to prevent the development of rheumatic fever, which can lead to permanent heart damage. It's a rare complication of strep throat, and studies have shown that treatment with antibiotics essentially eliminates the risk of rheumatic fever, but there has been some concern that the risk of complication from using antibiotics exceeds the risk of getting rheumatic fever in developed nations (David Newman, who is an awesome speaker, talks about this a bit in his book Hippocrates' Shadow). But, antibiotics should only be given in patients who have a positive strep test, or who have a high suspicion for strep throat, which is not the case in most instances of a sore throat.
Bottom line, those physicians who argue with you about the need for antibiotics are trying to help you. They are not trying to make your life more difficult. Instead, they are trying to eliminate the risk of a complication from taking an unnecessary medication. If they're doing their job right, they should provide you some information about how to treat your symptoms and get you back to your normal self, even without antibiotics.
If they aren't explaining to you why, ask. It's your right as a patient to know what your physician is thinking when deciding on treatment. And if you don't agree, talk about it. Don't get mad and run off to another physician who will just give you what you want--those aren't the type of physicians you want around when things get hairy because they truly don't have your best interests at heart.
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