question from a pediatrician

[Anonymous]

OP - can you tell me, if a 2 year old gets ear infections, do they need antibiotics? I know it is viruses that cause him to have fluid in his ears that then doesn't drain. They tell me his ears are red and sometimes they say 'very infected'. Is that a case where antibiotics are needed? I hate the fact that my 2 year old was on antibiotics 3 times in 3 months. I always question it because I don't like the kids to be on antibiotics. But I'll never know if they got better quickly because of the antibiotics or not.

Anyway, I have personally been given antibiotics as a precaution when the doctor and I both know it's a virus. I recently had bronchitis and was told by the doctor to take antibiotics as a precaution (because it was chronic). Are too many doctors trying to 'please' patients? Should I be questioning the doctors more?

[Anonymous]

For many people there is probably nothing you can say that will convince them that your decision to withhold antibiotics is justified, and/or not motivated by a desire to save money/deny coverage to disadvantaged groups. You can just explain as best you can, send them out, and move on to the next patient. That's life.

[Anonymous]

Anonymous wrote:OP here - thanks for the replies - I do work for a very underserved population and their access level to health information is probably well below the average dcurbanmom or dad level...

I guess the tricky thing, as you all noted, is that bacterial infections can develop on top of viral infections and require antibiotics and that many illnesses CAN worsen and develop into something very serious (RSV cold to RSV bronchiolitis to RSV pneumonia to bacterial super-infection of pneumonia to hospital patient for 6 days) and while I always mention this to patients/parents (and I know my colleagues do as well), I find parents are angry at having to return if their child worsens and think that a course of antibiotics 3 days ago would have prevented this current illness...

Also, to the poster above who recommended I ask the hospital admin to provide information, we provide very thorough discharge paperwork that describes viruses, why antibiotics are not needed, and what to return for, and I'm not really looking for what an administrator thinks we should do to educate the community; I'm looking for what an individual parent wants/needs to hear to feel comfortable in the knowledge that their child is safe right now and to feel comfortable caring for their child at home and knowing what to return for... and I think how you want your doctor to talk to you is universal across socioeconomic lines, so I think its worthwhile asking in this forum.

Is there data that says that a course of antibiotics DOESN'T prevent a secondary infection? I am not the type to demand antibiotics, but I also do not know if there is real data to answer that question. For all I know, people are behaving rationally as individuals, even if it costs the public as a whole by reducing the long term effectiveness of antibiotics.

[Anonymous]

If it's a low income population, I imagine a lot of parents are in a difficult position of trying to work while dealing with a sick kid that maybe can't go to day care. I understand the wanting a magic bullet. I agree with the PPs about explaining why you think it's a virus (antibiotics won't help and could give kid diarrhea, etc.) and not bacterial (in which case antibiotics would work), and that sometimes it can turn into a bacterial infection but not usually, and that it is better for the kid's overall health NOT to take antibiotics unless necessary. And stress that if you had any indication that there was a bacterial infection you'd definitely recommend antibiotics, but since there is not, it wouldn't be good for the kid to take the antibitotics.

[Anonymous]

Is there data that says that a course of antibiotics DOESN'T prevent a secondary infection? I am not the type to demand antibiotics, but I also do not know if there is real data to answer that question. For all I know, people are behaving rationally as individuals, even if it costs the public as a whole by reducing the long term effectiveness of antibiotics.[/quote]

I think the poster above exemplifies what is going through the minds of parents in these situations. Oftentimes, especially if one has had to miss work to stay home with a cranky toddler, parents are at the ends of their ropes already. Add to this the reality that people often equate more with better, and you get the demands for antibiotics. Every medication, even something as helpful and nice sounding as antibiotics, has side effects. If you have a confirmed infection that an antibiotic will treat, those side effects (nausea, stomachache, yeast infections, allergic reactions) may be well worth your while, but taking them just in case you might be preventing something seems like a less than ideal option in the long term. It seems like the relevant question is whether taking antibiotics prophylactically has any benefit compared to watchful-waiting and taking the antibiotic upon confirmation of bacterial infection?

[Anonymous]

OP here - thanks everyone for your posts and ideas... you've given me a lot to consider.

some of the questions really got me thinking that if THIS audience doesn't understand that antibiotics can not and do not prevent infections (but instead breed resistant bacteria), then I need to spend much more time with my patients discussing the biology of it all...

in terms of ear infections: most are viral, in fact, 90% are probably viral and its actually best practice in Europe to give pain medications only (ear drops which can be used every 1-2 hours and oral meds like tylenol or motrin)... another option that has a lot of academic support in the US, but which few primary pediatricians are actually practicing, is to tell the parents the infection is likely viral and to recommend pain medication both in the ear and oral and then give a prescription and tell the family not to fill it or use it unless the child is still sick or worse 48 hours from the start of the ear pain. I've actually successfully used this in the ER setting - parents are satisfied and in control, but who knows? maybe they just run out and fill the script right away...

I find a lot of primary care doctors give antibiotics very quickly and don't utilize telephone or in-person follow-ups to determine if the patient is truly worsening or not improving, especially doctors for adults... and the patient will take the Z-pak or equivalent med and feel better in 3 days, which they would have anyways, but they've now developed a connection that Z-pak made them better...

for instance, in the case of Strep throat, a true bacterial infection that can be confirmed quickly by a test in the office, while children should be treated promptly for 10 days (to prevent the risk of rheumatic heart disease), in adults (who have NO risk of rheumatic heart disease), treatment with appropriate antibiotics DOES NOT decrease the number of days of symptoms or the severity of symptoms at ALL. This is shown in large placebo controlled clinical trials. Its good medicine NOT to treat Strep in an otherwise healthy adult (who had no contact with little kids).

[Anonymous]

Thanks for that strep throat factoid - I had no idea!!!

So, no antibiotics for strep in adults, it will go away on its own, but for kids, antibiotics are important to manage symptoms so they will not develop into complications.

[Anonymous]

This is very interesting. I feel that I personally, if anything am way too ANTI-antibiotics. I feel like my own doctor is way too eager to prescribe them. I get a lot of sinus infections, though, probably bacterial, and they don't go away without them, so eventually I need antibiotics but I just wish she wouldn't throw antib's at everything so that I could trust her when she says I DO need them.

I think the problem is that it is hard to find a good primary care physician in this area and more and more people feel almost combative when it comes to dealing with their doctor. We need them for the prescription but often disagree with them about everything. Which SHOULD be ludicrous given that none of us have medical degrees but, sadly, we're often right!

I found a great pediatrician for my son and I really wish she were my physician as well. She is an allopath who will prescribe but is very careful about doing so. She actually told us the same thing about ear infections! It feels good to think we can medicate away every illness but I'm glad to have a doctor who will be honest with me.

so OP, respect your patients and their parents as you seem to already do, give them as patient an explanation of why antibiotics may actually harm and not help the child, and then that parent will be a better participant in their child's health care even when you're not the doctor.

Maybe.

[Anonymous]

Show your patients this article about how antibiotics are losing efficacy:

http://finance.yahoo.com/insurance/article/108931/rising-threat-of-infections-unfazed-by-antibiotics?mod=insurance-health

[Anonymous]

"Is there data that says that a course of antibiotics DOESN'T prevent a secondary infection? I am not the type to demand antibiotics, but I also do not know if there is real data to answer that question. For all I know, people are behaving rationally as individuals, even if it costs the public as a whole by reducing the long term effectiveness of antibiotics. "

I don't think this poster was making the more is always better argument bt the individual vs public health argument.

Now I am curious about something...a doctor can only diagnosis a bacterial infection when you exhibit a certain threshold of symptoms. The bacterial infection did not present at that instant, it was present before but the symptoms had not built up yet. Even if you only have a viral infection, wouldn't a bacterial infection be unable to take hold if you were already on a course of antibiotics and therefore they are preventative? At the individual level, this sounds perfectly rational. A study that showed that an individual on a recent dose of antibiotics was just as likely to develop a secondary bacterial as an individual who was not would be compelling but I don't think that is what the medical studies show.

[Anonymous]

OP, something to consider - you indicated that your patients are underserved - poor, without health insurance, or whatever that entails. They probably want to get the antibiotics while they are there in order to avoid having to come back and rack up another bill. I still see your point, but maybe this will help you to better understand where they are coming from.

[Anonymous]

I think in an underserved population sometimes healthcare providers use too big of terms and might benefit from thinking of real life examples or analogies to explain the diagnosis and treatment. Also, I do think that some are fearful of a return trip, another bill, etc. Recently my son spiked a fever (102) after having a viral infection for one week. I took him to Nighttime pediatrics because of my concern for a pneumonia and they felt it was another viral infection. Sidenote - I work in healthcare and don't like antibiotics but don't want to create the super infection you were referring to either! I was a little frustrated at the pediatrician telling me it was a viral infection again just because that was $150 down the drain and it was what my gut told me but I couldn't be for sure. I was most frustrated that it could still turn bacterial and if it was off - hours for my primary pediatrician (it was a Friday night) that I would have another $150 plus out of network charge if I had to return. The pediatrician that I saw at Nighttime went on to say to me - these are the symptoms to look for, this is why you would come back if it is off hours, see your pediatrician on Monday, and we will not issue a second bill IF this turns into something bacterial over the weekend. He was confident that it would not. It did not and my son got better but I was worried.

This advice is probably not helpful to you because most of your patients probably use you as their primary pediatrician.

[Anonymous]

Anonymous wrote:OP, something to consider - you indicated that your patients are underserved - poor, without health insurance, or whatever that entails. They probably want to get the antibiotics while they are there in order to avoid having to come back and rack up another bill. I still see your point, but maybe this will help you to better understand where they are coming from.

I've had the one experience where I was coughing, throat hurt, lost my voice and went to my doctor on day two and he/she said it was viral. I was like you gotta be sh***ng me. There is nothing you can do for me. The doctor went on to explain a virus versus bacteria and being very clear - must be bacterial to get antibiotics. It was like the old joke - "take two Tylenol and call me in the morning". I had to self-medicate with theraflu at work until my voice came back. I think I was frustrated that I wasted my time and money (I was out of town for work) going to the doctor when there was nothing they could do for me. I'm very careful now to wait something like 4 - 5 days before I go to the doctor to lessen that I will go and be told it is viral not bacterial. I just pray I don't ever get some fast moving illness because since the "it's just a virus", I wait it out a few days.

So anyway, I think after someone has waited at the ER - which could be a 2-4 hour wait, and don't even want to imagine the bill - to be told there is nothing that can be done is not a great feeling. Imagine if you brought your car into the garage and took half a day off work and they told you - oh it's related to the cold weather - this will clear up on its own - please pay $150 at the front desk (many insurance companies have a higher co-pay if you go to the ER by the way). I know it isn't an exact example but that is the closest I can think of. The only thing that could soften the blow of finding out there is no antibiotics on the horizon is the knowledge that if you get antibiotics when it won't make you better, it lessens the chance it will work when you really need them. Also, if for some reason it does turn into a bacterial infection - you have an option to be seen quicker and at less expense that next time around.

[Anonymous]

OP, I am also a doctor, when I traveled to Europe years ago, I noticed that people there had a MUCH better understanding of the "no antibiotic for virus" policy.

In this country, there was a time when doctors did give antibiotics for any "cold" to make the patient fell they were getting something out of the visit.

Sad, but I have heard European doctors say that American doctors are afraid of their patients. Maybe a bit true.

[Anonymous]

Short answer; most people are sheeple idiots, so nothing you can say will change their minds re: abx. Of course, this opinion is coming from a mom whose 4.5 yo has never been to the dr for an illness. Also, he's never had a vaccination, so I'm sure you think I'm the idiot. That is immaterial to me. If DS had something treatable by drs ie a bacterial infection, being hit by a car, drowning, a broken bone, etc, I'd be there to see you in a heartbeat, otherwise, I'll treat him with supportive care and hope for the best (whereas generally, you'd treat him with expensive "medical" supportive care and hope for the best, IOW, not a huge difference in treatment modalities). Drs are God's gift to humanity for some things; for most, they're useless....no offense intended, seriously (99% of things we go to drs for are viral and therefore largely untreatable by doctors).