question from a pediatrician

[Anonymous]

If I came to the public ER as my primary source of medical care, and I'm worried about my sick kid, and I waited to see a doc (probably for a long time), then I sure as hell don't want to be told by some doc that "it's probably just a virus" and be sent away with nothing tangible to show for my efforts. And I also don't want to risk coming back to do it all again later, so I want to leave with some medicine just in case. Give your patients something tangible, even if it's just a free sample of Theraflu or an aspirin. (Can you prescribe a placebo?)

Also, while I might understand the long-term societal risk that over-prescription of antibiotics could lead to drug-resistant bacteria, I'm not really interested in the long-term risks to society when my kid is sick. I just want something to make her feel better, and I don't like some doctor telling me there's nothing I can do. I feel like I'm being screwed, and maybe the hospital is just trying to cut costs by withholding medicine.

I agree with PPs that if you're going to withhold medicine, you need to explain the risks of taking the medicine. "Here's what will happen to your child tonight if I give her antibiotics: ...." I've had several situations where doctors will give me a prescription for antibiotics "just in case." When this happens, many people (including me) start to see antibiotics like chicken soup for the dead man in the old vaudeville joke (i.e, "it couldn't hurt!").

[Anonymous]

I have actually turned down antibiotics when an NP suggested them as preventative. I don't know if they are effective before a bacterial infection shows up. I am not risking all the side effects until I know for sure.

I talk to people about this all the time. I am shocked that otherwise intelligent and informed people think antibiotics are going to clear up their cold or flu.

Explain the risks to their child and maybe add that taking too many antibotics is bad for all of us.

[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....

OP, I am a doctor and a minority. I really wish that we as a profession would stop making such generalizations. They are not helpful. The upper SES are the people I see getting the most unnecessary "care" in the US because they are misinformed. Not meaning to hijack your thread.

[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...

2nd poster here - we may work in the same ER.

[Anonymous]

Anonymous wrote: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.

This is interesting. I lived in Chile for 3 years (back in the late 90's) and antibiotics were sold over the counter. If you had a cold, the advice would be "go get some antibiotics". It always shocked me. So that is quite the other extreme.

[Anonymous]

Anonymous wrote: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).

This might be one of the stupidest posts I have ever read on DCUM.

[Anonymous]

Anonymous wrote: (99% of things we go to drs for are viral and therefore largely untreatable by doctors).

Really? I've been in for a lot of things, but only have I rarely been in for a virus. I've gone for advice because the risks of the virus seemed higher than normal (ie severe dehydration during 3rd trimester).

I think your stats are a little off.

[Anonymous]

OP here - three final things I want to say and then I'll sign off...

one, to the previous poster who said something about being a minority physician and thus, not generalizing, how do you know what I am not one as well? How do you know if I'm not African American, like 70% of the patients presenting to DC ERs? Or a child of immigrants, like 15% of our patients?It is not a generalization to say that my patients are underserved and don't have access to healthcare info - I am the physician in that population and I know where they go for care and where they can get information. I know how few have personal computers in their homes (I ask this all the time to encourage people to look things up on their own).

two: to the anti-immunization PP: Feel free to believe what you like about immunizations, but here's the deal from my point of view: if you come to the ER with your under-2-year old child and they have a fever over 102.2 (and is well-appearing), we need to do some testing (based on research of height of fever and risk of serious bacterial infection)... if your child is fully immunized, these tests are fewer and less invasive b/c your child is at much lower risk of a serious illness. Immunizations (for instance, the Prevnar and the Hib) have helped drop the rate of deaths due to Strep pneumoniae bacteremia and pneumonia and H. flu epiglottiis in children immensely. These bacteria are still floating around in the community, so herd immunity won't protect your child. I have seen children with Strep pneumoniae pneumonia deteriorate and die in my training. Devastating.

and three: drug-resistant bacteria is not a public health issue, its a personal issue... for instance, if i look at your pretty well-appearing kid who has a viral syndrome and i can't find a single source of a bacterial infection (they have no ear infection, no pneumonia, no UTI, and no strep throat) and i want to give an antibiotic to prevent "something" from developing, what medication do I choose? Low-dose Amoxicllin? Perfectly adequate for a first-time ear infection, but not for a pneumonia. Do I pick high-dose Augmentin, which kills some resistant bacteria? Good for some pnuemonia,s some recurrent ear infections, but bad for a UTI... Do I pick Ceftin, which overcomes even more drug resistance than Augmentin? Good for some pneumonias, some UTIs... Or should I admit you for Vancomycin, which kills pretty much everything?

Giving antibiotics without thought for what is being treated and what is needed leads to resistance in INDIVIDUALS. It makes your child need stronger and stronger antibiotics each time they get sick with a bacterial infection... That's why when I'm your child's doctor, I try to avoid using antibiotics if at all possible...

[Anonymous]

Anonymous wrote:

Anonymous wrote: (99% of things we go to drs for are viral and therefore largely untreatable by doctors).

Really? I've been in for a lot of things, but only have I rarely been in for a virus. I've gone for advice because the risks of the virus seemed higher than normal (ie severe dehydration during 3rd trimester).

I think your stats are a little off.

ITA. I have been to the doctor more than anyone I know, for all kinds of things. Never once has it ever been for a virus.

[Anonymous]

Anonymous wrote: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.

I don't see how you won't get complications just cause you're an adult. I seriously doubt that adults have never had a Strep complication. Also, if you are Mother, you would want to get on antibiotics so you don't give it to your kids.

Have you ever had Strep Throat as an Adult??? I did and it was horrible. I tried to wait it out, but after not eating anything but juice for three days and being in constant excruciating pain I went to the doctor and got on antibiotics. If I get it again, I will go the first day. The only thing I got out of the experience was loosing 6 pounds.

[Anonymous]

Ditto on the strep. I woke up one Sunday morning with it. The pain was so excruciating, like knives every time I swallowed. I went to the ER.

[Anonymous]

Same strep pain as a PP and I'm 33 with a high pain tolerance (chose natural childbirth and dealth with the pain). The Strep SUCKED.

Back to the original ques, though, one somewhat silly is that in some sense, antibiotcs means it will be over sooner. I have a PhD and I'm a smart, scientific person and I KNOW antibiotics won't help a virus. But when my kid has a fever and is ill, a teeny tiny part of my hopes that it's an ear infection or something simple that can be treated with antibiotics because that means after 2-3 doses, s/he will be better.... unlike a a virus where, odds are, it could last a week, you don't know the course of it and what to expect and that you might get a secondary bacterial infection anyway. It's hard to see you kid miserable, and that small notion of it getting better in 24-48 hours versus 5 days or whatever makes a big difference, at least emotionally. I'm not saying I want the antibiotics for a virus just sometimes antibiotcs = kids better faster.

Also, I too have had my 4 month old discharged from the ER (where I was sent by the ped's office) for "a virus" when in fact she had a double ear infection that he MISSED because her little ear canals were so small (the ER doc's words). Nice. She lost weight and suffered a lot in those two ensuing days that I was told to wait to bring her back in. And at 4 months, that is a big deal bc she didn't eat/nurse much at all, etc. Anywa, I digress... I think I felt blown-off by the guy and thus suspicious of the "virus" answer.

[Anonymous]

Definetly focus on the damage giving the antibiotics could do to the child. THe child could develop a resistance. There could be horrible side effects and no benefit.

And realize that some people are never going to understand. They want a quick fix. You aren't going to make them happy. Just know you are doing the right thing.

[Anonymous]

Nothing. I am a microbiolgist though...so I get it. I understand the mechanics of how antibiotics work.

If you use them for viruses they are ineffective and contributing to the rise of antibiotic resitant microorganisms for which we are running out of antibiotics that can effectively treat them.

My 2 and 4.5 year old have never had ear infections or anything requiring antibiotics...in fact they've never had diarrhea or any other illness other than very minor colds. I am against the overuse of antimicrobial santitizers (outside of hospitals and medical facilities) and I am not neurotic about them washing their hands (obviously after they go to the bathroom, or touch raw eggs, etc...) but I'll be honest not before eveytime they eat something. I think their immune systems are strong for part of this reason.

[Anonymous]

OP - I think it is just hard. Some people want a magic pill. I think definitely including inf about the negative side effects could help dissuade some people -- and info about what to look for re possible secondary infection. But I also think the cost of a second ER visit leads some to demand the script right away.

Re your comment on strep, I was surprised to hear no antibiotics for it for adults (who have no contact with little kids). I had strep last year, waking up on a Friday with a fever. I did not get to the doc until Monday, when I still wasn't feeling better. Got diagnosed with strep, started on antibiotics, and was improving by that evening. Of course, maybe I would have anyway? Is that what you're saying? It sure didn't feel like it at the time! Then again, I do have contact w/ little kids...