question from a pediatrician

[Anonymous]

Hey, i'm a pediatrician in a busy ER - I often see children who have waited several hours to be told they have a virus. I find that no matter how much I explain that viral and bacterial infections are different and that there is no evidence of bacterial infection in their child, parents often leave dissatisfied if they leave without an antibiotic prescription. Many parents also want antibiotics to "prevent" a more serious infection from occurring and don't really believe that antibiotics can't be used as prevention.

What would you need to hear to trust that doctor's advice that your child does not need antibiotics?

Recall, I'm working in an ER; they don't know me and may never see me again even if they return to the ER, so I don't have the luxury of trusted relationship that a primary care physician does.

[Anonymous]

I leave happy that I don't have to force antibiotics down my toddler. But then again I work in an ER too.

[Anonymous]

I don't think you can, really. I completely understand where you are coming from, but there's always that case where a bacterial infection develops on top of the viral one, for whatever reason. I had a sinus infection for a month, no fever, no other symptoms of bacterial infection, but it did not go away until I got TWO courses of different antibiotics. And while many parents will be wrong about their being a bacterial infection, I am not a firm believer in mom's (and dad's) intuition that something is just not right with their kid.

So what I'd like to hear from a doc is that it's a viral infection, and 99% of the time it will clear on its own. But in the slight chance a bacterial infection develops as well, then you'll need antibiotics. Here are the signs to look out for. And go to a Nighttime Pediatric or other clinic before hitting the much more expensive ER.

[Anonymous]

There has been a huge movement and a lot of success in curbing this issue in health care. I'm surprised your hospital does not have resources for you?

Maybe it has been centered in primary care. Overuse of antibiotics has been a major problem and it seems to be getting better due to the quality initiatives put in place that rates doctors, hospitals, etc. Maybe ask the administrator in your hospital. There are hand outs, etc. you can give to parents about the harms of taking antibiotics for viruses (in terms of creating resistant strains of bacteria, etc.).

Honestly, if you are posting from the DC area, I'm surprised to hear this. In my circle, parents are more averse to the over-medicalization of their kids (hence the anti-vaccine clusters). I'm surprised to hear this is a problem here, but it could be you are serving a different demographic - possibly uninsured (otherwise they would be at their ped's office and not the ER for a virus).

[Anonymous]

Anonymous wrote:I don't think you can, really. I completely understand where you are coming from, but there's always that case where a bacterial infection develops on top of the viral one, for whatever reason. I had a sinus infection for a month, no fever, no other symptoms of bacterial infection, but it did not go away until I got TWO courses of different antibiotics. And while many parents will be wrong about their being a bacterial infection, I am not a firm believer in mom's (and dad's) intuition that something is just not right with their kid.

So what I'd like to hear from a doc is that it's a viral infection, and 99% of the time it will clear on its own. But in the slight chance a bacterial infection develops as well, then you'll need antibiotics. Here are the signs to look out for. And go to a Nighttime Pediatric or other clinic before hitting the much more expensive ER.

Meant to say I am NOW a firm believer....

[Anonymous]

Good question!

I am a parent who totally understand the difference between a viral and bacterial infection and how antibiotics works for one but not the other.

So I guess what I'd want to know is why you are reasonably sure my child has a viral infection, not a bacterial one. Instead of hearing "it's just a virus" I'd like the Dr. to take a bit of extra time (not even a minute) to explain why you think it is viral, not bacterial in nature; and what symptoms I should look out for later that could indicate bacterial infection; with reassurance that if I see those, a return visit and prescription would be called for.

My big fear is the news reports I read where a child is sick, sent home with a "viral" diagnosis, but it turns out the child had an underlying bacterial infection. We parents are told to watch for a child who is sick, seems to get better, but then a high fever returns, as that is a sign of bacterial infection; however, as a parent I have to tell you the last two times such an event happened with my kids, the doctors told me it was probably a different virus! So it's hard as parents to know where to draw the line between wanting to be laid back, and not wanting to overlook anything.

[Anonymous]

Anonymous wrote:Good question!

I am a parent who totally understand the difference between a viral and bacterial infection and how antibiotics works for one but not the other.

So I guess what I'd want to know is why you are reasonably sure my child has a viral infection, not a bacterial one. Instead of hearing "it's just a virus" I'd like the Dr. to take a bit of extra time (not even a minute) to explain why you think it is viral, not bacterial in nature; and what symptoms I should look out for later that could indicate bacterial infection; with reassurance that if I see those, a return visit and prescription would be called for.

My big fear is the news reports I read where a child is sick, sent home with a "viral" diagnosis, but it turns out the child had an underlying bacterial infection. We parents are told to watch for a child who is sick, seems to get better, but then a high fever returns, as that is a sign of bacterial infection; however, as a parent I have to tell you the last two times such an event happened with my kids, the doctors told me it was probably a different virus! So it's hard as parents to know where to draw the line between wanting to be laid back, and not wanting to overlook anything.

This.

[Anonymous]

I agree with others that you need to be explicit as to why you do not think there is not a bacterial infection.

If the parent had an experience in the past with the child being sent home with just a virus, only to be back two days later and then be diagnosed with a bacterial infection they will push harder. As long as the kid doesn't end up in the hospital or die, it is not really an issue for the doctor but for the parent they saw their child suffer in pain for an extra two days. They also will second guess themselves whether they should have pushed back on the doctor.

I agree that referring to a NightTime Pediatrics is a good idea. Some primary care peds use the ER as their after hours office and liberally send patients there on evenings and weekends.

[Anonymous]

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.

[Anonymous]

I don't think anyone has mentioned this yet - but instead of being defensive, go on the offensive. Explain to them in a few clear points, why it is damaging to their children to give them antibiotics that are not needed. Some people have no idea that there is harm in giving too many, or unneeded, antibiotics. The only way our society as a whole is going to stop demanding antibiotics at every sniffle, is for them to understand that it is risky. Our continual access to fear-based media also makes people think that a life-threatening bacterial infection awaits at the end of every viral infection - so you need to make sure they understand this is not that common.

I also agree with the other posters that you need to explain why you are diagnosing a bacterial vs. viral infection, the risks of it turning into bacterial (ie, "in about 95% of cases the patient will get better, but in 5% a secondary bacterial infection could develop), and explain what specific things to watch for.

[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...

and, it would have, right? So they aren't wrong to think that.

[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.

i think the fact that is grouped in with the discharge paperwork could be a problem, as their is likely lots of info in their discharge that is not medical and that they don't need to read.

i think you need a basic handout with pictures. and you should hand it to them directly.

[Anonymous]

Anonymous wrote:I don't think anyone has mentioned this yet - but instead of being defensive, go on the offensive. Explain to them in a few clear points, why it is damaging to their children to give them antibiotics that are not needed. Some people have no idea that there is harm in giving too many, or unneeded, antibiotics. The only way our society as a whole is going to stop demanding antibiotics at every sniffle, is for them to understand that it is risky. Our continual access to fear-based media also makes people think that a life-threatening bacterial infection awaits at the end of every viral infection - so you need to make sure they understand this is not that common.

I also agree with the other posters that you need to explain why you are diagnosing a bacterial vs. viral infection, the risks of it turning into bacterial (ie, "in about 95% of cases the patient will get better, but in 5% a secondary bacterial infection could develop), and explain what specific things to watch for.

This is what I was going to say. And you can give examples of how antibiotics are harmful. Not just the long-term super-bug implications, but also the GI side effects. "It probably won't clear up his cold, and it probably WILL give him diarrhea."

[Anonymous]

Anonymous wrote:

Anonymous wrote:I don't think anyone has mentioned this yet - but instead of being defensive, go on the offensive. Explain to them in a few clear points, why it is damaging to their children to give them antibiotics that are not needed. Some people have no idea that there is harm in giving too many, or unneeded, antibiotics. The only way our society as a whole is going to stop demanding antibiotics at every sniffle, is for them to understand that it is risky. Our continual access to fear-based media also makes people think that a life-threatening bacterial infection awaits at the end of every viral infection - so you need to make sure they understand this is not that common.

I also agree with the other posters that you need to explain why you are diagnosing a bacterial vs. viral infection, the risks of it turning into bacterial (ie, "in about 95% of cases the patient will get better, but in 5% a secondary bacterial infection could develop), and explain what specific things to watch for.

This is what I was going to say. And you can give examples of how antibiotics are harmful. Not just the long-term super-bug implications, but also the GI side effects. "It probably won't clear up his cold, and it probably WILL give him diarrhea."

Right. Patients might think that you are simply trying to skimp out on them, because they are low-income or whatever. Be very clear that you are fully committed to their child's health, and that you will spare no expense in helping them become well.

[Anonymous]

Anonymous wrote:I leave happy that I don't have to force antibiotics down my toddler.

Agreed.

I think there needs to be more done to educate the public on the bad effects of overusing antibiotics. How parents are really doing their kids a disservice by demanding ABs for every little sniffle.

Why not wait 3 days and see if it clears up on it's own. If it does end up being bacterial and the symptoms worsen, then treat it. I know it stinks having a sick kid, but it will stink even more when all the bacteria are AB resistant and we have not good treatment options left.