Antibiotic Overuse

I am so concerned about antibiotic overuse. Could you help get the message out to parents? If you could I’m sure we could get a real head start on this problem.
April Parker

Antibiotic Overuse

Dr. Greene’s Answer:

Parents, print this page and bring it with you to doctor visits.

About 40% of the time kids see a doctor, they leave with a prescription for antibiotics. This astounding figure includes sick visits and routine well-child checkups. Antibiotics are wonderful, life-saving tools, but their overuse is dangerous.

Because antibiotics were such a revolutionary advance in the treatment of infectious diseases, doctors slipped into the habit of prescribing them for minor illnesses, even those known to be viral, just to “be on the safe side.” They also thought they might help the child get better a bit faster.

Now we know that the opposite is true. This practice is harmful to children and to the environment by selectively breeding ever-more frightening bacteria. Children may get better a bit quicker at first, but then they are likely to get sick more often, with longer, more stubborn infections caused by more resistant organisms.

The routine use of antibiotics makes life worse for children and parents–even apart from the side effects and allergic reactions many children have. To be on the safe side, antibiotics should be withheld unless they are clearly needed.

Nevertheless, up to 60 % of children with common colds are treated with antibiotics (Journal of Family Practice 1996; 42:357–361). Because children average three to eight colds each year, most accompanied by green or yellow runny noses, they can get many, many rounds of unnecessary (and therefore harmful) antibiotics.

Why do we still do this? There are many reasons, but the one cited most frequently by physicians is that parents want or expect a prescription (Pediatrics 1998; 101:163–165). Admittedly, we physicians should know better. But when we see you in the office, things sometimes get muddled. Your child has a fever and is cranky. His or her nose has been running for 5 days, and the mucus is getting thick and green. His or her appetite is down, and no one is sleeping well. You’ve waited for this to get better on its own, but it is getting worse. And you can’t afford to miss more work. We want to be able to help you and your child get through this faster. Prescribing an antibiotic this one time won’t hurt–much.

I will teach you one sentence that can greatly improve your child’s health.

Use this tool before the doctor even examines your child. When you are explaining why you came in, add the sentence, “If there is any way to safely help her feel better without antibiotics, that is what I would prefer.”

When not to use antibiotics!

Recognizing the urgent problem of antibiotic overuse, the Centers for Disease Control and the Academy of Pediatrics have issued guidelines for when to use (and when not to use) antibiotics for the most common pediatric respiratory infections (Pediatrics 1998; 101:163-184 and Pediatrics 2004; 113:1451-1465). Ear infections, sinus infections, bronchitis, sore throats, and colds account for three fourths of all antibiotic prescriptions. These guidelines should not be rigidly adhered to for every child, but they do give a good general idea of when to avoid antibiotics. I will summarize the guidelines for you. I will not explain each statement, but you can use them as excellent discussion points with your physician:

Sore Throats

  1. Strep throat is diagnosed with a Strep test, not by looking in the mouth.
  2. Antibiotics should not be given for sore throats without a positive test for Strep or another bacterial infection.
  3. One of the penicillins (not the newer, broad-spectrum antibiotics) is the best choice unless the child is allergic to it.

Bronchitis

  1. Regardless of how long it lasts, bronchitis or a nonspecific cough illness in children rarely warrants antibiotics.
  2. Occasionally, if the cough has lasted for more than 10 days and specific bacteria are suspected, one round of antibiotics may be worthwhile. Children with underlying lung disease (not including asthma) might also benefit from antibiotics when their diseases flare up.

Colds

  1. Antibiotics should not be given for the common cold.
  2. Thick, discolored nasal discharge is a normal part of a cold and is not a reason for antibiotics unless it lasts longer than 10 to 14 days.

Sinus Infections

  1.  Most children should not be given antibiotics for a sinus infection unless there are both nasal discharge and cough without any improvement after more than 10 to 14 days. If there is some improvement by day 10, antibiotics are probably not helpful.
  2. Children with severe symptoms (facial swelling, facial pain, a fever over 103) may benefit from earlier treatment.
  3. Use the most narrow-spectrum antibiotic possible.

Ear Infections

  1. Not all ear infections are the same. Each ear infection should be classified as acute otitis media (AOM) or otitis media with effusion (OME). Most children with ear infections have OME — fluid in the ear without signs of an acute middle ear infection. Half of young children with colds get OME. AOM is fluid in the ear accompanied by signs such as pus behind the eardrum, eardrum pain, distinct redness of the eardrum, or discharge from the ear. Ear pulling, runny nose, fussiness, and changes in sleep pattern can accompany either AOM or OME and do not establish a diagnosis of AOM.
  2. Antibiotics may be appropriate for AOM with documented fluid in the ear and clear signs of acute illness. The Ear Check Middle Ear Monitor is a good way to confirm the presence of fluid. A red eardrum without fluid is not AOM (or OME for that matter).
  3. Healthy children greater than 2 years of age with uncomplicated, nonsevere AOM may be better off observed without antibiotics for 48-72 hours. Treatment for pain with pain relievers is appropriate. If severe symptoms (moderate to severe pain or fever above 102.2 degrees) develop or the child is not better in 48-72 hours, antibiotics can be prescribed at the time.
  4. Antibiotics are not useful for the initial treatment of OME, although they may be worth a try if OME lasts for longer than 3 months. OME is important in that it reduces hearing when present, but antibiotics are usually not the solution.
  5. Continued fluid in the ear found at an ear recheck after AOM is to be expected and does not necessitate another round of antibiotics, except in the less common situation where signs of acute infection are still present.
  6. Preventive antibiotics should only be given, if at all, after three or more separate cases of documented AOM in 6 months or four or more in 12 months.

Children fight off most childhood illnesses better without antibiotics. The physician’s job is to gently treat children with uncomfortable symptoms so they can get the rest and fluids they need. Occasionally, antibiotics are a vital part of the healing process. Equipped with this information, you are in an excellent position to remove the “pressure to prescribe” and to work with your doctor to offer your child the very best care.

The good news is that more parents and more physicians seem to be aware of the dangers of antibiotic overuse. At Stanford University and throughout the nation, the next generation of doctors is being taught the guidelines above. In my own experience, practicing and teaching pediatric medicine, I see more physicians explain why they are not prescribing antibiotics and more parents willing to “wait out” their children’s infections. I am hopeful that soon we will see studies documenting a decrease in antibiotic overuse.

Dr. Alan Greene

Dr. Greene is the founder of DrGreene.com (cited by the AMA as “the pioneer physician Web site”), a practicing pediatrician, father of four, & author of Raising Baby Green & Feeding Baby Green. He appears frequently in the media including such venues as the The New York Times, the TODAY Show, Good Morning America, & the Dr. Oz Show.

  1. Amber

    My 5 year old daughter was having difficulty hearing but no ear pain, so I brought her to her pediatrician and sure enough she had an ear infection. She was prescribed Amoxicillin for 10 days. We went back for a follow up and her Dr. said that she still sees redness and puss so she wanted to give her a stronger antibiotic. I opposed saying is it possible to see if it clears up on its own(having no pain made it possible for me to do that) and she said sure. About 5 days later, I noticed that her hearing was still somewhat muffled so I brought her back to the Dr. and we went ahead with the next course of yet another, stronger antibiotic(Augmentin) for yet another 10 days. That was 2 weeks ago and we went in today for a follow up and would you believe that her ear infection is cleared up but my daughter said that her throat hurt a little so they swabbed it and it tested positive for strep. We are now on yet another antibiotic(Cephalexin) for 10 more days. Now my question for you is, why didn’t the antibiotics that she was on, protect her from picking up strep?

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    • Natalie

      The possible cause is that the antibiotic treatment for her middle ear infection lowered her resistance when combined with the overall inflammatory response in the surrounding tissues. Two things are key to bear in mind, the first is that the middle ear drains into the sinuses, via the Eustachian tube, and any infectious content would drain down the back of the throat. Bacterial debris can be toxic in high concentrations and mildly irritating to local tissues; dying bacteria, at least some strains, release toxins . Secondly, antibiotics wipe out all bacteria – the good and the bad – and gut flora is a primary constituent of our immune system. Your child’s resistance was lowered both by the illness of an infection and the compromise to her immune system from such lengthy courses of broad-spectrum antibiotics. The recent push for using probiotics is based in the recognition that gut flora plays a huge role in our natural immune defense against pathogens. I gave probiotics to my daughter, from infancy and my granddaughters are given probiotics and prebiotics on a regular basis to bolster their immune systems. It is key, Imo, to provide these for anyone who has been on antibiotics to replace the beneficial flora that antibiotic therapy wipes out. Do the research and come to your own conclusions. Assuming that you will decide to give your child probiotic, I would strongly recommend that you use the high-grade, refidgerated type that is found in health food stores, these provide the specific strains needed by kids and have many billions of the lactobacteria needed to recolonize the gut and bolster your child’s immunity.

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  2. Wrestlemania 32

    Good information. Lucky me I recently found your blog by chance (stumbleupon). I’ve saved as a favorite for later!|

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  3. Akhunzada Ayatullah

    Thanks Dr, Greene, for such a nice article, very useful…being a father of a child i myself was very concerned about prescription of antibiotic in minor issues but my wife always insist for medication, may be this article can help us for better care of our child.

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  4. pratheek

    nice!!!!!!!!

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    • norlarooney

      Very useful!

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