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.