Why your doctor might not prescribe an antibiotic

When your child has a cold, sore throat and cough – and you just want him to feel better. Surely an antibiotic will help. Not so fast, says Infectious Disease Specialist Sandy Arnold, MD. Dr. Arnold explains when antibiotics should be used and what the long-term effects can be on the child and a community.

In 1998, the American Academy of Pediatrics (AAP) published a set of guidelines outlining the judicious use of antibiotics for respiratory infections in children doctor’s offices. This year, the guidelines have been updated and include recommendations on antibiotic treatment for ear infections (otitis media), bacterial sinusitis and strep throat (streptococcal pharyngitis).

When is it appropriate for my child to be prescribed an antibiotic?

Most respiratory infections are caused by viruses. This includes colds, sore throats and coughs. These infections should not be treated with antibiotics as antibiotics do not help these infections get better more quickly. Some children, who start out with a cold, may develop another infection as a result of the cold such as ear infections or bacterial sinusitis.

Many ear infections will get better on their own but giving antibiotics may help them get better faster and help cure those that do not improve on their own; however, an ear infection is often diagnosed in children who do not have one because the child has a “red ear.” If the specific criteria for the diagnosis of ear infections are followed, many fewer children are given the diagnosis. The AAP recommends, “antibiotic therapy for children diagnosed with [ear infections] on the basis of presence of established clinical criteria. Observation can be considered for selected children, particularly children older than 2 years with non-severe symptoms and unilateral (on one side only) disease.”

Sinusitis is frequently diagnosed in children with colds as symptoms of colds and sinusitis can overlap. During the common cold, nasal discharge often turns green for a few days and does not mean that there is a bacterial infection. Also, symptoms from a cold can go on for many days but should be improving by 7 to 10 days. The AAP recommends, “antibiotic therapy for children with clinical features of acute bacterial sinusitis, especially those with symptoms that are worsening or severe. Observation with close follow-up or antibiotic therapy can be considered for those with persistent symptoms (more than 10 days).

Strep throat is an infection of the throat caused by one bacteria, the group A streptococcus. Some children (10-15%) with sore throat have strep throat; however, most children with sore throat have colds with cough and runny nose as well. These children should not be tested or treated for strep throat. Treating strep throat may help a child feel better a little more quickly but the main reason for treating sore throats cause by group A streptococcus is that it can prevent rheumatic fever, a rare complication of strep throat that can damage the heart. The AAP recommends that children with fever, sore and swollen throats and swollen glands in the neck and who do NOT have cough should be tested for strep throat and be treated with antibiotics if the test is positive.

Why should doctors not prescribe (and parents not request) antibiotics unless absolutely necessary?

Every treatment has potential benefits and potential harms. Doctors have to weigh these two things against each other whenever they are making a decision to treat an infection or other illness. Side effects of antibiotics in individual children can range from mild (mild rash, mild diarrhea) to severe (allergic reaction, severe diarrhea including C. difficile colitis, deadly heart rhythms).

In addition, there are effects of antibiotic use on the bacteria that live in our bodies. We know that exposure to antibiotics increases the risk of antibiotic-resistant bacteria in the individual and the community and can lead to infections that are difficult to treat. Finally, new research is revealing that the effect of antibiotics on the normal bacteria in our bodies can have long-term effects and possibly increase the risk of diseases such as asthma, eczema, inflammatory bowel disease and even obesity.

What are we doing at Le Bonheur to make sure we're only using antibiotics when necessary?

Le Bonheur has an “Antimicrobial Stewardship Program” run by infectious disease specialists and pharmacists. This group has been working for several years to reduce the unnecessary use of antibiotics in the hospital through a variety of interventions. In the future, we are planning to expand this program to the Le Bonheur community to educate physicians and patients on the most appropriate ways to use antibiotics for infections seen in the clinic setting.