Search for tag: "antibiotics"

Dr. Gellner: As a parent, I completely understand that when a child is sick, you want any medicine you can have to make them feel better and fast. However, antibiotics are not always a good choice. I'll discuss myths and facts about when antibiotics are really needed on today's Scope. I'm Dr. Cindy Gellner.

Announcer: Remember that one thing that one person told you that one time about what you should or shouldn't do with raising your kids? Find out if it's true or not. This is Debunking Old Wives Tales with Dr. Cindy Gellner on The Scope.

Dr. Gellner: Ask any pediatrician and the number one question when a parent brings a sick child to the doctor is, "Are you going to give them antibiotics? Often parents will bring in their children for fevers, coughs, or sore throats. So giving them antibiotics will make them better more quickly right? Not true. Most of these symptoms are caused by viruses, not bacteria. And so antibiotics will do nothing to make them feel better and may make them feel worse, especially since one of the big side effects of antibiotics is diarrhea.

When antibiotics are used, they kill all the bacteria in the body, good and bad, that are sensitive to that antibiotic. Too much antibiotic use means that the stronger antibiotic resistant bacteria take over and then the problem is sometimes, we see these new bacteria require heavy duty antibiotics that can only be given by IV, or sometimes we don't even have a good antibiotic to treat these resistant bacteria.

So if your child is given an antibiotic, it must be taken for 10 days to kill all the bad bacteria, right? Well, no, some antibiotics only need to be taken for five to seven days for treatment. The bottom line is be sure you give the antibiotic exactly as your doctor prescribes.

But what about if your child's snot is thick and green? This means antibiotics are needed, right? No again. Studies have shown that mucus color results from white blood cells and proteins fighting inflammation in the mucus and not any harmful bacteria. In fact, the longer mucus is produced, the greener and thicker it becomes. That's why a common cold lasting more than three to four days produces green mucus. Now, if the drainage has been going for an extended period of time and your child is getting worse, then your child's doctor will help you decide if antibiotics are needed at that point.

I've often heard from parents that this or that antibiotic doesn't work for my child. They're immune to it or it's not strong enough. Well, the fact is people don't develop immunity to antibiotics. If the antibiotic didn't work for your child in the past, maybe they were being treated for a viral illness and not a bacterial one, or the bacteria had developed resistance. The only time a child shouldn't be prescribed a particular antibiotic is if they have a true documented allergy to it.

Finally, some parents worry that if their child takes too many antibiotics, it will lower their immunity. False. Antibiotics have no adverse effects on the immune system. What too many antibiotics will do is cause all the good bacteria in your child's body to be killed and put them at risk for issues like chronic diarrhea and resistant bacteria.

So remember, when it comes to prescribing antibiotics for your sick child, trust your pediatrician. They have the training to determine when an antibiotic is needed and when it's not. And don't be afraid to ask about our decisions. We want parents to be involved in their child's health care decisions.

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Interviewer: Antibiotics, what do they help, what don't they help, and why should you care? That's next on The Scope.

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Interviewer: Dr. Sara Lamb has a wide range of patient experience from being an internist, a hospitalist, and a pediatrician. So I'm sure you're asked a lot about antibiotics. Do you find that there is still confusion with patients when they should be and shouldn't be used?

Dr. Lamb: Absolutely.

Interviewer: All right. Well, let's clear that up first and then let's talk about why somebody should care about that. So the way I remember it is antibiotic, antibacteria, that's my little . . .

Dr. Lamb: But also antivirus, antifungal, antiparasites.

Interviewer: Also they do . . . I thought it was just antibiotics were just bacteria.

Dr. Lamb: So antibiotics, I think, are a broad sort of category for what we would maybe call antimicrobials.

Interviewer: All right. So then what are the rules when they should be used and when they shouldn't be used? Like for example a cold, antibiotics aren't going to help.

Dr. Lamb: Correct.

Interviewer: Strep throat, antibiotics would help.

Dr. Lamb: I think it depends on, number one, what you think the actual cause of the problem is. Is it a bacteria, is it a fungus, is it a parasite? And then it depends on the host. So the patient in front of you, do they have problems that would put them at risk of having an unnecessarily risky course, a bad outcome if they weren't treated? Or are they an otherwise healthy patient with really a very intact immune system who's likely to be able to fight off this infection without any assistance?

Interviewer: And in the past, I get the feeling that at what point doctors would prescribe or recommend them more often than not?

Dr. Lamb: I think we didn't completely understand what may be the cause of many illnesses that patients presented with and what the likelihood was that they would get better on their own without our intervention with an antibiotic. And you know, since, even since I've been in practice, which was really only about 18 years, we've learned a lot from, you know, evidence-based medicine, from doing population-based studies, looking at outcomes for patients on a very broad scale to be able to have more meaningful, more precise information about who's likely to get better, who's likely to not get better, and who is actually most in need of an antibiotic for a particular condition.

Interviewer: Are we in a bit of a transition where doctors are still prescribing or recommending them when they really shouldn't or they don't need to?

Dr. Lamb: Yes.

Interviewer: So some physicians are on board with kind of what you're talking about, some aren't, why is that?

Dr. Lamb: I think, in part, physicians have a tendency to do what they are most comfortable with, meaning what they have done in the past historically or what they have seen done. And the further we get out from, say, our training experience, in residency or fellowship, the more we rely on our own devices to keep ourselves informed. And one of the most beautiful things about working in an academic center is you're constantly surrounded by medical students, residents, fellows who are constantly asking that question of "Why? Why not?" And that, in and of itself, forces you to stay current with what evolves in the medical literature.

So the further you sort of get away from your training experience and being forced to be kept up to date with the evidence, the medical literature, you can lag in your sort of working knowledge of what is a best practice. We've also seen a great deal of sort of evolution of, you know, clinical practice guidelines that have become more the mainstay of practice for things that we have a lot of evidence for, but that still requires physicians to stay up to date with that information on their own.

Interviewer: So in a lot of ways it brings it back to myself and patients in general that we probably need to educate ourselves a little bit . . .

Dr. Lamb: Absolutely.

Interviewer: About this sort of thing. So I think that transitions into what's the downside of just throwing antibiotics at all sorts of problems? One of which, I think a lot of people have heard about is antibiotic resistance.

Dr. Lamb: Resistance.

Interviewer: Yeah.

Dr. Lamb: Absolutely, without a doubt.

Interviewer: Yeah. So explain briefly what that means.

Dr. Lamb: So antibiotics, when they're given to someone, they will not just take care of the bacteria in your body causing the infection. They will take care of all bacteria that are susceptible to that drug in your body. So that may not affect a few bacteria that would not respond to that antimicrobial. And it sort of disrupts the balance of like the bacteria that are susceptible with the bacteria that are not susceptible.

And then that potentially allows the resistant, unsusceptible organisms to kind of grow out of control. And so those resistant bacteria then proliferate in the system of the person and then they can, they're more likely to be passed on from person to person or from person to door handle which then gets picked up by the next person walking through that hallway.

Interviewer: And that type of anti, maybe it's a different term, but that type of antibiotic resistance is different than kind of what I was thinking of which is these super bugs that are developing.

Dr. Lamb: Well, but that is how super bugs develop.

Interviewer: Okay.

Dr. Lamb: Yeah. So by selecting for bacteria that are in our environment that don't respond to these really big drugs . . .

Interviewer: Oh, I see.

Dr. Lamb: You essentially allow them to propagate and then spread.

Interviewer: And then cause sickness and illness and problems.

Dr. Lamb: Correct.

Interviewer: And then even beyond that, there are some people where the antibiotic can actually mess up your bacteria.

Dr. Lamb: Your own bacteria that are healthy bacteria.

Interviewer: Yeah, in your gut, especially. C. diff comes to mind.

Dr. Lamb: Absolutely.

Interviewer: So how can I be a responsible patient? Should I say no to all antibiotics if I go in for a surgical procedure and they say they want to give me a course of antibiotics as part of that? Should I say no, I'd rather not?

Dr. Lamb: No, I think there's a lot of good evidence to suggest that antibiotics have their place and they have a good role in good medical practice in preserving health, and you know, keeping people without having a complication. So there's lots of good evidence but there's no reason why you can't push your physician, your provider to say, "Well, can you explain that to me? Explain why this is going to be beneficial for me and maybe give me some information about what would happen if I didn't go along with this plan."

Interviewer: And then maybe if the attitude . . . is this a good attitude to have, only use them when you absolutely have to?

Dr. Lamb: Absolutely.

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updated: June 6, 2019
originally published: August 15, 2017

Dr. Gellner: Diarrhea in children can be caused by many things, but some Old Wives' Tales out there about diarrhea are just plain not true. We'll separate diarrhea facts from fiction on today's Scope. I'm Dr. Cindy Gellner.

Announcer: Remember that one thing that one person told you that one time about what you should or shouldn't do when raising your kids? Find out if it's true or not. This is Debunking Old Wives' Tales with Dr. Cindy Gellner on The Scope.

Dr. Gellner: Everyone says that diarrhea is part of the stomach "flu." Imagine me doing air quotes. That's a myth. There are many viruses that cause diarrhea, however, influenza normally affects the upper respiratory system, not the digestive system, thus, the flu vaccine will not protect against diarrhea.

When it comes to medications, yes, this is true. Some medications can cause diarrhea, especially antibiotics. They kill both good and bad bacteria in the entire body. Giving your child probiotics will help replace the good bacteria and decrease the diarrhea.

What about sugar? This one's true, as well. Sugars in soda, sports drinks, and even natural sugars found in fruit can cause diarrhea. We see diarrhea in toddlers a lot because they drink a lot of juice, and actually, the diagnosis for that is "toddler's diarrhea" and it resolves when parents cut out juice. Sugar draws fluid into the intestines, making the stools more watery. Some sugar substitutes, like Sorbitol, and caffeine even, have the same effect.

Parents often say that their child has diarrhea because they're teething. That one's a myth. Your baby can be cranky or irritable, but if they have diarrhea or a fever, that's going to be a virus, not teeth.

What about fiber? Okay, this one's tricky. Soluble fiber, like what is found in beans, peas, oatmeal, peeled fruits, and cooked vegetables, causes water to be absorbed in the intestines and the stool gets harder, but insoluble fiber, found in the skins of raw fruits and vegetables, whole grains, and wheat bran, may speed up stools as they pass through the intestines and cause diarrhea.

If your child has diarrhea, the most important thing is to make sure your child is hydrated. That's the biggest risk for kids, and the younger they are, the bigger the risk. And if your child's diarrhea lasts longer than three weeks or has blood in it, then it's time to visit your pediatrician.

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Interviewer: Antibiotic resistant bacteria are a big public health concern. These superbugs are resistant to life-saving drugs that we take for granted. We'll talk about how changing doctors' attitudes about antibiotics could help overcome the problem, up next on The Scope.

Announcer: Examining the latest research and telling you about the latest breakthroughs, the Science and Research Show is on The Scope.

Interviewer: I'm talking with Dr. Barbara Jones with University of Utah Health and the VA IDEAS Center for Innovation. First of all, what is a superbug, and why are they such a threat?

Dr. Jones: Well, superbugs are a bacteria that are resistant to standard antibiotic therapies. Bacteria can mutate with every generation, and some of these mutations can give bacteria resistance. When you're constantly exposing these bacteria to standard antibiotics, what emerges is a selection pressure for those bacteria that are resistant to those antibiotics.

Interviewer: Something that you helped to find in your research is that doctors are actually part of this problem of emergence of antibiotic resistant bacteria.

Dr. Jones: In many cases, we use antibiotics unnecessarily. And one of the biggest diseases that we do this in is in acute respiratory infections or kind of the common cold. Most of those diseases are caused by viral infections that really don't respond to antibiotics at all, and what we found across the VA system was that doctors just tend to get into habits. So some doctors prescribe antibiotics for colds almost every time that they have a patient with one. And other doctors, though, have figured out ways to prescribe a lot more judiciously.

Interviewer: And is this something that you experience? I mean, do you sometimes feel pressure to prescribe antibiotics when it might not be the best thing to do?

Dr. Jones: Well one of the things that I think is also a misperception for a lot of providers is we tend to assume that patients have an expectation that they'll receive the antibiotics, and when there's that assumption, when you only have 15 minutes to see a patient, you don't necessarily have the time that is taken to really get to know what your patient's expectations are.

And so if we then have a cultural assumption that our patients are expecting this, we have a busy clinic, we don't have a whole lot of time to educate our patients about the dangers of the antibiotics and why we would not prescribing, it's a lot of times easier to give the prescription than to have that conversation about the risks of antibiotics and what other things that you should do to take care of yourself during a viral infection.

Interviewer: Why is it important to understand these pressures that doctors face?

Dr. Jones: I think that the more we understand the perspectives of the providers and the physicians taking care of the patients, the more we can design interventions that support them to more rationally weigh the risks and benefits of antibiotics appropriately, and that will help replace some of the bad habits with better ones.

Interviewer: It sounds like what that means is changing behaviors, attitudes, habits, and that is not easy.

Dr. Jones: What we've found so far is giving providers data about their practicing of patterns is a really powerful tool to change behavior. So we call it audit and feedback, and what we've been doing across the VA settings that we've been implementing some of the stewardship efforts has been to show providers their prescribing patterns over a month or a six-month period and to show them kind of what their proportion of prescribing is and then start a conversation from there about what interventions they might be able to do to change their habits.

A couple other things have been clinical decision support systems that are often tied to an electronic health record. In a busy clinic, a lot of times you don't have a chance to have those important patient education conversations. If you have an electronic health record that supports prescribing symptomatic therapies that substitute that antibiotic or help print out a patient education handout, spend some of that time educating the patient for you, that can really help physicians feel like they're listening to their patients.

They're giving them the empathy that they need when they're feeling poorly, but also reserving the antibiotics for times that are more appropriate.

Interviewer: This is all a little different from the usual doom-and-gloom scenario that you hear about when it comes to superbugs. Are you optimistic?

Dr. Jones: Just like any shift, I feel like this is a cultural thing that can get to a tipping point. The more doctors start prescribing differently, the more their colleagues can see this and feel like they can change as well. I'm really optimistic that we can change our habits and our attitudes toward antibiotics, and so I think that some of these interventions for humans is really important. I think that if we do this, we can really impact that selection pressure and help reduce the emergence of superbugs.

Announcer: Interesting, informative, and all in the name of better health. This is The Scope Health Sciences Radio.

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Scot: Dr. Miller, you told me that one of the questions you get around this time of the year is people wanting to get an antibiotic because they are going to be doing some traveling and they are afraid that they are going to go to some country and then get a bug that's going to cause diarrhea. Is that something that you can even do?

Dr. Miller: I get that question quite frequently. People will come in and they'll say, "I'm going on a trip and I just want to make sure that when I go to this new country, I might get diarrhea. Should I start an antibiotic to prevent getting diarrhea?"

Scot: They want to do something to prevent it?

Dr. Miller: They do, and the reality is taking antibiotics can cause far worse side effects than you might even ever get from traveler's diarrhea.

Scot: I think that's hard for people to understand because it's like . . .

Dr. Miller: Well, we've got into the notion that antibiotics, there's no downside to taking them, that there's no side effects from antibiotics. That's just simply not true. The issue is using an antibiotic when you need it, not as a prophylaxis or preventative, especially when you're going traveling.

Scot: Some of those downsides from what I understand is it can mess up your gut flora and fauna in some instances.

Dr. Miller: Yeah, one of most common things we're dealing with now is C. difficile colitis, which is an awful antibiotic induced diarrhea that is very, very difficult to treat.

Scot: Wouldn't that be ironic? They want to take it to prevent diarrhea . . .

Dr. Miller: Sometimes when they take antibiotics, they actually come back with the C. difficile colitis and it's not traveler's diarrhea. They've self-induced the problem and so after diagnostics, you figure out, "Oh, my gosh. This was induced by the antibiotic that they took to prevent traveler's diarrhea," not a good situation.

Scot:Taking it before, not a good idea. What about having it with you, when you do travel, if you do get something?

Dr. Miller: Right, so that's another issue entirely. It depends on where you're going. If you're going to a third world country and you're going to be out of major urban areas and in the rural areas, probably having antibiotics prescribed by a physician that you can keep with you and understand that when you develop symptoms consistent with traveler's diarrhea, you begin to take those antibiotics. That does make sense. However, people will also request antibiotics when going to other first world countries. That's probably not necessary, unless you're in certain situations where water is unclean, but most major cities of Europe and Asia have clean water supplies and it's not an issue. Also tourists are also in the habit of buying bottled water now.

Scot: I'd heard that . . . I went to Cancun one time and I was under the impression that I should not drink the tap water there, to drink bottled water there. How would I know if where I'm going is some place that's safe or not?

Dr. Miller: That's a really good question. One of the things people can do is get on to the CDC website for travelers and look up the information about particular countries. In addition, we have a travelers clinic here at the University of Utah that can advise people on what are the correct situations under which you might want to begin taking antibiotics if you develop certain symptoms, and also in which countries you'd want to be concerned about the safety of the water supply.

Scot: It sounds like bottom line, taking antibiotics as a precautionary measure - bad idea, could actually cause worse problems, anything that it prevents.

Dr. Miller: No question about that. Yeah, absolutely. There are some things that people can do also to cut back on the risk of developing antibiotic or excuse me traveler's diarrhea, which is caused by certain strands of bacteria. Those would be making sure that the food you eat is cooked, not eating raw vegetables in areas where the water supply in question. If you're in rural areas and have the ability to purify water, you can bring now very simple water purification kits and you can use those, they're very effective. I've been camping in the back country for years and years and years and never have had a problem when I use water purification tools.

Scot: You can take those with the iodine tablets if you really need to use any of that kind of stuff?

Dr. Miller: Iodine tablets, if used correctly, you can take purification filters. They're now very small and pack easily in a backpack or a suitcase. Again, it's important to know where you're going and also to be aware of the situations you're going to be in where you're eating and the environment that you're in. That is probably more important than anything.

Scot: That knowledge of knowing what's going on.

Dr. Miller: Right. So keeping the antibiotics as a backup if you need them. That's the best.

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Interviewer: A study finds disparities in how ear infections are treated in children of different races, up next on The Scope.

Announcer: Examining the latest research and telling you about the latest breakthroughs. The science and research show is on the scope.

Interviewer: I'm talking with Dr. Adam Hersh, assistant professor of pediatrics at the University of Utah. He's led a research study published in the Journal of Pediatrics with some thought-provoking statistics that give clues as to why antibiotics are over prescribed for the treatment of ear infections in children. Dr. Hersh, what were the main results of your study?

Dr. Hersh: There are two main results here. First, we found that there was a difference in the rate at which ear infections were diagnosed for children between black children and non-black children. We found that non-black children were more likely to be diagnosed with ear infections when they were seen in a doctor's office for respiratory symptoms.
Second, we found that once the diagnosis of an ear infection was made, we found differences in the types of antibiotics that were chosen by doctors between black children and non-black children. More specifically, what we found is that non-black children were more likely to get broad-spectrum antibiotics, antibiotics that are actually not indicated in most circumstances for this specific infection.

Interviewer: First of all, maybe we should define what does non-black children mean?

Dr. Hersh: For the purposes of this study, we did use two different groups, black and non-black. This was largely to be consistent with previous research in this area that used similar groups. Ninety-five percent of the group of children that are categorized as non-black are Caucasian.

Interviewer: What kind of differences are we talking about?

Dr. Hersh: These differences are pretty big. In terms of the rate of diagnosis of an ear infection, it appears that black children are about 30% less likely to be diagnosed with an ear infection than non-black children. In terms of the antibiotics that are chosen, black children are about 20 to 30% less likely to get a broad spectrum antibiotic than non-black children. These differences are of pretty significant magnitude.

Interviewer: These differences are because of access to care, you think?

Dr. Hersh: That's an important question to think about. We found that the rate at which black children and non-black children are seen nationwide for respiratory tract infections. In fact, for care in general is actually the same.

Interviewer: An interesting point is that black children are actually receiving the preferred treatment. Can you explain that?

Dr. Hersh: At least in terms of the antibiotics that are chosen for black children as compared to non-black children, that's absolutely correct. Black children are more frequently and more likely receiving the preferred, first-line recommended antibiotics. Again, that's important, not just because of the concerns about killing off more of the good bacteria and leading to antibiotic resistance, but also because some of these broader spectrum antibiotics actually are more likely to cause harm to the child. For instance, some of the board spectrum antibiotics that are more frequently prescribed for non-black children are those that are most frequently linked to certain types of antibiotic associated diarrhea, something called clostridium difficile.

Interviewer: How was this study done?

Dr. Hersh: This study was done using a database that's collected and maintained by the Center for Disease Control. It's a nationally representative database of outpatient health care encounters that's conducted annually. What we understand, what we know from these databases is that somewhere between 30 and 40% of all diagnoses for children, at the doctor's office, are related to respiratory tract infections. We know from these databases, from this work, that about one in five times that a child is seen in a doctor's office, they'll leave with an antibiotic prescription in hand. An ear infection is the single most frequent diagnosis that leads to an antibiotic prescription.

Interviewer: This wasn't exactly addressed by your study, but can you help us understand some of the reasons that might lead to differences in care?

Dr. Hersh: We know that in many cases, physicians perceive that patients want an antibiotic. That perception is one of the strongest drivers of an antibiotic prescriptions. Particularity in circumstances where it's kind of a gray area, when it's not clear cut. If the physician perceives that this parent wants an antibiotic for their child and they're not going to be satisfied any other way, there's a much greater likelihood that they'll prescribe an antibiotic than if they didn't have that same perception.

Interviewer: I think you can look at the other way as well, that there could be an under-diagnosis or an under-treatment of black children.

Dr. Hersh: That's a really important point. There really are two potential ways to interpret this. Over-diagnosis and over-treatment, or under-diagnosis and under-treatment. Historically, in a lot of other areas of medicine, there have been well-identified health care disparities where patients of black race get less care. In some cases, lower quality care. That may not be what's going on here.

Interviewer: It seems like understanding those causes will be important for addressing this problem.

Dr. Hersh: That's absolutely right. I think that why this is occurring is a much more complicated research question.

Interviewer: Yeah. Absolutely. What's the take home message from all of this?

Dr. Hersh: I think there's really two take home messages. The first is that all of us, patients, parents, physicians, anyone that works in the health care environment, we need to remind ourselves that we do bring stereotypes and biases into the exam rooms with us. We need to think about how these biases may ultimately influence the care that children receive.
Second, this study really reinforces and reemphasizes a critical point about the diagnosis and treatment of upper respiratory tract infections. That's that physicians need to use really stringent criteria to diagnose respiratory tract infections that justify antibiotics and only prescribe antibiotics when those stringent critical criteria are met. I think a message for parents is that they should ask their doctor when the diagnosis is being made.
For instance, of an ear infection, they should ask their doctor how certain the doctor is about the diagnosis. If there's some uncertainty, they should ask whether or not it's possible that maybe watching and waiting would be a reasonable approach rather than taking the antibiotic when there still remains some uncertainty about what the diagnosis is. I think that's a really key thing for parents to understand, that the vast majority of upper respiratory tract infections that kids have are caused by viruses and helped at all by antibiotics.

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