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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

Announcer: Need reliable health and wellness information? Don't listen to the guy in the cube next to you. Get it from a trusted source, straight from the doctor's mouth. Here's this week's Listener Question on The Scope.

Interviewer: My daughter's two and has been admitted to the hospital, and they can't get her temperature to stay down. It's only down long enough until the medicine wears off. It varies between 103 and 105, and I can't help but wonder if something more serious is going on. This listener question is going to be answered by Dr. Cindy Gellner. She is a pediatrician at the University of Utah. Dr. Gellner?

Dr. Gellner: So we get this question a lot. Fever phobia is a common phenomena among parents, because it's scary. It's scary to watch your child have a fever that's high, and your child is miserable. But parents need to remember that a fever turns on the body's immune system. Fevers are actually one of the body's protective mechanisms, and it means their child's immune system is doing its job.

Parents worry about how long a fever lasts, but fever normally will last up to five days with most viral illnesses, and most fevers between 100 and 104 are actually good for sick kids. They help the body fight infection. Fevers with infections don't cause brain damage. That's a question I get a lot. And only body temperatures over 108 cause brain damage. The body temperature for that only gets really high with extreme environmental temperatures, like if a child is locked in a closed car in hot weather. That's when we worry about the brain temperature.

It's also important for parents to remember that fevers that don't respond to medicine can be caused by either a virus or a bacteria. And when the fever medicine wears off, the fever is going to return, and it needs to be treated again until the body's immune system overpowers whatever is causing the illness. And whether the medicine works or not doesn't relate to the seriousness of the infection. If the fever is really, really high, the cause may or may not be serious. The more important thing is looking to see if your child is very sick because if they're very sick-appearing, then it's more likely to be serious.

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Interviewer: The bigger the family, the more likely they are to get sick. More about that next on The Scope.

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Interviewer: I'm talking to Dr. Carrie Byington, Professor of Pediatrics at the University of Utah and Co-Director of the Utah Center for Clinical and Translational Science. You and your team have published a study in the journal, "Clinical Infectious Disease" monitoring how often families or households are infected with virus. Some of your findings are really striking.

Dr. Byington: We're really excited to publish our findings on the study that we call the BIG LoVE Study, which stands for Better Identification of Germs-Longitudinal Viral Epidemiology Studies. And we've found that individuals who are living alone had a virus detected in their nose between three and four weeks out of the year. When we looked at families with six children living in the household, a virus was detected in the house 87% of the weeks. Almost the entire year

Interviewer: Oh, my gosh.

Dr. Byington:
someone had a virus in the household. So as a pediatrician, it helps me a lot to be able to talk with families who come in and say, "Someone's always sick in the household." And in fact, that's true.

Interviewer: There it is.

Dr. Byington: And it's probably fairly normal. And so that helps us in our practice to be able to reassure families, are they seeing something normal or is their child having more infections than they should be having? And that's a common question I get as a pediatrician.

Interviewer: With each additional child in the family does the amount that that family's infected with virus increase?

Dr. Byington: Having one child changes your risks quite a bit as a household. And you go from having virus in the household from about 7% of the time to about a third of the time, you'll have virus in the household. But, for those families that have two, three, or four children, the risk of virus was fairly constant within the household, about 50% of the weeks. After you passed the threshold of four children, so families with five and six children, we saw another sharp increase in the number of viruses.

Interviewer: And so is it the kids that are bringing the virus into the household?

Dr. Byington: In many cases, yes, it looks like it is the child that's bringing the virus. And especially the very young child. I think it would not be a surprise to parents who have children younger than five that they are commonly infected with a virus. And we've found that in our group that children younger than five had a virus in their nose 50% of the week. One out of every two weeks, they had a virus in their nose.

That, for me, again, as a pediatrician and an investigator is very, very interesting. On the one hand, I'd like to find ways to prevent people from getting sick and to interrupt the transmission, like giving them the flu vaccine to protect them. But on the other hand, I'm very interested in finding out whether there is a benefit to getting certain viruses at certain times during our lives. And I think that that's something

Interviewer: Oh, interesting.

Dr. Byington:
that we can really begin to explore with the data that we've collected. We're learning more and more in the field of infectious diseases about the microbiome and bacteria that we have in our system that may be beneficial to us. And I think we're also going to be learning about the virome, about the virus that we have and carry. How do those viruses interact with the bacteria in our microbiome? How do they interact with our own immune system?

Interviewer: So being infected with virus as a child might be a good thing?

Dr. Byington: Yes, in many cases, I think it can be a good thing. And it can often serve as almost an immunization, if you will, to protect you down the line. But I don't think that we yet know which viruses and which order is important. That's what some of these studies are going to begin to help us do.

Interviewer: And it also might be hard to convince parents of that when it becomes inconvenient to keep kids home from school and things like that.

Dr. Byington: Absolutely. And we need to try to understand how often that's going to happen. And I would say for parents of young children, they can be assured that they're going to have six to seven viral respiratory illnesses each year, their children will have those, and that's quite normal. And they as parents will also get to share in some of those viral illnesses.

Interviewer: So parents of children, are they sick more often than other adults that do not have children?

Dr. Byington: Yes. We did find that in our study. And we found an interesting age breakdown. So parents of younger children, so those in the ages of 18 to 39, were nearly twice as likely to have viruses as older parents who were over the age of 40. So again, the younger parents may have had more exposure through their young children, but maybe the also developed better immunity during that period of time that protected them when they were older than the age of 40. So it's interesting.

Interviewer: Yeah, very interesting. What can we do with this information? What can families do with this information and what can healthcare providers do?

Dr. Byington: Well, I think what this information really does for both families and for healthcare providers is say what's normal, what is the baseline for normal. When should I relax and say this is just what I have to go through in the first two to three years of my child's life and when do I have to be more concerned? It also helps us to know which viruses are really associated with mild illness and which viruses may often result in needing medical care. And so, as a clinician, as a pediatrician, it helps me say which viruses would be really important to focus on for vaccines to try to prevent more serious consequences.

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Interviewer: How does Ebola change your travel plans? We'll examine that next on The Scope.

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Interviewer: We're speaking with Dr. Sankar Swaminathan. He's the Chief of Infectious Disease Division here at the University of Utah. And if you have travel plans, now you are thinking about Ebola. Does that change your travel plans, or is there something you can do?

Dr. Swaminathan: We have our travel clinic here at the University of Utah Hospital. At the Medical Center here we provide services both to people who are returning from abroad as well as people who are preparing to go abroad.
Now regardless of the current outbreak, the Ebola outbreak, there are a variety of other transmissible infectious diseases that one could pick up abroad. So we encourage anyone who's planning to travel to visit a qualified clinic or provider who can give that traveler the right advice as to what to do to keep themselves healthy, and also importantly provide them with medications that they may need to take as a preventative measure or a prophylactic medication. There may be medications that they need to just take if they get sick while there that they could carry with them.
And finally and probably just as important as anything else is having all the immunizations necessary. Now, depending on where you're going, you may need some immunizations that you may not need even in the United States. This gets very complicated, and it's a rapidly changing field, even on a weekly basis, as emerging infections crop up in places. There may be precautions that you need to take that you might not have had to take the last time.
So we provide this service not only to individuals but to groups that are traveling, for example, student groups or humanitarian aid workers. We can counsel them, give them their immunizations, give them a travel booklet and this kind of thing. We're all set up to do that.

Interviewer: So when you're getting ready for a trip, it's always very difficult to get all the things done that you need to get done. And I don't know that traveling out of the country I've ever done this before.

Dr. Swaminathan: Like you said, there's a lot of things that come up that you have to do, get your passport, this, that, and the other, but this is probably something that you should make time to do. You don't want your vacation of a lifetime ruined by this nor do you want a serious illness that's preventable. It's also in this current situation where there are so many serious threats that seem to be arising, emerging. It's important to at least prevent the ones that we can prevent.
If you come back with a fever, it rapidly becomes a potentially serious situation where many, many things have to be ruled out. The more you can help keep that from happening by preventing those preventable things, like malaria. Much of malaria is preventable. There are many other illnesses that you can get, as I said, immunization for, prophylactic medicines for. It's well worth your time.

If not here at the University of Utah, at state public health clinics, and so on. They also provide travel counseling and immunization. We work with several of these municipal health clinics, and we provide them consultation. We have physicians who are specifically expert in travel. Some who have lived in places like Bangladesh and have traveled abroad to various parts of Africa, for example.

So if you have something that you've acquired abroad, we've probably seen it. At least, one of our physicians has had some experience with it.

Interviewer: So if I'm traveling out of the country, regardless of where I'm going, I should probably stop by one of these clinics.

Dr. Swaminathan: Absolutely.

Interviewer: And if I've returned and I'm getting some symptoms of I'm getting sick, don't just blow it off as a cold or something like that, go see one of these clinics.

Dr. Swaminathan: That's right. We can provide very rapid appointments for people who are returning from travel, generally, within a day or two. If you call, we can also have one of our physicians call you back to discuss what the issues might be as well, and see how urgently you should be seen. And they can often just provide reassurance, if nothing else, when you've returned from abroad.

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Interviewer: So Dr. Madsen, I'm curious, physicians, nurses, doctors, when they get sick they can't necessarily take a day off. Sometimes you have to go in.

Dr. Madsen: Right.

Interviewer: For people that are suffering from colds or whatever right now, what are the things that nurses and doctors do to try to keep going that maybe we could do, or to even get better quicker. Is there anything? Is there a magic bullet that you guys know about that you're not telling us?

Dr. Madsen: See, I think you're trying to get free medical advice from me.

Interviewer: Yes.

Dr. Madsen: Because you're sick right now.

Interviewer: Yes, I am. I am. I'm trying. I've got this cough and this congestion that's been going on for a number of days.

Dr. Madsen: But I'm more than happy to offer the advice here, because I went through the exact same thing a couple weeks ago and it is just a miserable thing. And you're exactly right; I have called in sick for one shift in the last 10 years. That's one day of work. So I do everything I possibly can to get through work. And something I deal with on a regular basis is very severe colds. I'm exposed to a lot of people who are really sick and can make you feel really miserable if you catch what they've got.
So the things I do to get through a shift are, number one, I use Tylenol. Acetaminophen is the generic name. I take that one a regular basis and I alternate it with Ibuprofen. I alternate it back and forth every three hours. So that means you're taking each of those, individually, four times a day. You're not overdosing on either one, but it can help a lot with the body aches, the fever, just that feeling of misery you have. And I stay on top of it. I don't wait until I feel miserable. I take the acetaminophen and then I take the ibuprofen, alternating every three hours.

Interviewer: What kind of dosage?

Dr. Madsen: I usually take just a 500mg tablet. You're okay doing 2 of the 325 for the 650 total. And then the ibuprofen I take 600mg, so over the counter comes in 200mg tablets; you're taking 3 of those. For both of these dosing, you will find instructions on the bottle and precautions to avoid overdosing on either of them.

Interviewer: All right. What else do you do, medical professionals?

Dr. Madsen: So the other thing I do, there's the issue with the congestion and the coughing, and that's what can make you feel really miserable. So, typically I'm also staying on top of things and I take a combination of guaifenesin and dextromethorphan. So guaifenesin is a congestion medicine; dextromethorphan is a cough suppressant. And the brand name of that is Mucinex-DM. Again, you can find that as a generic, and I just usually get the generic because it's the same thing. It's half price. I take that also on a regular basis.
Just staying on top of things, morning and night. I think it's just a twice a day dosing on that. Maybe a little bit more. I'd have to look it up. Maybe four times a day, but I take it on a regular basis so I don't kind of get behind the game where I start feeling miserable and then I take it and wait for an hour to kick in.

Interviewer: Yeah. Anything else?

Dr. Madsen: So the other thing I've found is pseudoephedrine. Also known as Sudafed, but again, pseudoephedrine is the generic name. That's one of these things, if I find that these other things aren't cutting it, I take pseudoephedrine and that really just kind of dries my sinuses up. It helps me a lot with the congestion, runny nose. I don't like to take it a lot because personally, it gives me a little bit of a headache, but I usually kind of have it available during a shift if just nothing else is cutting it.

Interviewer: Would you use that on top of everything else we have talked about?

Dr. Madsen: If I'm in a situation where maybe I have taken the guaifenasin and the dextromethorphan and it's been two or three hours, I'm okay with taking it then.

Interviewer: Is there any concern about taking it all these medications? It sounds like a lot of stuff, or isn't it really?

Dr. Madsen: It is a lot of different stuff, but keep in mind these are all different classes of medication. You know, taking all of them can make you feel a bit jittery sometimes, honestly because they can kind of have that effect. The pseudoephedrine can kind of dry your mouth out and with any cold medicine, it's going to make your head a little cloudy. And it's probably already cloudy from feeling miserable from a cold. But they are different classes of medication, so aren't necessarily going to have a cumulative effect with each other.

Interviewer: So you talk a lot about controlling symptoms. Is there anything you can do to shorten duration?

Dr. Madsen: There is some evidence suggesting that if you start taking zinc early in the course of a cold, say within the first 24 hours, that it actually does have an effect. And for years, maybe even physicians have thought, "Well, it's maybe not scientifically based," but there have been several studies that have come out, including a nice review of all the studies that came out about a year ago, looking at zinc based medications. You may have heard of Zicam; that's the brand name. But if you start taking that early on, it very well may shorten the duration of your cold and the intensity of it.

Interviewer: What about drinking lots of orange juice?

Dr. Madsen: Yeah, high dose vitamin C, I've tried to look some things up on that. Personally, I take it, just because I'm like, "It's not going to hurt me, and it may help me." Evidence is a little mixed on it. I feel that personally, it kind of has an effect. Maybe it's a placebo effect. Maybe it's a real effect. Again, trying to look up some studies, kind of a mixed bag on it.

Interviewer: Sure.

Dr. Madsen: But I don't think there is any harm, and it may help.

Interviewer: So that leads me back to another question: Is there anything you do just kind of on a daily basis to help boost your immune system?

Dr. Madsen: Yeah, so on a daily basis, it's funny that you ask that too, especially with the vitamin C question, I take Vitamin C every day because I figure I am exposed to so much junk and so many different types of viruses and illnesses that I'll do whatever. And maybe it helps; maybe it doesn't. It's cheap, it's easy to do, but I do take vitamin C supplements every day.
And of course, the other thing is trying to get sleep. And that's one thing for me, personally, that's a challenge. Just with working night shifts, I find that when I do that, man, a couple days later, I'm really a set up for a cold. But if you're in a situation where you can sleep on a regular basis, and not interrupt your sleep pattern, that's going to help you to stay healthy. And certainly, just exercising. I personally exercise on a regular basis, but I think doing that keeps your immune system up and helps you to hopefully avoid some of these things.

Interviewer: So do you have any concern when you go . . . because there's a lot of discussion nowadays about when you're sick you should just stay home. It used to be, "Oh, I've never been absent a day in my life." But now there's a chance you might spread it to people. In the medical profession that's not an issue, because you said you've had one sick day in 10 years.

Dr. Madsen: Yeah. I mean, if I tried to call in for work, it's just not that simple.

Interviewer: They're going to be like, "Uh, I don't care. You need to come in to work."

Dr. Madsen: They're going to say, "We need you here." I mean, reality is if I'm sick, I'm going to wear a mask. I don't want to spread it to patients if it's really a concern. Unfortunately, that's a big reason people should avoid the E.R. in general. There are just so many bugs floating around there when you walk in the door.

Interviewer: Yeah.

Dr. Madsen: That's why a big thing I always try and talk about is what you can do to avoid the E.R. But certainly anyone who had any immune system compromiser would be a set up for an infection. I'm wearing a mask in that room if I'm even a little sick.

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