ANTIBIOTICS: GOOD, BAD, or UGLY ???
Antibiotics, drugs that cure bacterial infections, are one of the greatest medical advances of the 20th Century – second perhaps only to vaccinations. Antibiotics have turned many previously fatal diseases into treatable minor illnesses. They have eliminated the long-term complications of bacterial disease in many situations, and overall have vastly improved the health of the world. Nevertheless, like so many things nowadays, they are surrounded by controversy.
Antibiotics are very safe drugs. Correct doses do nothing to people. They do not “weaken the immune system”, nor do people become immune to their action. When an antibiotic doesn’t work, it is because the germ causing the infection was not sensitive to the medicine – it has nothing to do with the person taking the antibiotic.
What are the down sides of antibiotics? ALL medicines have side effects and risks. With antibiotics, the major risk is a serious allergic reaction. These are rare, however and the side effects we see from antibiotics tend to be relatively minor. The real issue arguing against over-use of antibiotics is bacterial antibiotic resistance. Many bacteria over the past century have developed methods of resisting antibiotic action. A resistant bacterium is much harder to treat. It requires newer, stronger, broader spectrum antibiotics – and sometimes can’t be cured at all. That this phenomenon of antibiotic resistance has happened is not surprising. From an evolutionary perspective, it was inevitable: as soon as the human race invented antibiotics, germs would start inventing ways to evade them.
We thus find ourselves in a “foot race” with the world of germs – hoping that we can stay a few steps ahead of them in our antibiotic designs. The only way to stop this foot race would be to find immunizations for everything and stop using antibiotics altogether. Otherwise, the race will continue – we slow its pace by reducing our overall use of antibiotics, but we can never stop it.
PUSH & PULL: Doctors often feel torn between competing pressures around antibiotics. On the one hand, there has been much press in recent years about antibiotic resistance and about how over-used antibiotics are (with the implication that we physicians are to blame). On the other hand, during sick visits it often seems like parents really wish (secretly or not so secretly) that they could go home with a prescription for one. Certainly, the parents who walk out the door with such a prescription often seem* more satisfied than the ones who don’t. How do we balance these conflicting pressures?
It must be recognized that antibiotics are inherently neither good nor evil. Rather, they are good when used appropriately, and bad when used inappropriately. The challenge is to use them wisely and judiciously. Antibiotics are obviously appropriate when a patient has a definite bacterial infection – something which will not get better without them and when there is no doubt about the diagnosis. They are equally obviously inappropriate when all the evidence points in the direction of a non-bacterial disease process such as a virus, which is not responsive to antibiotics. The more difficult decisions about when to use antibiotics come when the diagnosis is uncertain, or when antibiotics are contemplated as prophylactic or preventative therapy for a patient who is not sick currently but is deemed to be “at risk”.
HOW DOES THIS WORK? It is important to realize that antibiotic resistance in germs is not something that develops in a single patient during a single course of antibiotics. Antibiotic resistance arises by “natural selection” – the same force that helped humans evolve from apes. Evolution proceeds much more quickly in germs than it does in mammals, however, because entire generations pass in matters of hours & days rather than years & decades. As a result, populations of germs can undergo changes in a matter of decades that would take thousands of years for mammals to accomplish. Nevertheless, these changes are evolutionary in nature. They effect populations of bacteria, not individual germs, and they play out over a long time scale (years) in large geographic areas (continents). The germs living in your child’s body this week and the antibiotics we are treating those germs with are but a drop in the ocean of this process.
It is also important to realize that when it comes to the total “ocean” – worldwide use of antibiotics – America, Western Europe, and “Western Medicine” are not the major culprits. In many parts of the world including Latin America, Southeast Asia and much of Eastern Europe, very strong, broad spectrum antibiotics are available without prescription. Indeed, it is often much easier for a citizen in those countries to buy an antibiotic and treat him/herself than it is to obtain the attention of a good medical doctor. If we were seriousabout reducing overall world-wide antibiotic usage, we would make far more progress by forcing those countries to enact prescribing laws similar to our own than by criticizing the prescribing practices of the “western” medical community.
What to do?
Nevertheless, it certainly is true that over-prescribing in this country does occur. This is a complex phenomenon, which results from both physician laziness/weakness and patient ignorance/pressure. At this office, we are not lazy or weak. We try ONLY to prescribe antibiotics for situations in which bacterial illness is certain or highly likely or, as prophylaxis, when increased risk of bacterial infection is definitely established. You can help us by understanding the importance of judiciousness in the use of antibiotics, and understanding that not every cold or childhood illness requires treatment with an antibiotic – indeed the majority do not. When we do feel that antibiotics are necessary, we would always be happy to explain to you exactly what it is we are treating with them, and what might happen if treatment were not undertaken.
Examples of when antibiotics should and shouldn’t be used.
REQUIRING ANTIBIOTIC TREATMENT:
WHICH DO NOT REQUIRE ANTIBIOTICS:
WITH ANTIBIOTICS IS DEFINITELY INDICATED:
- Chronic Ear Infections
- Recurrent UTI with anatomic abnormalities of the GU system
- Immune Deficiencies
- Close exposure to confirmed cases of Bacterial Meningitis or Pertussis
- Travel to countries where Malaria is endemic.
- Positive “TB” test.
- Any fever under 2 months age (until multiple cultures are negative)
ANTIBIOTICS MAY BE CONSIDERED BUT IS CONTROVERSIAL:
- Recurrent but not chronic Ear Infections
- Recurrent or chronic Sinus Infections
- Recurrent UTI’s with no anatomic abnormalities
- Deer Tick Bites (exposure to Lyme Disease)
- Close exposure to suspected but unconfirmed cases of Bacterial Meningitis or Pertussis
- Travel to countries where “travelers diarrhea” is common.
- Fever over 104°F under 3 years age with no source found on physical exam (until blood & urine cultures negative).
TREATMENT WITH ANTIBIOTICS IS NOT INDICATED:
- Exposure to strep
- Traveling with a cold
- Exposure to viral meningitis