Ask the Pediatrician: Antibiotics?

Photo by Rebecca Tredway Photography

This is part three in our Ask the Pediatrician series focused on seasonal illnesses. A big thanks to Dr. Mark McColl for sharing his wisdom here.

When do we need antibiotics? Are they over prescribed? What should a parent do if they are concerned they are being unnecessarily prescribed antibiotics for their child?

Antibiotics are a powerful class of medications designed to kill off bacteria that have invaded the body. They are useful medications that can rapidly change the tide of a worsening infection. In the strictest sense, antibiotics are only used when the invading bacteria are not being sufficiently killed off by the body’s typical defense mechanisms thereby causing significant risk to the individual’s health.

This indication for using antibiotics is not as simple as some would like to think. For instance, ear infections in children may commonly be a bacterial infection that would dramatically improve with antibiotics. Different countries and cultures have different levels at which their healthcare community typically prescribes antibiotic help. In the United States, we have a low threshold for pain and suffering in our children and the standard for treatment is much sooner than the Northern European countries. The trade off is more antibiotic use but less complications from untreated infections.

The advice I give my patients is that I use antibiotics only when I feel they have a bacterial infection that their body cannot clear adequately enough on its own. Sometimes the evidence is very clear and sometimes it becomes a decision based on experience.

It’s important to note that there is a difference between an antibiotic and an antiviral medication. Antibiotics only attack bacteria and they do so largely by killing them. After a day or two of antibiotics there are fewer bacteria. The reduction is rather dramatic, honestly. Antiviral medications don’t work that way. They tend to stop the virus from replicating itself within the body. So if there are 100,000 copies of the virus present when the antiviral medication is started that number begins to stagnate. It only declines when the body begins to appropriately process and attack the infection. This is why antibiotics often have impressive effects in the first 48hrs while antivirals don’t.

I think antibiotics get over prescribed because physicians often assume the worst and patients often expect the best. Patients expect to heal more quickly than they really will and when that doesn’t happen they come in asking for something to make it better. Physicians are all too eager to help because as a group we want to “do something” to help our patients. If more antibiotics had annoying (but not harmful) side effects like turning your hair purple fewer people would over prescribe them. Even today a parent said to me about their child “But she can’t be sick, we’re going to be out of town in three days. Can’t you do something?” There is great pressure from many sides to over prescribe.

Parents who think they are being prescribed antibiotics unnecessarily should ask a few simple questions. Where, specifically, is the infection? Which bacteria is likely causing the infection? What do we gain by starting the antibiotic today? What do we risk by waiting to start the antibiotic? I would welcome any parent asking me these questions because they are the ones going through my mind each time I write out my prescription therapy. I need to be able to answer them well before deciding on the best course.