WHEN I trained as a general practitioner I was told that I should avoid prescribing antibiotics unnecessarily because it causes antibiotic resistance and thrush. Although my mentors meant well, I was lied to.
Firstly, the issue of antibiotic resistance goes against logic. In each individual case a clinician should either prescribe or not prescribe antibiotics depending on what the best thing is for the child in front of them. The issue of bacterial resistance is an important one, but the interests of the patient override this at the moment of decision making. Antibiotics only fulfil their purpose when used appropriately, so avoiding their timely use is like saving money and never spending it.
Secondly, in paediatrics, thrush is thankfully an infrequent problem and I don’t believe that I have seen many cases where it could be blamed on antibiotics. The vast majority of thrush in children is oral thrush in babies. Most of them have acquired this as a result of vertical transmission and there is little to suggest that normal colonisation with bacteria reduces candida infection in normal clinical situations. I would take a different view with a child on an intensive care unit, but the child with a straightforward suspected bacterial illness should have the most appropriate antibiotic without the risk of thrush troubling the prescriber.
However, I have come to realise that there are plenty of good reasons to avoid prescribing antibiotics to children unless there is a good indication. These reasons to hold back are all reasons close to the heart of clinicians, parents and patients alike.
So here are the 10 real reasons not to prescribe antibiotics (unless you really should):
1. It’s the wrong medicine
Antibiotics don’t have much effect on most childhood illnesses. Upper respiratory tract infection (URTI) is mostly viral, including ear and throat infections that look to the examining eye like they should respond to antibiotics (by traditional measures such as exudate on tonsils). Accordingly, numbers needed to treat (NNT) for sore throats, earaches and runny noses are high. If there is fever or pain (i.e. any child with URTI worth treating) then Paracetamol and Ibuprofen have a number needed to treat of 1. Everyone improves with these medicines either alone or in combination. If antibiotics are prescribed, parents may diligently give these as instructed and stop putting enough emphasis on the medicine that makes the child better. Many a child presents acutely having become suddenly worse after antibiotics are started, because less or no antipyretics are being given.
2. It will make you think that they are allergic to the antibiotic
Because so many children have antibiotics prescribed during viral illnesses, they happen to be taking antibiotics when they suddenly develop a rash or vomiting. These are blamed unfairly on the antibiotic when in fact these are just symptoms and signs of the viral illness. The result is that when the child needs this antibiotic (usually amoxicillin) for a definite indication they are unable to take this because they have been incorrectly labelled as allergic. They then have to have a different antibiotic, often with more side effects and possibly with less chance of success.
3. The child may have an actual allergic reaction
There is nothing quite like anaphylaxis to make parent and clinician both question the indication for a prescription.
4. It may give them diarrhoea
Most antibiotics can contribute to or cause diarrhoea. This is not good for the child or the parent and may cause the child to come back for further assessment. Often this results in the stopping of the antibiotic.
5. It may cause nausea
…as this is one of the most common side effects of antibiotics. This will also compound the difficulties that you and the parents have in keeping the child well hydrated.
6. Rare but serious side effects
There is always the small chance of a rare but serious side effect. Some of those listed for the usual broad spectrum antibiotics are kidney failure, jaundice and seizures.
7. Medicalisation of a problem
Medicalisation of a viral illness occurs when antibiotics are prescribed. This reason, research has shown, increased re-attendance rates following antibiotic prescription. There is no rationale for waiting a few days and then prescribing antibiotics either, despite this being common practice.
8. Refusal to take the medicine
Many children resent having to drink down something when they feel unwell and so become quite non-compliant with their other medicines.
9. Inconvenience and cost
There is an inconvenience associated with having to obtain the antibiotics and a cost associated with the prescription.
10. It’s the wrong medicine
Unless it really isn’t, and if it wasn’t then none of these issues would even be a consideration because the indication for the antibiotics would be clear.
So, considering all these problems associated with antibiotics, they really are a nuisance and should be avoided for reasons far better than bacterial resistance. Ultimately, the number needed to annoy (NNA) for antibiotics is about 1.
Most children will do one of the following: refuse their antibiotic, get nausea or diarrhoea, break out in a rash or develop a real complication. So, I don’t think I’m going to recommend a delayed prescribing strategy for any condition, whether it is otitis media, a bad cold or a persistent cough. Instead I will recommend that the indications for antibiotics are nothing to do with the passage of time if the clinical picture is one of viral illness.
Edward Snelson is paediatrician specialising in paediatric emergency medicine at Sheffield Children’s Hospital
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