When do your kids really need antibiotics?

Here in Japan, it is very common for doctors to prescribe antibiotics as long as the sick child has a high fever, or if the child hasn’t recovered by the second visit. Parents in Japan can be heard asking for their antibiotics prescription, just in case … they are particularly anxious for their children not to miss school, and more importantly their expensive afterschool cramschool classes. 

The spotlight on the twin problem of antibiotics abuse and antibiotic resistance came about when Streptococcus pneumoniae bacteria developed drug-resistance. (Streptococcus pneumoniae is the pathogen that’s reponsible for most of the upper respiratory tract infections (URIs), lower respiratory tract infections, and other serious infections in children.)  

The CDC reports that nearly all important bacterial infections throughout the world are becoming resistant to antibiotics. Judicious use of antibiotics is the key to controlling the spread of antibiotic resistance. There are now ongoing major initiatives in various countries to educate medical practitioners and parents about the need to use antibiotics judiciously for children.

Research data shows a wide variation in the prescribing rate of antibiotics for upper respiratory infections by individual doctors in Japan and that many doctors over prescribed antibiotics.

The Working Group for the Judicious Use of Antibiotics in Pediatric Ambulatory Practice warns:

“The use of antibiotics inevitably entails the appearance of more resistant strains of bacteria. Until recently, new antibiotics have been repeatedly created to combat the new strains of resistant bacteria. However, itis becoming impossible to continue using this method, because bacterial resistance is developing faster than new antibiotics. The isolations of the resistant bacteria are closely related with the usage of antibiotics in each country. In Japan, not only are a large amount of antibiotics used, but broad-spectrum antibiotics are also used more widely than in other countries. As a result, the rate of resistant bacteria is very high, causing difficulty in treating severe bacterial infections such as meningitis.

It has been known that most children’s fevers are caused by viral infection. However, from the lack of data in daily practice and the fear of serious bacterial infections such as OB or meningitis, oral antibiotics have been prescribed to all febrile children. Such an approach may have been effective for preventing possible complications secondary to OB in the era of a few or noresistant bacteria. However, the resistant strains of pneumococcus and Hib (common causative agents for OB) are increasing rapidly, and the conventional approach will soon be ineffective in Japan.

Prescribing oral antibiotics without risk assessment to all febrile children will result in an increase of resistant bacteria and difficulty in treatment of OB and other serious bacterial infections. Oral antibiotics have possible effects of slightly decreasing risks of pneumococcal OB. However, they are not only ineffective on OB due to Hib, but also the use of them may delay the correct diagnosis, and result in a poor prognosis if bacterial meningitis has already developed. Therefore, it is not recommended to prescribe antibiotics to all febrile children.

Prevalence of resistant strains of bacteria in Europe has been very low, compared to other parts of the world. Penicillin has been principally used in Europe, where as broad-spectrum antibiotics (such as cephalosporin) have been used in Japan.”

The Working Group has recommended the following Guidelines for the use of antibiotics:

1) Antibiotics should not be prescribed for viral diseases. Prescription for the prevention of a secondary bacterial infection should also be avoided.

2) Even if a bacterial infection is suspected, antibiotics should not be used when the risk of severe complications is low and a recovery without antibiotics is expected.

3) Antibiotics should be used when there is evidence of bacterial infection and the therapeutic effectiveness, of antibiotics, has been confirmed.

4) The use of antibiotics is appropriate when a patient has a fever and the laboratory data* suggests a high risk of serious bacterial infection.

5) Narrow-spectrum antibiotics, whenever possible, should be the first-line of therapy for bacterial diseases.

6) When a disease such as sepsis, bacterial meningitis, or other severe bacterial infections is suspected, broad-spectrum antibiotics (sufficiently effective against possible resistant strains) should not be used until the causative pathogen is revealed.

(*With the widespread use of medical equipment, it is now possible to manage a risk control of fever by both rapid blood examinations and rapid antigen tests in the outpatient settings. In these Guidelines, we propose a principle of not administering antibiotics to the cases with leukocyte count of <15,000/μl, with the exception of both infants of less than 12 months old with fever of ≧40°C and cases with bad general condition.)

But what do we do when we are panicking over that persistent fever or horrible cough? Much as we all tend to want “to beat the bad guys before they get a foothold”, resist that urge to demand for antibiotics. Some things you should run through your mind first (according to the Working Group):

• Antibiotics are not needed for the common cold. 
• Most cases of pharyngitis/tonsilitis are viral infections. There is no need for antibiotics except when group Abeta-hemolytic streptococcus (GABHS) is the cause in which case benzylpenicillin benzathine is the first-line agent for the strep infection.
• In the case of acute otitis media watch the symptoms – only if the symptoms (otalgia or fever) have not subsided within 48-72 hours, bring your child to see your pediatrician immediately who may then prescribe an antibiotic.
• Most cases of acute sinusitis are viral infections. Antibiotics use should not be used for the first 10-14 days, even if purulent nasal discharge is present.
• Most of cough illness/bronchitis are caused by viral infections. Antibiotics are not justified for the treatment. Erythromycin is recommended if pertussis is suspected. Where there is a fever, the doctor should advise observation period of the patient’s condition without administering antibiotics. However, when one of the findings below is present, intravenous ceftriaxone is recommended: 1) Infants of 3-12 months old with either a temperature of ≧40°C, or 38.5°C or more and leukocyte count of ≧15,000/μl( or neutrophil count of ≧10,000/μl). 2) Infants of 12-36 months old with a temperature of ≧39°C and leukocyte count of ≧15,000/μl (or neutrophil count of ≧10,000/μl).

Finally, know that you, as parent, are entitled to or can expect the following communication with your medical practitioner:

1. Discussion of the nature of the illness

2. Explanation of reasons for prescribing or not prescribing an antibiotic (including risks)

3. Review of a contingency plan–the expected duration of symptoms and follow-up plan (telephone call or appointment)

4. Provision of recommendations for relief of symptoms, such as over-the-counter or other palliative measures

5. Patient and parent should be involved in the decision-making process and share the responsibility for follow-up

6. Ask and expect to be asked questions and to be provided answers about your concerns (eg, previous experiences; why do you want an antibiotic?)

7. Neither patient or parent should feel ashamed or ignored regarding your child’s illness and possible expectations for antibiotics.

Sources / references:

Guidelines on when to use antibiotics (Working Group for the Judicious Use of Antibiotics in Pediatric Ambulatory Practice)

Educating Parents About the Judicious Use of Antibiotics in Children by Myra Carmon, EdD, CPNP, RN

Fears rise over flu strains resistant to oral drug Tamiflu (Oct.23)

Related articles:

Skylines Organic Alternatives to use of antibiotics  (Producers are feeding their animals commercial feeds containing low levels of antibiotics and/or other drugs every single day, as a preventive measure. This relates to exacerbating the problem of increasing the resistance of pathogens to drugs as well as the issue of the antibiotic residue ending up in our food supply.)