This week I brought my 10-month old in to see the pediatrician. I was worried about an ear infection. “He has had a high fever for two nights,†I explained, “and do you see all that yellow gunk coming out of his nose?â€
The doctor showed appropriate concern and (despite my baby’s protests and squirms) she was able to get her ear scope at least half-way into each ear for what seemed like a millisecond. “I got a great view. Wouldn’t you know it—his ears look great.â€
As she told me she no longer thought an ear infection was a possibility, I must have looked crestfallen. “Well,†she said, “I would bet this is a viral illness, not an ear infection. But I will give you an antibiotic prescription just in case, and if the fever keeps up for another four or five days, you can start the antibiotic.â€
Carrying the antibiotic prescription in my hand as I left, I felt like I was carrying contraband. I badly wanted to do something to help treat my baby’s illness, but I had been told not to fill the prescription without due time and continuing symptoms. The doctor in me said “no antibiotics†and yet, the mom in me saw some magic in that paper prescription. Wouldn’t it help a little? What if the doctor was wrong?
I am sure that some patients leave my own office feeling disappointed and full of doubt when I decide to end an urgent care visit without giving antibiotics.  Sometimes I bring up the fact that we are seeing more and more drug-resistant bacteria, and widespread use of antibiotics is certainly to blame. When you take antibiotics, you kill sensitive bacteria. Some of these bacteria are a natural part of your body, living on your skin, in your intestine, nose, throat or other areas that are not normally sterile—they are called your “normal floraâ€. If there are any organisms among your flora that happen to be protected from antibiotics by a special gene, these remain. These genetically stronger or “resistant†bacteria can then multiply, and can stay around in your normal flora. It is straight-up survival of the fittest. This discussion really falls flat when I bring it up—I think most of my patients think I am sacrificing their needs to help solve a broader public health crisis. When you are sick, no one feels like being a hero. Of course the truth is, drug-resistant bacteria create risks both to the larger community and to the individual. After all, who is the most likely to get infected with a strain of drug-resistant bacteria? It is the person who carries those bacteria around in his own normal flora. In other words, if you take antibiotics (whether they are needed or not), you may be the one whose next infection will be “resistant.â€
Guidelines have advised doctors to avoid antibiotics for acute bronchitis infections, sinusitis that has lasted for less than a week, and ear infections without fever in children over two, since these infections can clear without antibiotics. Do antibiotics help these problems? Yes, in many cases they do. Even in acute bronchitis which is usually triggered by a virus, clearing bacteria can sometimes speed recovery. If you study bronchitis, the cough that brings up phlegm will last for an average of about a half of a day longer for people who don’t get an antibiotic. But what else happens? Side effects, antibiotic resistance and complications from antibiotic treatment occur in many people who are treated.
In the end, for these particular infections, the risks cancel out the benefits. I’m not sure why my patients don’t believe me when I tell them this. Maybe it is because we (doctors) usually don’t have time to give a full enough explanation about the side effects that we see. Most of us mention allergies (and boy, some of these reactions are severe) and stomach upset.
I don’t usually have time to elaborate about the consequences that occur from collateral damage—the loss of your normal flora. Lost normal flora can cause nuisance symptoms and in some cases, serious or life-threatening complications, including:
- Diarrhea from digestive failure: Bacteria in your intestine help you to break down carbohydrates. Without the bacteria (which are killed by antibiotics), some carbohydrates stay undigested and remain with your stool as it goes through the digestive tract, and the carbohydrates draw water into your intestine as they pass through you. This results in watery stool.
- Diarrhea from infection: It is normal to have some spores from bacteria named Clostridium difficile (“C. diffâ€) in your intestine. When your normal flora is varied and healthy, C. diff stays in its spore form. When your normal flora is killed, the changed chemistry in the gut can allow C. diff to change from spores into more active bacteria. When C. diff transforms, it makes a toxin that can cause diarrhea and life-threatening inflammation of the colon.
- Vaginitis: It is normal for women to have some yeast in the vagina. Lactobacilli and other bacteria in the vagina contribute lactic acid and other acids to the mucus in the vagina. After subtle adjustments in their environment’s acidity, yeast not only multiply but also change shape. They begin to make glue-like proteins that allow them to attach to the surface of the vagina and to form clumps. Yeast in this changed form irritate and inflame the vagina, causing vaginitis.
- Allergic asthma: Studies suggest that if babies get antibiotics, they are more likely to develop asthma as kids. Is this the result of antibiotics, the infections that babies get, or another explanation? We aren’t sure, but many experts blame the antibiotics. There is a window of time during young childhood when your immune system is learning and maturing. Your body needs to be exposed to harmless bacteria and proteins in your early life, so that your immune system can recognize them as familiar and harmless. It may be that the fewer bacteria you have during this early development, the more likely your immune system is to react later against harmless proteins, as it does when it creates allergy symptoms such as allergic asthma. In other words, if your immune system is “sheltered†in early development, it may be more likely to show “stranger anxiety†when it meets a potential allergy trigger.
- Upper respiratory infections: Antibiotics for acne have been linked to more frequent head colds. Even topical antibiotics (creams, lotions, soaps or gels) eliminate certain types of normal flora from the nose and, over time, from the throat and mouth. These moist areas are repopulated by “not-so-normal†flora, which may be slightly more irritating to the mouth and throat. Changes in your flora can apparently make it easier for a virus to begin an infection. A study that reviewed medical records from more than 118,000 people found that those taking antibiotics to treat acne for six weeks or longer got twice as many upper respiratory tract infections as otherwise similar people from the same clinics.
- Normal flora is hard to restore. Eating yogurt can help a little. I live in Oregon and I sometimes think about normal flora when I drive by an old-growth forest that has been clear-cut by loggers. Replanting can’t provide the rich variety of foliage that had been present in the old-growth forest. That takes time and the mysterious forces of nature. We need to be good stewards of our normal flora; we may not get it right when we get it back.
I am extremely grateful that we have antibiotics. By emphasizing side effects, I don’t mean to imply that we shouldn’t use antibiotics when we need them.
Are doctors striking the right balance in the way we prescribe antibiotics? All these thoughts filled my head when I left the pediatrics office with my sick baby. I’m curious. Would you have filled that prescription?
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Mary Pickett, M.D., is an Associate Professor of Medicine at Oregon Health & Science University where she is a primary care doctor for adults. Her field is Internal Medicine. She is also a Lecturer for Harvard Medical School and a Senior Medical Editor for Harvard Health Publications.
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Comments: 19
Even when I do get an antibiotic filled, I don't take it for the full dosage time. Mainly because I don't want to become resistant to them.
It is cases like this where people don't take their full course of antibiotics that is leading to antibiotic resistance and is hurting the community as whole. Please ALWAYS FINISH YOUR ANTIBIOTICS as described on the label. I don't mean to be disrespectful, but this should be common knowledge, and it can potentially hurt other people.
Michelle W., you brought up the length of treatment for infections, and you suggested that a shorter antibiotic treatment time than what is prescribed might help us to minimize the development of drug resistance. Although this sounds sensible, it doesn't work. In fact, it can make the problem worse.
It takes time for an antibiotic to kill all the bacteria in an infection. In some cases (for example, an abscessed area where a "pocket" of bacteria has formed) the treatment time is needed due to slow spreading of the antibiotic through the infected area. In other cases the antibiotic may need to be around for a while in order to catch and kill each bacterium in the infection during a specific vulnerable part of its life cycle. Bacteria that have just begun to build resistance to the antibiotic tend to be the ones that last through the early days of treatment. Still, if you stay on the antibiotic and take the full dose, those tough survivors will eventually succumb and die off just like the rest.
Let's assume that an antibiotic has been prescribed for an important infection such as pneumonia. Almost of the bacteria in your infection is sensitive to the antibiotic, but a few organisms are present that have a mutation making them faintly resistant to the antibiotic. If you take a shortened course of treatment, you may allow these more "hard core" bacteria to remain and then you are at risk for a relapse of your pneumonia. The second time around, all of the bacteria that have regrown have come out of that more "hardy" strain, so you may have a harder time killing the infection.
Researchers test various lengths of treatment for infections before an antibiotic is allowed on the market, so we have a good idea about the range of time that is needed for most kinds of infections.
Once you do decide to take antibiotics, take all of the pills that are prescribed.
Excellent article. I have long been a proponant of :letting infections run their course" versus antibiotic treatment. People sometimes don't realize that the human body is a wonderful thing, and has its own mechanisms for killing infections, like the fever. I explain to my classes: when you start to get a fever, you get the chills, this is because your innards are hotter than your outards. Once the skin is as hot as the internal temp, a fever occurs. fever means heat, heat kills bacteria. It is the body's way of fighting off an infection. I recommend not even administering tylenol, etc..till the fever is 101 in adults and 102 in kids, unless there is a comfort factor to consider, like earache.
You are right in theory that a fever can slow down or kill some bacteria types. Studies of bacterial growth in different incubator temperatures do show this, and some animal studies suggest that it is harder for the body to get infected if it is "hot". But does this make it healthy for people to have fevers? Most experts don't think so.
Even though the immune system makes some of the chemicals called "pyrogens" that cause fever, it doesn't make all of them. Some are made by bacteria, too. Good examples of toxins from bacteria that trigger fevers in us are "endotoxin" from E Coli and related bacteria, or the "toxic shock syndrome toxin" from staph aureus bacteria.
The cells of the immune system are as sensitive to temperature as are bacteria. The immune system works best when certain "pyrogens" are actually blocked from causing fever. For example, prostaglandins are the most important pyrogens we make. If you prevent prostaglandins from being active after giving a flu shot (you can do this by using ibuprofen), study data shows that you make a bigger supply of antibodies against influenza.
High fevers are dangerous. Fevers temporarily increase our oxygen need, which can be a dangerous problem for people with heart or lung disease who might not have much reserve. Fevers also temporarily cloud thinking, particularly for people with early stages of dementia. High fevers can cause seizures in infants or toddlers.
I recommend treating just about every fever. Good choices to lower or prevent fevers during infection are acetaminophen, ibuprofen, or naproxen.
I do not recommend NOT treating fevers. I merely suggested to let them do what they are meant to do, fight for you. I definitely advise treament when the fever reaches 101. My point is that many people start ingesting typenol, Ibuprofen etc...when their child or themselves hit 99.0, and that is unnecessary, unless there is a comfort factor to consider.
Fortunately, I kept my children from antibiotic-overload but admit they were not prone to ear infections.
The following infections are considered self-limited illnesses. Most of them (but not all of them) are caused by viruses:
• Colds
• Laryngitis
• Sore throats that are not caused by strep
• Ear infections that occur without fever in children older than two
• Acute bronchitis
• Sinus infections that begin to improve during the first week of symptoms
• Gastroenteritis
Many bacterial infections that aren't on this list need antibiotics, because they won't heal easily without them. Some infections need to be treated without a delay so that they do not spread or cause complications. Be sure to contact your doctor to ask whether an evaluation is appropriate, if you have an infection and you are not certain that it is a self-limited illness.
Second - and, I'm sure you didn't mean to sound condescending, but your inability to understand your patients' impatience with you when you don't prescribe an antibiotic seems to come from a belief you have that they won't be able to comprehend your reasoning in the alloted time you have to explain. I say balderdash! Give it a try. Use laymens' terms. You may find far more understanding than impatience.
I recently went through all this with my 10 year old and azrithromycin prescribed for strep. She already has a lot of skin allergies, I immediately gave her the maximum dose that her Dr said is safe for her age when I saw the first red blotch that looked like a hive. Within 6 hours she was covered over 70% of her body in what looked like "strawberry patch birthmarks".
I thank the stars that it was her that reacted to it and not her 3 or 4 year old siblings, who were also on the medication. I bet if it were them, they would not have alerted me to it so fast and it could have been a worse reaction at that age.