This week I brought my 10-month old in to see the pediatrician. I was worried about an ear infection. â€œHe has had a high fever for two nights,â€ I explained, â€œand do you see all that yellow gunk coming out of his nose?â€
The doctor showed appropriate concern and (despite my babyâ€™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. â€œI got a great view. Wouldnâ€™t you know itâ€”his ears look great.â€
As she told me she no longer thought an ear infection was a possibility, I must have looked crestfallen. â€œWell,â€ she said, â€œI 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 babyâ€™s illness, but I had been told not to fill the prescription without due time and continuing symptoms. The doctor in me said â€œno antibioticsâ€ and yet, the mom in me saw some magic in that paper prescription. Wouldnâ€™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. Â 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 sterileâ€”they are called your â€œnormal 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 â€œresistantâ€ 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 upâ€”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 â€œresistant.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 donâ€™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. Iâ€™m not sure why my patients donâ€™t believe me when I tell them this. Maybe it is because we (doctors) usually donâ€™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 donâ€™t usually have time to elaborate about the consequences that occur from collateral damageâ€”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 (â€œC. 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 environmentâ€™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 arenâ€™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 â€œshelteredâ€ in early development, it may be more likely to show â€œstranger anxietyâ€ 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 â€œnot-so-normalâ€ 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 canâ€™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 donâ€™t mean to imply that we shouldnâ€™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. Iâ€™m curious. Would you have filled that prescription?
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.
You can find the following related articles on Gather:
Using antibiotics appropriately
C. difficile-associated disease on the rise
Antibiotic resistance: The problem with overdoing antibiotics