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Friday, March 2, 2012

Post #29 Mom and Dad are on antibiotics, why not the kid?

Let's start with the kid.

Fact: Bacterial illnesses typically need antibiotics. Viral illnesses do not.

Antivirals help in certain rare cases - but for the purposes of this blog I will assume a typical viral illness encountered in a primary care physician's (PCP) office.

Your average child per the Centers for Disease Control and Prevention (CDC) will encounter 6-12 viral illnesses a year (typically colds and stomach bugs) and most of these will be concentrated during the wintertime when viruses tend to spread more easily due to humidity and temperature factors.

What this means is your child will be sick a lot - especially during the winter; and antibiotics will not help any of these viral illnesses. Of course should your child have a bacterial illness (often preceded by a viral illness) they should be prescribed antibiotics. The typical bacterial illnesses encountered in a PCP's office include: ear infections, pneumonia, sinus infections, and skin infections.

The majority of the sick children that I see on a daily basis have a fever or symptoms from a virus. I educate the parents on what a virus is, why antibiotics will not help, and what to look for in case the viral illness progresses to become a bacterial illness - in which case they will need to return to be placed on antibiotics. Overtime, my parents become adept at distinguishing the child who appears viral and the child who seems to have something a bit more serious. This in turn saves them visits to my office and decreases their overall expenditure of time and money - not too mention a significant reduction in frustration.

But every so often, a parent mentions that their adult PCP prescribed them some antibiotics for their recent illness and they wonder out loud why I am not following suit.

It is a fair question. Most of the time from my cursory visual exam of a parent I think to myself it is unlikely the mom/dad needs to be on antibiotics and thus ensues a dance to explain why I don't recommend antibiotics for colds, but perhaps the adult has something more serious - but in truth I suspect most of the time they have the exact same cold as their kid.

So why the discrepancy?

Let's move on to the adult.

The most common reason that an adult is prescribed antibiotics is for bronchitis or sinusitis.

The following information on bronchitis and sinusitis is straight from Up To Date, a website that most doctors trust and pay a hefty annual sum to access.


Acute bronchitis is one of the most common conditions encountered in clinical practice. Acute bronchitis is a self-limited inflammation of the bronchi due to upper airway infection. Patients with acute bronchitis present with a cough lasting more than five days (typically one to three weeks), which may be associated with sputum production.

Acute bronchitis is one of the most common conditions associated with antibiotic misuse. This respiratory condition is generally caused by a virus. However, reports indicate that more than 60 to 90 percent of patients with acute bronchitis who seek care are given antibiotics.

Guidelines from the American College of Physicians and the Centers for Disease Control and Prevention (CDC) are intended to dissuade clinicians from prescribing antibiotics for acute bronchitis. Both guidelines state unequivocally that pertussis is the only indication for antibacterial agents in the treatment of acute bronchitis. However, the frequency of prescriptions for antibiotics for acute bronchitis has decreased only modestly, from approximately 75 to 60 percent in the past decade. Additionally, the choice of antibiotics prescribed for the treatment of acute bronchitis has changed substantially during the same time span. Prior to 1990 approximately 20 percent of antibiotics prescribed for the treatment of acute bronchitis were broad spectrum; more recently approximately 60 percent of all prescriptions written for this condition were for broad-spectrum agents.

MICROBIOLOGY — The usual causes of acute bronchitis are viral infections of the upper airways including influenza A and B, parainfluenza, coronavirus (types 1-3), rhinovirus, respiratory syncytial virus, and human metapneumovirus.

Although it has been suggested that the bacterial pathogens that cause pneumonia (eg, Streptococcus pneumoniae, Haemophilus influenzae, Staphylococcus aureus, Moraxella catarrhalis, or even gram-negative bacilli) can also cause acute bronchitis, there is no convincing evidence to support the concept of "acute bacterial bronchitis" caused by these pathogens in adults. An exception is in patients with airway violations such as tracheostomy or endotracheal intubation, or those with exacerbations of chronic bronchitis.


Acute rhinosinusitis (ARS) is defined as symptomatic inflammation of the nasal cavity and paranasal sinuses lasting less than four weeks. The term "rhinosinusitis" is preferred to "sinusitis" since inflammation of the sinuses rarely occurs without concurrent inflammation of the nasal mucosa.

Acute rhinosinusitis is further specified as acute bacterial rhinosinusitis (ABRS) or acute viral rhinosinusitis (AVRS).

The most common etiology of ARS is a viral infection associated with the common cold. Viral rhinosinusitis is complicated by acute bacterial infection in only 0.5 to 2.0 percent of episodes. Uncomplicated AVRS typically resolves in 7 to 10 days. ABRS also is most commonly a self-limited disease, with 75 percent of cases resolving without treatment in one month.

Distinguishing AVRS of colds and influenza-like illnesses from bacterial infection is a frequent challenge to the primary care clinician. Antibiotics may be indicated for ABRS, but are ineffective and not recommended for AVRS. Despite the overwhelming prevalence of a viral etiology, however, 92 percent of patients in the United Kingdom and 85 to 98 percent of patients in the United States (US) are prescribed an antibiotic when seen for an upper respiratory or sinus infection.

As you can see, for both bronchitis and sinusitis antibiotics are rarely needed in the adult patient. Bronchitis, unless caused by pertussis (uncommon), does not need antibiotics and less than 2% of sinusitis cases are caused by a bacteria.

However, the statistics repeatedly show a high prescription rate of antibiotics for both conditions.


1. Adults in general are more willing to try medications because they are less concerned about side effects. With their kids they are more scrupulous with what they feed them.

2. Even if the success rate is low, adults feel more pressure to return to work and are willing to get any advantage they can in feeling better sooner.

3. Past success with antibiotics makes adults assume future illnesses continue to require them.

4. Adult doctors know this is what patients expect and they do not want to lose business.

5. Some adult doctors are not aware of the Up To Date information posted above.

6. Educating a patient about the difference between a virus and a bacteria and the statistics on bronchitis and sinusitis can be time consuming.

7. Some doctors feel safer treating all patients with antibiotics so that they do not risk missing the 2% of sinusitis cases that are actually caused by bacteria.

8. Placebo effect.

Over the years, I have convinced many of my close friends and parents of patients of the above information. This has saved them trips to their doctors, co-pays, trips to the pharmacy, money spent on antibiotics, and unnecessary side effects incurred.

Of course, this is not to say that antibiotics are never needed. But just as my patient's parents have become astute with when their kids have something greater going on than a typical cold, adults too can become more in tune with their own body's illnesses.

Overtime, this will lead to better health and less frustration. Antibiotics are one of the greatest advances of modern medicine, but they are powerful tools that need to be utilized judiciously.

And often if your pediatrician is not recommending an antibiotic for your child, chances are you don't need one either.

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