Transcription:

Melanie Cole (Host): There’s no handbook for your child’s health, but we do have a podcast. Featuring world-class clinical and research physicians, covering everything from your child’s allergies to zinc levels, this is Kids Health Cast by Weill Cornell Medicine and our topic today is children and antibiotics. My guest is Dr. Paul Chung, he’s the Site Medical Director for Brooklyn Heights and an Assistant Professor of Clinical Pediatrics at Weill Cornell Medicine.

Dr. Chung, what a great topic we are discussing today as many parents run to their pediatrician and say I need an antibiotic, when a child is coughing or sneezing, Tell us a little bit about what's going on with antibiotic use today with pediatricians and children and when are we watching and waiting and when are we really recommending antibiotics.

Paul Chung, MD (Guest): Hi Melanie. Thank you for having me and you’re right, this is an issue that most pediatricians are dealing with on a daily basis, multiple, multiple times and having these discussions with parents. The current trend in antibiotic use these days is that there is more and more over prescription and overuse of antibiotics. So, in outpatient pediatrics, about one in five visits results in an antibiotic prescription which means that there’s about 50 million antibiotic prescriptions in these settings for children.

And research has shown that about one third or 30% of these are unnecessary and aren’t going to have any impact on the course of the illness. So, to answer your question, one thing we can clarify is what in fact is an antibiotic. An antibiotic is a medication that damages or kills bacteria so if you are dealing with a bacterial illness; then it will alter the course of the illness, help prevent complications and potentially be life-saving. Antibiotics don’t have any mechanism or affect on viruses. So, any type of viral illness, then it won’t alter the course of the disease at all.

Host: So, as parents, when do we want to use antibiotics? Talk about strep throat, ear infections because that’s kind of one where we are not sure, but parents may be scared to do the watch and wait thing. Tell us when it’s advised and when it’s not.

Dr. Chung: And you know it’s interesting that you named two conditions that aren’t the most common diagnoses that we see in the office. Most upper respiratory infections which is the most common complaint that antibiotics are prescribed for, most of these upper respiratory infections are going to be due to viruses and they are going to be colds that don’t need antibiotics. Now you named two bacterial infections that are a little bit of a different story.

And one thing that parents can do is they rely on their pediatrician to distinguish when they evaluate their child to do a thorough history, to do a thorough physical and to stay up to date on the newest guidelines from the American Academy of Pediatrics because they put out updated criteria on how to distinguish these more innocent viral illnesses versus more progressive and sometimes more serious bacterial illnesses.

So, you brought up strep throat. Now streptococcus pyogenes is the bacteria that causes strep throat and that’s – because that is a bacteria, that is one infection that you are going to want to treat with a full ten day course of oral antibiotics or one injection of penicillin. And it’s not that strep throat is in itself going to cause so many problems in those few days when you contract the illness, because most cases of strep throat do get better on their own, although they cause discomfort through different symptoms. But the immune system can over the course of time have some reaction to the strep and there is a risk of rheumatic fever or rheumatic heart disease and that’s not a common condition, but because of that risk; in the case of strep throat, the benefits of prescribing the antibiotic outweighs the risks.

For an ear infection, there isn’t this down the road long-term complication, autoimmune complication years later and so for ear infections whether you treat with antibiotics depends on the age of the child. So, like every time you offer an intervention in medicine, like certain medications including antibiotics; it’s always important to have that consideration and have the discussion with the family; these are the benefits of taking the antibiotic and these are the risks and we can talk through and most of the time, if it’s not black or white which decision is ultimately the healthiest for your child; then we partner with the parents and having that discussion so we can decide together.

So, in general, the younger an infant is, the more chance that the ear infection will progress and not get better on its own, so we provide the antibiotic. If the child is older then it’s optional see whether you take a wait and watch approach, whether the ear infection is going to resolve on its own or whether you should give the antibiotic due to issues of comfort and to prevent the infection from progressing further.

Host: Well you mentioned one thing about take that full ten day course. Tell parents how important that is and any side effects that they should watch out for. Can their kid go in the sun if they are on antibiotics? And how important it is that they finish that pack and don’t just take a few say oh look, the symptoms are gone and then stop.

Dr. Chung: Well with every medication including antibiotics; there is going to be a list of potential adverse effects. And the antibiotic that pediatricians are routinely choosing are the ones with the safest side effect profile at the same time that’s effective against the bacteria that you are trying to treat. And we as pediatricians, are trained to give very specific recommendations for how long you should treat with antibiotics for the specific condition that you are talking about. Whether it be sinusitis, or an ear infection or a urinary tract infection or strep throat. And we will try to find the right balance of treating long enough so that all the bacteria are eradicated but not over treating so that you are not increasing the chance of adverse effects.

There are certain conditions where there is a range of what could be the appropriate dose. For example, depending on the age of the child; the range of treating an ear infection ranges from about seven to 10 days. The range of treating a skin infection can range from anywhere from three to many more days. Strep throat is one of the ones that again, the long-term complication that isn’t common but that can be very serious of rheumatic fever is serious enough that we say you need to finish the full ten day course. So, that’s something that we always clarify is if we give you this ten day course of amoxicillin for strep throat, your child will most likely feel much better and maybe have no symptoms after two or three days. Many antibiotics, it’s not critical to finish the full course, but strep throat is one of the ones you have to finish the full ten days.

Host: So, we worry because we are hearing more and more about bacteria that are becoming resistant to antibiotics and I think I told you that my son got one of them when he was at college in the gym, just his first two weeks in college. Tell us what is antibiotic resistant and why is this happening and what is meant by that term antibiotic stewardship.

Dr. Chung: Sure. If we list the potential adverse effects of antibiotics; there are milder things like stomach upset, and loose stool, there are potentially immediate dangerous things, although it’s not common, but like a serious allergic reaction. And then antibiotic resistance falls into the category of something that happens if you extensively use antibiotics repeatedly over and over and over in a community over a period of time. And there’s many different classes of antibiotics and doctors are trained to choose the antibiotic that is the least broad or the most narrow that’s going to be effective against the bacteria that you are trying to kill.

The broader the antibiotic, the widest mechanism that it has, the more resistance can develop with repeated use over a period of time. So, I’ve seen that develop in real life in many situations in the hospital over and over again, over the past 15 years. For example, for a urinary tract infection, the first line treatment for the most common cause of urinary tract infection used to be a certain antibiotic called Bactrim or Septra and we’ve had to adjust what the first line treatment for urinary tract infections multiple times over the past 15-20 years because those organisms or bacteria, they mutate the more that they are exposed to a virus and they become resistant to the mechanism that they used to be sensitive to.

And unfortunately, now there’s more and more cases of that bacteria has become so resistant it’s not sensitive to any oral antibiotic and a child just because they’ve gotten that resistant organism infected by that; they have to automatically spend multiple days in the hospital because the only antibiotic that’s effective against that infection is an IV antibiotic. You mentioned what happen with the child so I anticipate it might be something along the lines of a skin infection and that’s something that people hear a lot about in the community where one of the most common causes of skin infections is staph aureus because of more and more exposure to antibiotic has become resistant and now there’s methicillin resistant staph aureus and MRSA.

And in certain communities in New York, unfortunately, that’s becoming more and more prevalent with the more and more prevalence of antibiotic use and with these emergence of resistant organisms; there’s a higher chance for more invasive disease and you are just having to use broader antibiotics and then you end up on a uphill battle. The broader the antibiotic that you have to shift to, now the more resistant that organism is going to become and the fear is that now, as we move into the future, the discovery of new antibiotics by the pharmaceutical companies isn’t going to keep up with the rate of emergence of resistance and so then you have organisms that aren’t going to be treated by any antibiotic which obviously puts us in a very dangerous situation.

So, that brings us to what can we do about it. And the broad term for what we’re trying to do to try to prevent or break this cycle is antibiotic stewardship and in general, that means we as a medical community are charged with being responsible with how we use antibiotics. We should be stewards with the responsibility that’s given to us and that means when you see patients, be responsible about taking the time, keep updated with guidelines, and do your best to distinguish which are innocent viral infections that you don’t need antibiotics for and which of these conditions are in fact bacterial conditions that would warrant antibiotics.

When you do, after you do distinguish that, pick the best agent that’s not any more broader than you need to and to have discussions with families about the benefits and risks for antibiotics when you consider employing them.

Host: Wow. What a great description. You are an excellent educator Dr. Chung. That was really very informative. Thank you so much for explaining that so very well. As we wrap up, what the most important thing you’d like parents to know about antibiotics and questions to ask their pediatrician when their children have a UTI or strep throat or an ear infection or simply just a cold?

Dr. Chung: I would say, I would encourage parents to have that discussion with your pediatricians about the benefits and risks any time you are considering an intervention and I will say the majority of parents these days that I encounter have that attitude and are very open to that discussion. There’s more and more emergence these days of direct to consumer telemedicine companies that aren’t integrated within your primary care medical home and there are statistics, recent research that shows that there tend to be more inappropriate antibiotic prescriptions in those types of settings where follow up isn’t as readily to be able to coordinated. So, to be aware of that. And again, look to your pediatrician to provide more education about this.

Host: Such great information Dr. Chung, So important for our parents to hear. Thank you to our guest Dr.Chung and to our listeners.

This concludes today’s episode of Kids Health Cast. Please remember to subscribe, rate and review this podcast and all the other Weill Cornell Medicine podcasts.

For more health tips and updates on the latest medical advancements and breakthroughs, follow us on Facebook and Twitter. Until next time, I’m Melanie Cole.