Wednesday, 9 December 2009

The antibiotic war.


Posted by: Dr. Thunder.

What are we doing wrong?

Why have we not got the message out there about antibiotics?

How come we struggle to get parents to give their kids life-saving vaccines, but we've convinced them to to demand an antibiotic for their little ones, at the first sign of a sniffle.

I saw a 5 year old boy, Thomas, a few days ago in the emergency department. Thomas had a mildly elevated temperature, a runny nose, a sore throat, and a pain in the side of his head.

"We're here because we can't trust our GP any more".

"Really? And why is that?".

"He told us Thomas IS sick, but he won't give us an antibiotic", mum answered.

As Thomas sat there on the trolley-bed watching his portable DVD player, and laughing loudly at the cartoon on his screen, I began to suspect that A) He did not have a bacterial infection and B) This consultation was not going to end well.

I gave him a good look over, and concluded that he had an improving, self-limiting viral infection. Red ear, red throat, runny nose and a bit of a temperature. He was eating and drinking normally again, and seemed to be on the road to recovery.

I sat down with Thomas' parents, and explained the difference between viral and bacterial infections. I told them that this infection seemed viral to me, and reassured them that their GP had made the right decision.

"Look, can we stop all the side stepping here? Are you telling us he's not going to get an antibiotic?".

"I'm sorry. I'm not going to prescribe an antibiotic because....."

"OK, can we get a second opinion. He gets these infections several times a year, and ALWAYS needs an antibiotic".

I told them I'd happily get the consultant involved, but that this would take some time.

They agreed to wait, and Thomas loaded another DVD to watch.
After about 20 minutes they started to complain loudly to each other, as people do when they're trying to get your attention.

"I told you we should have brought him to the other hospital", dad said to mum, VERY loudly. "At least THEY know what they're doing".
This went on and on, and I ignored them.

20 minutes later, they got up to leave. On the way out, they told random nurses and patients int he corridoor that they were going to find a private doctor "Who bloody knows what he's doing".

The thing is, I suspect they may have.

These parents are very likely to have found a doctor who agreed to give Thomas some Amoxicillin. Then Thomas will have continued to get better, except for his antibiotic-induced upset tummy. In two more days he'll be right as rain, and they'll tell all their friends that the antibiotics cured them, and that the pillock paediatricians at the local hospital haven't a CLUE what they're doing.

It has bewildered me for so long that we give out so many antibiotics without any justification. It's hard not to, and when I was a bit more junior I did so, when I couldn't stomach the fight. I don#'t resent the doctors who prescribe them easily. But I really wish they wouldn't.

Anyone got any thoughts on what percentage of antibiotics given for acute respiratory illness actually result in improvement? I've no idea, but I'm sure it's very low.

Dr. Thunder.

12 comments:

  1. I was very lucky when my daughters were small in having a GP who was ready to discuss everything - OK it was in Germany and so half-privatised, but the private bit didn't actually apply at the GP. Both the girls suffer from asthma and the trigger for the younger one was always an infection. It always took a particular form and for several years she got antibiotics to prevent the secondary bacterial infection that was almost inevitable. Every so often he would say "I want to try without - OK?". I always concurred, even though it meant a 6 mile round trip over country roads and he wanted to see her every day. Every single time on day 3 he would look at me and say "No, antibiotics it is".
    Eventually we returned to Britain where I had to learn to deal with the new system. No antibiotics, it's viral. In vain did I explain the history - "we'll wait and see". I have studied microbiology, I have a medical background - I know about the problem of resistance. Not until I had taken her to a doctor on the third day with DIB, using every muscle to breathe, did she ever get her antibiotics. Every time she spent at least a week off school.
    Once in Germany our GP was away. The locum pooh-poohed the concept of antibiotics as "anyway, she hasn't got asthma, there's no wheeze". On the way home I was so concerned that I called at the local paediatrician where the staff told me to come back in half an hour as the doctor was with a patient. When I returned, she took one look at my daughter and, on her way to get drugs out of the cupboard, called the staff in. "Look at this child - don't EVER send someone like this away, call me immediately, whatever I'm doing!" She was blue round her mouth by then. She, too, saw my daughter every day for a week. The GP never used that locum again.
    But I promise, I have never asked for antibiotics unless I thought it was about to progress like that. Today, she is 27 and working as a paramedic. A few weeks ago whilst delivering a patient to A&E she was grabbed by a nurse who informed her she was going to neb her! She got both antibiotics and a high dose of steroids from the doctor on duty - but he said he'd not have given her the antibiotics much sooner. She'd only had the infection for 2 days.
    So which is worse - just amoxicillin taken properly, full 5-day course, to abort such an attack, or leave it until she has to have a week (at least) off work and get high-dose steroids as well so she can breathe - plus a couple of goes with the nebuliser too? It's a question that has bugged me ever since I came back to Britain. I was lucky in that I am freelance and work from home, no child-care issue - but how much of this demand for antibiotics is fear that the parents might have to have time off work, and then their employer starts looking at the sickness record? In my daughter's case the NHS "sickness record" procedure is also an issue. However you look at it it's a big problem.

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  2. The problem is that people make this link between severity and the fact that it's bacterial.

    I get loads of parents who tell me their kid always needs antibiotics by day 3 or 4 or whatever because they've gotten so bad.

    But a severe infection doesn't mean it's not viral.

    I wouldn't comment on your case because that's between you and your GP.

    But it's quite the struggle convincing parents that severe means you need to see a doc, but doesn't mean it's a secondary bacterial infection and doesn't mean that it needs antibiotics.

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  3. What about the option of sitting down and discussing the reasons against blassé antibiotic prescribing with the parents? Or is it rather pointless to try, it seems to me as this is just another case of confirmation bias at work, much like the whole vaccine nonsense.

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  4. People often attribute the healing powers of a Tincture of Time to antibiotics. Like Dara O'Briain says about rubbing a cat on your head for curing headaches.
    Youtube vid link here: http://preview.tinyurl.com/y8hc7j2

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  5. My Gp tutor used to say to patients "Your infection MAY have gone away after a few days of antibiotics every time you've been to a GP. But if I sat with you for 3 days and hit u over the head every hour, you infection would also have gone away. Doesn't mean a smack on the head cures flu!".

    @Steve, you can sometimes convince people. But very often you can't. Most people start out trying enthusiastically to educate the public. But people tend to lose the will to fight.

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  6. I'm living proof of why you need to get the message out there about antibiotics.

    After years of antibiotic treatment, I now have a long history of allergic reactions and resistance to antibiotics plus a history of serious MRSA infection and repeat osteomyelitis.

    Problem is, I still need antibiotics to stay alive!

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  7. To be fair though, antibiotics have been conclusively proven as life savers. There is a lot of bad science and poorly conducted trials when it comes to vaccinations however. Some vaccinations are great, but others not so much.

    Can you explain in graphic detail the concept of antibiotic resitant fatal infections to these types of pateints? Can you tell them about how reaccurent cases of antibiotics are not good for gut health?

    Or will they never listen no matter what you say?

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  8. Everything looks good in your posting.
    That will be necessary for all. Thanks for your posting.
    Bathmate

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  9. Anonymous, I don't think you can say that the research on vaccines is sketchy. In fact, I think most would agree that vaccines have been responsible for more of our improved health in the last 100 years than antibiotics have.

    Dr. Thunder

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  10. I discovered your site through, Bock, Dr. T.
    One of my children was very prone to ear infections until he was five years old. He had mighty high temperatures and several febrile convulsions as a result, which needed hospital admission three times. I insisted on anti-biotics for him, so that it would not get to that stage. My other children very, very seldom ever in their lives had an antibiotic, and this child (now 21) has had maybe two since turning five. I'm telling you this so that you know I'm not a hysterical mother, but a pragmatic person. Antibiotics on day one or two meant far, far less drama and avoidable suffering than waiting and seeing.
    Add to this that we live 10 miles from the nearest doctor (9-5 and best of luck to you after that), 40 miles from the nearest hospital... well, I wasn't about to mess around with maybes.
    Also,the doctors hereabouts charge €50-€60 per visit, and I am not rich, so I can't afford to experiment and pay that each time. I'll tell you what might help - if doctors didn't charge for the subsequent visits for the same illness, especially for children, or even only for children. I think that would help an awful, awful lot. Parents are desperate, and need to trust their GPs - this would go a long way on that journey.

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  11. I'm not going to discuss anyone's particular case, but I'm always amazed at how many people think that severe illness = bacterial, and needs an antibiotic, whereas not so severe = viral and gets away with no antibiotic.

    I think most paediatricians would tell you that more febrile convulsions are caused by viral illnesses than anything else.

    Obviously, people need to see their doctors and voice their concerns as they see fit, and work out a treatment plan with their doctor. But the point I make is a general one.

    Dr. Thunder

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