Dr Jamie Kondis: Hi, I'm Dr. Jamie Kondis. I'm a pediatrician at St. Louis Children's Hospital and I'm a mom doc.

Melanie Cole, MS (Host): Cold and flu season is here. When your child gets sick, you want to make them feel better, of course we all do, and you want to stop the illness from spreading to other family members. Some people think antibiotics and they may come to mind, but what types of illnesses do really actually require antibiotics.

Welcome to Mom Docs, the podcast from St. Louis Children's Hospital. I'm Melanie Cole. Dr. Kondis, this is, you know, really a great topic. It's something that people talk about. It is something that we're learning more about antibiotic stewardship and when or when they should not be used. So, I'd like you to start by telling us about a little bit about antibiotics and how they actually work.

Dr Jamie Kondis: Yes. This is a great topic, especially as you said at this time of year. So, it's interesting, the term antibiotic literally means against life and, in this case, we're talking against microbes. So, antibiotic is really a broad term that refers to several different classes of drugs: antibacterials, antivirals, antifungals and antiparasitics. And some drugs are effective against many types of organisms. We call those broad-spectrum antibiotics. Some are only effective against one or a few organisms. So, the concept of antibiotic stewardship is really figuring out which medication you need for your illness, whether or not it needs to be an antibiotic, or whether it even needs a medication at all. So, that's really what we're trying to do as pediatricians, is figure out what the illness is and whether or not it needs an antibiotic.

So when people think of antibiotics, I think a lot of people think of penicillin, which would be the first antibiotic that was really discovered to treat a bacterial illness, and that dates back to the 1920s. Obviously, we've had a lot more discovered since then. And so, what we've learned as pediatricians over the years is really how to tailor the antibiotic to the infection in a way that treats the infection but doesn't make you resistant to other infections and also doesn't kill off a lot of the good bacteria in your body.

Melanie Cole, MS: Well, thank you for that excellent explanation. So when we think of where they work and when they don't, parents often think, "Okay, if there's green goo coming out of something," then we definitely need an antibiotic. If they're sneezing green or coughing green, I'd like you to speak about when they help, what those kinds of myths are really all about.

Dr Jamie Kondis: Oh my goodness, you have hit on the big question we get from parents all the time.

Melanie Cole, MS: Like every day, right?

Dr Jamie Kondis: Yes, the color of the mucus. Even my own husband's tried to mansplain that to me the other day about the color of the mucus. So, that's a huge question we get. I'd say the number one question we get from parents is, "My child has this really bad cold that won't go away, why won't you give me an antibiotic?" And we have to explain that the most common cause of the common cold, you know, the runny nose, cough and congestion that kids get is a virus, and it's a virus we don't have medication for, an antiviral. Some viruses, we do have antivirals. Influenza would be a big one. But the virus that causes the common cold, we don't have an antiviral for. So, that's something we would just, say, treat with Tylenol, fluids, rest, things like that. But that can be really frustrating for a lot of parents.

Another question we get is, "Well, won't this cold turn into a bacterial infection? So, why don't we start an antibiotic now? Kind of like a preventative thing." That almost never happens, actually. In a few cases, we do have some viral illnesses turn into more of a bacterial sinusitis, which we would treat with an antibacterial medication. But we really wait until that's been going on for more than 10 days. And most people are asking before we've hit that 10-day mark. And if we start an antibiotic too soon, that's going to cause diarrhea and a lot of other side effects that we don't want.

And then, the other question you hit on is, "Well, my child was having clear mucus and now they're having yellow or green mucus. Doesn't that mean they have a bacterial infection and need an antibiotic?" Not necessarily. During a common cold, it is normal for mucus from the nose to get thick and change from clear to yellow or green. Again, this is usually a viral infection, and it can last for up to 10 days. When we start to get concerned about bacterial sinusitis, is when the cold symptoms are lasting longer than 10 days and are getting worse, or if they are consistently having a fever higher than 102 degrees for at least three to four days, or if they're having facial pain in their face right over those sinuses plus fever. So, we definitely really try to wait it out in most cases.

The one exception to that is if they have an ear infection. So definitely anytime you bring your child in with those cold symptoms, we want to get a good look at their ears. And if we diagnose an ear infection, then we will usually give you an antibiotic. But for just that common viral cold, I guess there's another exception too, which would be strep throat. The ear infection and the strep throat. Strep throat is definitely caused by a bacteria. It's caused by something called group A streptococci. And if we do a test, fortunately, there is a quick and easy test for strep throat, it's a throat swab that only takes about 20 minutes to come back. Most pediatricians actually can do it in their offices, or they'll send you to some place like Children's Hospital or the lab. And then, we get that result very quickly. And then, we do treat that with antibiotics as well. Because with strep throat, it actually has a rare complication of affecting the heart, so that is something we would definitely want to treat. So, strep throat or an ear infection, your child is going to get antibiotics. But most of the time other than that, they are not.

Melanie Cole, MS: Well, I can say, Dr. Kondis, that when my kids were littler, it's not that I wished for strep throat, this is not what I mean, listeners. But when they were sick, I was like, "At least if it's strep, we will get an antibiotic and they'll feel better in 24 to 48 hours," whereas if it's a virus and antibiotics don't work on viruses, as you've made very clear, then it lasts longer and they feel like crap. And so at least with strep throat, the antibiotics really do work so well on those and there are, as you say, things that they're important for. Now, they also have side effects. You know, we don't want our kids necessarily going in the sun and maybe their stomachs could get upset. Speak about some of the things you talk to your patients about.

Dr Jamie Kondis: Definitely. And I must agree with you, Melanie. When I am working down in the emergency department and somebody comes in with cold symptoms, I sometimes secretly hope that they'll have an ear infection or strep throat because then I can just easily treat it and I don't have to have that whole conversation about just waiting it out and when to return and things like that. I totally agree.

Yeah. So, the main reason we want to be very judicious with these antibiotics is because of the side effects. Many of them have very serious side effects, especially when we're getting into some infections that are starting to show antibiotic resistance, and we have to prescribe a stronger antibiotic. So, the main thing that antibiotics do is that they kill. So, they kill both bad and good bacteria in your body. They're kind of indiscriminate. So, we have good bacteria that live in mainly our guts. And the antibiotic will disturb your child's gut microbiome, which is basically the good bacteria living in their gut. And that causes the symptoms such as diarrhea, abdominal cramping, nausea, vomiting, gas. And kids obviously don't like any of those things. So, we try not to give antibiotics for those reasons.

And as you mentioned, there are some antibiotics that have more serious side effects as well. Some can cause bad rashes that can really be disturbing. And really worry parents when their kid has, you know, a rash over their entire body. There is a small risk of an allergic reaction to antibiotics as well. And some can trigger breathing problems, especially in kids who already have asthma or breathing problem. Some can cause hives. And so, that can be really concerning to parents as well. So, we really do try to be not giving them unless we absolutely have to.

Melanie Cole, MS: Big word we're hearing, big buzzword is antibiotic stewardship. We're hearing this about opioids. We're hearing this about antibiotics. And we know, Dr. Kondis, that there's been a lot of studies that have shown that overuse of antibiotics can lead to this antibiotic resistance, which is what we're all afraid of. My son got MRSA his first semester at college on the gymnastics mat. And so, I know that this is a concern and it's a concern for us as a society, but also for us parents. So, talk to us a little bit about responsible antibiotic use and what do we do with leftovers? I mean, I guess there's not supposed to be leftovers, right? But tell us a little bit about antibiotic stewardship.

Dr Jamie Kondis: Yes, I would love to because you are exactly right. When people do not take antibiotics correctly, the bacteria can actually become resistant. For example, if your child doesn't take the entire course, if your pediatrician has prescribed antibiotics for 10 days, they need to take the full 10 days. And some parents want to stop because the child starts feeling better before then, which they should. They usually start feeling better within the first 24 to 48 hours. But if you stop taking the antibiotic early, some of the bacteria may actually stay in your child's body. And then, the symptoms will return and they won't be as susceptible to the antibiotic in the future. So, you really have to take that full course. And then, you also want to give the antibiotic exactly as directed. If it says once a day, twice a day, three times a day, you want to take the prescribed dose according to the schedule on the label and what was told to you.

The other thing is you never want to give your child antibiotics that were prescribed for another person or for a previous illness. You might be tempted to use old antibiotics you have in your medicine cabinet. Hopefully, you don't have any old antibiotics in your medicine cabinet. But the problem with that is they lose efficacy over time. So, they might be too old to work anymore, or it might just be the wrong one for the wrong infection. Like maybe it was an antibiotic given to you for a UTI, so it won't work for strep, you know, something like that. So if you ever have any leftover antibiotics, and occasionally you might, because maybe the pharmacy gave you a little extra for some reason, throw them out. Don't save them for future use, definitely throw them out.

The other thing is we are seeing resistant germs, as you mentioned. So if for some reason your child is not getting better on the antibiotic, again most bacterial infections improve within two to three days. So if your child's symptoms are getting worse or not improving after three days, definitely call your doctor. Because maybe you have a resistant bug and they might say that you need a different medicine or maybe your child would even need to come into the hospital to get an IV medication, hopefully not, but you just never know. So, all of those are things we recommend when kids are on antibiotics.

Melanie Cole, MS: This is really an important episode that we're doing and you're giving us a master class in antibiotic use and stewardship because I know that parents come to you all the time, and "Why can't I have antibiotics?" So, I'd like you to wrap it up for us, really what you want us to know about home care, things we can do for symptom management to help our children feel better when antibiotics are really not the thing that we can use, but then kind of reiterate when they actually are really just awesome to use.

Dr Jamie Kondis: Absolutely. Well, you are right, this is one of the definite biggest things I see in the ER, and general pediatricians in their offices as well. So, big thing, if your child is having any symptoms that you are concerned about, cough, sore throat, ear pain, runny nose, definitely fever, call your doctor first, because chances are they're going to want to see you in the office, and they're going to want to look at your child's ears, they might want to do a rapid strep test on their throat, and then you would get an answer right away about whether they need antibiotics. So, call your doctor first thing. Let them know how long the symptoms have been lasting, what kind of symptoms they're having.

After you are seen, if they tell you that it is a virus, you will probably have to wait it out, and that's okay. The only virus that we really are big on treating right away is influenza, which everyone should get their flu shot. But if for some reason you haven't gotten it and you get influenza, that is something we actually have a medication to treat in the early days of flu. So otherwise, though, if it is a viral respiratory infection, we're probably going to just tell you about supportive care and not a medication. If we do give you an antibiotic for something like strep throat or an ear infection, the big thing is give the medication exactly as directed, follow those instructions, take the whole amount, don't use one child's antibiotic for their sibling, you might give the wrong medicine and cause harm. Definitely keep those antibiotics and other prescription medication in a secure place, count the number of pills you have if it's a pill, you know, know how much liquid medication you have, keep them some place where the kids can't get to them. And then, dispose of any leftover antibiotics and other prescription medications. We have some great boxes here at Children's, these lock boxes when you first walk in from the garage that you can dispose leftover medications in. Lots of other places do too, like fire stations. So, it's easy to dispose of leftover medications. But really, just follow those instructions on the medication.

Melanie Cole, MS: I love that you. offer a place for people to dispose of medications because it's something you don't know what to do with them when you've got some old medications and you're not supposed to dump them down the toilet or in the sink because then they get into the water. So, wow, that is just such great advice.

Dr. Kondis, you're an excellent guest as always. Thank you so much. And I hope you'll return and give us more of your great pediatric advice. we look to our pediatricians. You guys are the gold standard. So thank you so much. And for more advice and articles, please check out the Mom Docs website at childrensmd.org. That concludes another episode of Mom Docs with St. Louis Children's Hospital. Please always remember to subscribe, rate, and review this podcast and all the other St. Louis Children's Mom Docs podcasts. I'm Melanie Cole. Thanks so much for joining us today.