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Does My Child Really Need Those Antibiotics
Dr. Elizabeth Wolf is a pediatrician and researcher at Children's Hospital of Richmond at VCU. She's also a mom of two young children. Dr. Wolf's recently published a research study article focused on low-value care, including overuse and over prescribing of antibiotics. She's here to tell us more about antibiotics and when your kiddos really need them, and when they don't.
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Learn more about Elizabeth Wolf, MD, MPH
Elizabeth Wolf, MD, MPH
Dr. Wolf joined the VCU faculty in August 2015. She is an active member of the American Academy of Pediatrics and received the 2016 Academic Pediatric Association Bright Futures Young Investigator Award from the Academic Pediatric Association. Dr. Wolf is co-chair of the Academic Pediatric Association Region IV.Learn more about Elizabeth Wolf, MD, MPH
Transcription:
Does My Child Really Need Those Antibiotics
Prakash Chandran (Host): Children getting sick is a normal part of life. But when that sickness includes a trip to the doctor, most parents expect a prescription for medications like antibiotics to help their child feel better. But what's the right time for an antibiotic? We're going to talk about it today with Dr. Elizabeth Wolf, a pediatrician and researcher at Children's Hospital of Richmond at VCU.
This is Healthy with VCU Health. My name is Prakash Chandran. So, first of all, Dr. Wolf, great to have you here today. Let's start with the basics. What exactly are antibiotics and how do they work?
Elizabeth Wolf, MD, MPH (Guest): Thanks very much for having me. So, antibiotics are really any medicine that kill germs inside your body. But most people use the term when they're describing a medicine that kills bacteria specifically. Antibiotics, they can fight bacterial infections either by killing the bacteria directly or simply by slowing its growth. And they can do this by either attacking the wall around bacteria or by interfering with its reproduction.
Host: This might be a little bit basic, but when we think about things like Advil or Tylenol, are those the same things as an antibiotic? Or are they different?
Dr. Wolf: Good question. Those medicines are not considered antibiotics. Those are considered medicines that would treat a symptom of an infection, specifically pain or fever. But antibiotics are actually targeted against the bacteria itself. And antibiotics have a long and glorious history. You know, they were first discovered in the 1920s when Dr. Fleming found that one of the molds that was growing on his petri dish was inhibiting the growth of a certain type of Staph. Staph is the bacteria that causes boils and abscesses. And that was really the first antibiotic that ushered in this new era of medicine.
Host: Yeah, that's really interesting. One of the other things that I wanted to learn more about is I've heard about viral infections and bacterial infections. Can you talk a little bit about the differences between the two and how it relates to antibiotics?
Dr. Wolf: So, this becomes confusing to some people because both types of organisms, the virus and the bacteria are very small. In fact, they're too small to be seen with the human eye and they both require microscopes in order to be seen. But viruses are even smaller than bacteria. The biggest virus is still smaller than the smallest bacteria and viruses are different as well in that they cannot replicate without a host, whereas the bacteria can live on its own.
So, an example of a viral infection would be the common cold, chicken pox, and of course, most notably the Coronavirus. But examples of bacterial infections would be Strep like you would see in Strep throat and many skin and wound infections.
Host: Okay, those examples are helpful. And just because you said that the Coronavirus is a viral infection, and I think that you said at the top of the episode that antibiotics only treat bacterial infections; we're saying that antibiotics do not work for coronavirus or COVID-19, is that correct?
Dr. Wolf: Every day we're learning more and more about what therapeutic modalities are helpful in treating COVID-19, but we do know that it is a virus. And so antibiotics for COVID itself, are not going to be effective. However, there are some patients who become sick with COVID and then after that will develop a bacterial superinfection. So, a bacterial infection on top of their viral infection. And in those cases, an antibiotic would be appropriate.
Host: Okay, thanks for that clarification. So, I want to move on, you know, I know that sometimes I see this in the news, or I talk to other parents about this. There's a known history of over-prescribing when it comes to antibiotics. So, I have two questions for you. Number one, why has that been the case? And number two, why is it actually harmful to use antibiotics when they're not truly needed?
Dr. Wolf: Antibiotics are one of the most amazing creations in medicine. And it's important to remember that before antibiotics, there was really no effective treatment for even common infections like pneumonia, gonorrhea or rheumatic fever. But the problem is, that the antibiotics worked so well, they even worked too well, they killed not just the bacteria that they were targeted against, but many other types of bacteria as well. And when this happens, it can actually raise the rates of resistance to antibiotics in the community. That means that these bacteria evolve so that certain forms of antibiotics are no longer useful against them. And some bacteria can even evolve to have resistance against multiple antibiotics.
Host: Yeah, that is fascinating. I'm wondering, is there any other place where our children are exposed to antibiotics or is it only when it is prescribed to them?
Dr. Wolf: You know, one of the more common ways that children or any patient really, is exposed to an antibiotic, is through the food that we eat. So, ranchers and farmers actually feed antibiotics to livestock because they recognize that small amounts of antibiotics can help the animals gain weight. And with an industry that really counts pennies for pounds, this became very important. The problem is that studies have shown that these antibiotics can then cause this antibiotic resistance in the bacteria. And those bacteria that contain the evolved antibiotic resistance can then be transferred to humans. So, we really need to think about humans as part of this larger ecosystem and being part of the system that is exposed to these antibiotics in smaller non-therapeutic ways.
Host: Yeah, I had no idea that we get antibiotics through the food that we eat, but that totally makes sense to me. You know, just as a rule of thumb, when we think about how we expose our children to antibiotics, do you have a framework around how parents can think about when antibiotics are needed versus when they aren't?
Dr. Wolf: Yes. This is a very important distinction. So, we really only prescribe antibiotics when we need to, when we're treating a bacterial infection that will not otherwise get better on its own. And furthermore, not only are we selecting an antibiotic only when we need it, but we're also selecting the narrowest antibiotic that we possibly need. Meaning we only want the antibiotic to kill that particular bacteria or those types of bacteria and not every single bacteria known to humankind. And so to help guide us in these decisions, here at Children's Hospital of Richmond at VCU and many other hospitals as well, we have clinical guidelines to help each medical provider choose the right antibiotic so that we're not giving kids an antibiotic that's too broad.
Host: You know, with the people that I talk to, I think there is an aversion to jumping on antibiotics right away. So, I think it might be helpful for you to talk about a framework around when you should wait to take antibiotics, versus when you should start an antibiotic regimen immediately.
Dr. Wolf: It's a very good point. There are certain conditions where you would want an antibiotic right away. An example of this would be a bacterial meningitis where really the difference in whether or not somebody lives or dies, is whether or not that person gets an antibiotic promptly right after diagnosis. But in many conditions in pediatrics, we do have the option to wait. One specific example is an ear infection. So, in a child who's over two years of age, who only has an ear infection on one side and doesn't have severe symptoms or fever, we do have the option to wait and see if that ear infection gets better on its own. Many of the ear infections are actually viral in which case an antibiotic would not help. Now, in some situations, providers will give a prescription for an antibiotic to the parents just in case it does not get better, or if the child worsens.
Host: So, I'd like to expand on that just a little bit more. You talked about the case of an ear infection in a two-year-old. Are there any other types of bacterial infections where it makes sense to either wait or hop on a regimen immediately?
Dr. Wolf: Some other types of situations where we don't use antibiotics are, one is called bronchiolitis, which simply means a viral infection in the lungs. It's basically a cold virus that has gone to the lungs. And it's a pretty common diagnosis in pediatrics. It's the number one cause of hospitalization in children. But in that situation, it's not a bacterial pneumonia, it's a viral disease. And so we do not recommend using antibiotics in that case.
Host: So, for kids that are taking antibiotics, do you have any tips around keeping them healthy or potentially preventing any side effects that are coming from the antibiotics while they're on it?
Dr. Wolf: As I mentioned before, it's important for the provider to pick the narrowest spectrum antibiotic. And these typically have the fewest side effects as well. So, one example would be amoxicillin, which we commonly use for pneumonia. We wouldn't want to use something broader as first line, so we use the narrowest antibiotic that's possible. But, even with amoxicillin, you can develop things like diarrhea. And so, one thing that some providers have found can help is using a probiotic such as lactobacillus to shorten the course of an antibiotic associated diarrhea, and really getting that microbiome back into shape.
Host: So, for the parents that are listening, I often find, and I'm sure that you get this as well, sometimes there can be an unnecessary contentious relationship with the provider because they're like, I don't want to give my child any antibiotics. But, in some cases, as you mentioned earlier, it might be necessary. So, as a parent myself, how can we be better partners to the providers around whether antibiotics need to be used or not?
Dr. Wolf: I've seen parents on both sides of the spectrum I would say. There are some parents who don't want antibiotics at all, and some who do want antibiotics even for viral conditions. And so what I try to do for both sets of parents is really explain what it is I'm thinking about. What are the possibilities for this child's diagnosis? What is the most likely possibility and why I think that. And then I also go through and explain the risks and benefits of each of the treatments. We like to think about medicines as being harmless, but we know that there's no medicine that's actually harmless. Each medicine that we use has some risk of an adverse event. And so I try to be upfront and honest with parents about those so that we're making decisions together about the best interest of their child.
Host: That totally makes sense Dr. Wolf. So, just as we close here, is there anything that we didn't cover today that you'd like to talk about with regards to children and antibiotics?
Dr. Wolf: I think we're really seeing an ideological shift. What I've noticed since I graduated from the Residency at Children's Hospital Colorado in 2009, is that the thinking around antibiotics has changed. So, those conversations with parents, whereas, in the past, I might've had more difficulty explaining why an antibiotic wasn't necessary, I think there are actually a lot more parents that understand that now. And so, just the public education campaign I think is moving in a successful direction, to try to let parents know that specifically for pediatrics, a lot of these kids do have self-limiting viral conditions and they will get better on their own.
Host: Well, Dr. Wolf, I think that's the perfect place to end. Thank you so much for your time today. That's Dr. Elizabeth Wolf, a pediatrician and researcher at Children's Hospital of Richmond at VCU. For more information visit CH for children's hospital, chrichmond.org, for more news, knowledge and healthy fun. To listen to other podcasts from VCU Health, visit VCUhealth.org/podcast. This has been another episode of Healthy with VCU Health. Thank you so much. And we'll talk next time.
Does My Child Really Need Those Antibiotics
Prakash Chandran (Host): Children getting sick is a normal part of life. But when that sickness includes a trip to the doctor, most parents expect a prescription for medications like antibiotics to help their child feel better. But what's the right time for an antibiotic? We're going to talk about it today with Dr. Elizabeth Wolf, a pediatrician and researcher at Children's Hospital of Richmond at VCU.
This is Healthy with VCU Health. My name is Prakash Chandran. So, first of all, Dr. Wolf, great to have you here today. Let's start with the basics. What exactly are antibiotics and how do they work?
Elizabeth Wolf, MD, MPH (Guest): Thanks very much for having me. So, antibiotics are really any medicine that kill germs inside your body. But most people use the term when they're describing a medicine that kills bacteria specifically. Antibiotics, they can fight bacterial infections either by killing the bacteria directly or simply by slowing its growth. And they can do this by either attacking the wall around bacteria or by interfering with its reproduction.
Host: This might be a little bit basic, but when we think about things like Advil or Tylenol, are those the same things as an antibiotic? Or are they different?
Dr. Wolf: Good question. Those medicines are not considered antibiotics. Those are considered medicines that would treat a symptom of an infection, specifically pain or fever. But antibiotics are actually targeted against the bacteria itself. And antibiotics have a long and glorious history. You know, they were first discovered in the 1920s when Dr. Fleming found that one of the molds that was growing on his petri dish was inhibiting the growth of a certain type of Staph. Staph is the bacteria that causes boils and abscesses. And that was really the first antibiotic that ushered in this new era of medicine.
Host: Yeah, that's really interesting. One of the other things that I wanted to learn more about is I've heard about viral infections and bacterial infections. Can you talk a little bit about the differences between the two and how it relates to antibiotics?
Dr. Wolf: So, this becomes confusing to some people because both types of organisms, the virus and the bacteria are very small. In fact, they're too small to be seen with the human eye and they both require microscopes in order to be seen. But viruses are even smaller than bacteria. The biggest virus is still smaller than the smallest bacteria and viruses are different as well in that they cannot replicate without a host, whereas the bacteria can live on its own.
So, an example of a viral infection would be the common cold, chicken pox, and of course, most notably the Coronavirus. But examples of bacterial infections would be Strep like you would see in Strep throat and many skin and wound infections.
Host: Okay, those examples are helpful. And just because you said that the Coronavirus is a viral infection, and I think that you said at the top of the episode that antibiotics only treat bacterial infections; we're saying that antibiotics do not work for coronavirus or COVID-19, is that correct?
Dr. Wolf: Every day we're learning more and more about what therapeutic modalities are helpful in treating COVID-19, but we do know that it is a virus. And so antibiotics for COVID itself, are not going to be effective. However, there are some patients who become sick with COVID and then after that will develop a bacterial superinfection. So, a bacterial infection on top of their viral infection. And in those cases, an antibiotic would be appropriate.
Host: Okay, thanks for that clarification. So, I want to move on, you know, I know that sometimes I see this in the news, or I talk to other parents about this. There's a known history of over-prescribing when it comes to antibiotics. So, I have two questions for you. Number one, why has that been the case? And number two, why is it actually harmful to use antibiotics when they're not truly needed?
Dr. Wolf: Antibiotics are one of the most amazing creations in medicine. And it's important to remember that before antibiotics, there was really no effective treatment for even common infections like pneumonia, gonorrhea or rheumatic fever. But the problem is, that the antibiotics worked so well, they even worked too well, they killed not just the bacteria that they were targeted against, but many other types of bacteria as well. And when this happens, it can actually raise the rates of resistance to antibiotics in the community. That means that these bacteria evolve so that certain forms of antibiotics are no longer useful against them. And some bacteria can even evolve to have resistance against multiple antibiotics.
Host: Yeah, that is fascinating. I'm wondering, is there any other place where our children are exposed to antibiotics or is it only when it is prescribed to them?
Dr. Wolf: You know, one of the more common ways that children or any patient really, is exposed to an antibiotic, is through the food that we eat. So, ranchers and farmers actually feed antibiotics to livestock because they recognize that small amounts of antibiotics can help the animals gain weight. And with an industry that really counts pennies for pounds, this became very important. The problem is that studies have shown that these antibiotics can then cause this antibiotic resistance in the bacteria. And those bacteria that contain the evolved antibiotic resistance can then be transferred to humans. So, we really need to think about humans as part of this larger ecosystem and being part of the system that is exposed to these antibiotics in smaller non-therapeutic ways.
Host: Yeah, I had no idea that we get antibiotics through the food that we eat, but that totally makes sense to me. You know, just as a rule of thumb, when we think about how we expose our children to antibiotics, do you have a framework around how parents can think about when antibiotics are needed versus when they aren't?
Dr. Wolf: Yes. This is a very important distinction. So, we really only prescribe antibiotics when we need to, when we're treating a bacterial infection that will not otherwise get better on its own. And furthermore, not only are we selecting an antibiotic only when we need it, but we're also selecting the narrowest antibiotic that we possibly need. Meaning we only want the antibiotic to kill that particular bacteria or those types of bacteria and not every single bacteria known to humankind. And so to help guide us in these decisions, here at Children's Hospital of Richmond at VCU and many other hospitals as well, we have clinical guidelines to help each medical provider choose the right antibiotic so that we're not giving kids an antibiotic that's too broad.
Host: You know, with the people that I talk to, I think there is an aversion to jumping on antibiotics right away. So, I think it might be helpful for you to talk about a framework around when you should wait to take antibiotics, versus when you should start an antibiotic regimen immediately.
Dr. Wolf: It's a very good point. There are certain conditions where you would want an antibiotic right away. An example of this would be a bacterial meningitis where really the difference in whether or not somebody lives or dies, is whether or not that person gets an antibiotic promptly right after diagnosis. But in many conditions in pediatrics, we do have the option to wait. One specific example is an ear infection. So, in a child who's over two years of age, who only has an ear infection on one side and doesn't have severe symptoms or fever, we do have the option to wait and see if that ear infection gets better on its own. Many of the ear infections are actually viral in which case an antibiotic would not help. Now, in some situations, providers will give a prescription for an antibiotic to the parents just in case it does not get better, or if the child worsens.
Host: So, I'd like to expand on that just a little bit more. You talked about the case of an ear infection in a two-year-old. Are there any other types of bacterial infections where it makes sense to either wait or hop on a regimen immediately?
Dr. Wolf: Some other types of situations where we don't use antibiotics are, one is called bronchiolitis, which simply means a viral infection in the lungs. It's basically a cold virus that has gone to the lungs. And it's a pretty common diagnosis in pediatrics. It's the number one cause of hospitalization in children. But in that situation, it's not a bacterial pneumonia, it's a viral disease. And so we do not recommend using antibiotics in that case.
Host: So, for kids that are taking antibiotics, do you have any tips around keeping them healthy or potentially preventing any side effects that are coming from the antibiotics while they're on it?
Dr. Wolf: As I mentioned before, it's important for the provider to pick the narrowest spectrum antibiotic. And these typically have the fewest side effects as well. So, one example would be amoxicillin, which we commonly use for pneumonia. We wouldn't want to use something broader as first line, so we use the narrowest antibiotic that's possible. But, even with amoxicillin, you can develop things like diarrhea. And so, one thing that some providers have found can help is using a probiotic such as lactobacillus to shorten the course of an antibiotic associated diarrhea, and really getting that microbiome back into shape.
Host: So, for the parents that are listening, I often find, and I'm sure that you get this as well, sometimes there can be an unnecessary contentious relationship with the provider because they're like, I don't want to give my child any antibiotics. But, in some cases, as you mentioned earlier, it might be necessary. So, as a parent myself, how can we be better partners to the providers around whether antibiotics need to be used or not?
Dr. Wolf: I've seen parents on both sides of the spectrum I would say. There are some parents who don't want antibiotics at all, and some who do want antibiotics even for viral conditions. And so what I try to do for both sets of parents is really explain what it is I'm thinking about. What are the possibilities for this child's diagnosis? What is the most likely possibility and why I think that. And then I also go through and explain the risks and benefits of each of the treatments. We like to think about medicines as being harmless, but we know that there's no medicine that's actually harmless. Each medicine that we use has some risk of an adverse event. And so I try to be upfront and honest with parents about those so that we're making decisions together about the best interest of their child.
Host: That totally makes sense Dr. Wolf. So, just as we close here, is there anything that we didn't cover today that you'd like to talk about with regards to children and antibiotics?
Dr. Wolf: I think we're really seeing an ideological shift. What I've noticed since I graduated from the Residency at Children's Hospital Colorado in 2009, is that the thinking around antibiotics has changed. So, those conversations with parents, whereas, in the past, I might've had more difficulty explaining why an antibiotic wasn't necessary, I think there are actually a lot more parents that understand that now. And so, just the public education campaign I think is moving in a successful direction, to try to let parents know that specifically for pediatrics, a lot of these kids do have self-limiting viral conditions and they will get better on their own.
Host: Well, Dr. Wolf, I think that's the perfect place to end. Thank you so much for your time today. That's Dr. Elizabeth Wolf, a pediatrician and researcher at Children's Hospital of Richmond at VCU. For more information visit CH for children's hospital, chrichmond.org, for more news, knowledge and healthy fun. To listen to other podcasts from VCU Health, visit VCUhealth.org/podcast. This has been another episode of Healthy with VCU Health. Thank you so much. And we'll talk next time.