Too Much of a Good Thing?
In the not-so-distant past, a quick glance into the medicine cabinet of any family with young children likely would have revealed one or more partially-finished bottles of "the pink stuff"--sticky, bubble-gum-flavored prescription antibiotics that pediatricians once handed out like candy to treat everything from ear pain to an upset tummy to a runny nose. Today, however, the Centers for Disease Control (CDC) and the American Academy of Pediatrics (AAP), as well as other public-health agencies, have launched informational campaigns warning that decades of rampant over-prescription of antibiotics by physicians, along with improper utilization by patients, has led to a serious problem: an alarming rise in potentially deadly bacterial illnesses which no longer respond to formerly effective antibiotic treatment.
Physicians have known since the advent of the modern age of antibiotics that the capability exists for disease-producing bacteria to evolve into untreatable strains. Only four years after pharmaceutical companies began mass-producing penicillin in 1943, scientists first encountered certain microbes that would no longer respond to the new "miracle medicines." This is because, in any given population of bacteria, a few members will naturally have the genetic ability to resist antibiotics. With repeated exposure to antibiotics, these naturally resistant bacteria are encouraged to grow and flourish, while the bacteria which respond appropriately to antibiotic use are demolished. Eventually, only the antibiotic-resistant bacteria remain, creating dangerously untreatable strains of various diseases. These antibiotic-resistant bacteria can make the host individual sick and, in many cases, can then be transmitted to other people as well. Alarmingly, an increasing variety of bacterial illnesses, including certain strains of pneumonia, tuberculosis, and salmonella, have now spawned antibiotic-resistant progeny.
"There was complacency in the 1980s," according to Dr. Michael Blum, FDA medical officer, quoted in an interview with the FDA's consumer magazine. "The perception was that we had licked the bacterial infection problem. Drug companies weren't working on new agents. They were concentrating on other areas, such as viral infections. In the meantime, resistance increased to a number of commonly-used antibiotics. . . . In the 1990s, we have come to a point for certain infections that we don't have (antibiotic) agents available."
Across the country, doctors and hospitals are seeing a steady rise in cases of antibiotic-resistant disease in both children and adults. For example, according to a report in the Journal of the American Medical Association, between 1979 and 1987, only 0.02 percent of pneumococcus bacteria in the United States were found to be penicillin-resistant. Today, however, at least 6.6 percent of pneumococcus strains are resistant, and that percentage is rising. The FDA reported that in 1992 alone, 13,300 hospital patients died of bacterial infections that should have been curable with the use of antibiotics. Certain bacteria, such as Staphylococcus aureus (commonly known as "staph infection"), have now developed resistance to almost all antibiotics. Until recently, one antibiotic--Vancomycin, known as "the antibiotic of last resort"--remained generally effective against these potentially deadly staph bacteria. In the past several years, however, frightening cases of vancomycin-resistant bacteria have appeared in hospitals across the United States.
Children have a unique risk for antibiotic-resistant disease due to the fact that pediatricians and parents tend to over- and misuse antibiotics for many common childhood ailments such as ear infections, thus allowing resistant germs to colonize. According to the AAP, the more antibiotics prescribed for a child over time, the higher the chance the child will become infected with resistant bacteria. Alternately, children without a history of excessive personal antibiotic use can contract antibiotic-resistant bacterial illnesses from other people in their immediate environment who have themselves been overexposed to antibiotics. Either way, the results are the same: illnesses that can't be stopped with what should be the appropriate medications.
According to Dr. Dennis Murray, Chief of Pediatric Infectious Diseases at Michigan State University in Lansing, and a member of the American Academy of Pediatrics' Committee on Infectious Diseases, pediatricians are now seeing the disturbing results of decades of routine and often inappropriate antibiotic use in their young patients.
"Pediatricians are more and more frequently finding that even simple infections will no longer easily respond to antibiotics," explains Dr. Murray. "For example, the bacteria most likely to cause ear infections are now often found to be antibiotic-resistant. In areas of rural Kentucky, up to thirty percent of bacterial ear infections are resistant to some degree. In some inner cities, such as in Memphis, forty to fifty percent are antibiotic-resistant. "
Janet Greenlee of Colorado Springs, Colorado is the mother of a two year old who has suffered from repeated ear infections. She says that her son's ear problems appear to no longer respond to any antibiotic.
"When he first began getting infections, amoxicillin would work for a short time. Then it stopped working and we moved up to something stronger. Now we have tried just about every antibiotic available and his pediatrician says that we have run out of options. He says we will have to have ear tubes put in. That's fine, but I worry whether antibiotics will work if my son ever needs them for something more serious, like a hospitalization," says Greenlee.
According to Dr. Murray, Greenlee's concern is not without merit. He says that he and other members of the AAP's Committee on Infectious Disease are now encountering situations in which children who were exposed to antibiotics for relatively minor illnesses--such as sinusitis or even for viruses--are later becoming ill with more serious, life-threatening infections which fail to respond to antibiotic treatment.
"I know of two young children recently hospitalized with invasive bone and joint infections caused by resistant strains of strep pneumonia, which is usually only associated with things like ear infections. These strep infections turned out to be totally antibiotic-resistant. Both of these children had previously been given antibiotics for relatively minor illnesses," says Dr. Murray.
In response to this troubling issue, the American Academy of Pediatrics is trying to get the word out that both physicians and parents have a role to play in lowering children's risk for acquiring potentially dangerous antibiotic-resistant diseases. According to the AAP's public awareness campaign, antibiotics should be prescribed for children judiciously and sparingly. But according to some parents, their own pediatricians continue to present them with a prescription for antibiotics every time their child has a sniffle.
Recent statistics released by the AAP support this perception. Authors from the Boston University School of Medicine state that in 1980, over 4.2 million prescriptions were written for the oral antibiotic amoxicillin to treat ear infections. In 1992, the number had grown to over 12.3 million--an increase of 194 percent. In 1980, 876,000 prescriptions for cephalosporins--another common oral antibiotic--were written to treat ear infections; in 1992 the number was over 6.8 million--an increase of 687 percent. Based on this data, the authors estimate that in 1998, thirty million prescriptions will have been written for treating ear infections
"I am very wary of over-use of antibiotics. I know that they shouldn't be given for viral illnesses, like a cold or the flu, but whenever my daughter gets a runny nose, her pediatrician seems determined to put her on antibiotics," says Lori Aiken, a Kansas City, Missouri mother of a five-year-old. "I privately question the wisdom of this, but I don't know what to say to him about it. He intimidates me. Most of the time we just never get the prescription filled and she gets well all on her own anyway."
According to Dr. Murray, parents should always respectfully question their child's physician when he writes a prescription for antibiotics. Research reported in the February, 1999 issue of the medical journal Pediatrics revealed that many pediatricians believe that parents actually expect their pediatrician to prescribe antibiotics each time their child is ill. In the Pediatrics study, forty percent of the pediatricians surveyed indicated that ten or more times in the past month a parent had requested an antibiotic when the physician did not feel it was indicated. Forty-eight percent reported that parents always, most of the time, or often pressure them to prescribe antibiotics when their children are ill but antibiotics are not indicated. In follow-up questions, approximately one-third of physicians reported they occasionally or more frequently comply with these requests. Seventy-eight percent felt that educating parents would be the single most important program for reducing inappropriate oral antibiotic use and fifty-four percent indicated that parental pressure contributed most to inappropriate use of oral antibiotics. The authors of this study concluded that pediatricians acknowledge prescribing antibiotics when they are not indicated and that pediatricians believe educating parents is necessary to promote the judicious use of antibiotics. Clearly, it's important that parents and their pediatricians are able to communicate clearly and easily with one another concerning this important topic.
"Pediatricians need to get the message that--with the current antibiotic- resistance problem--it is simply no longer okay to prescribe antibiotics every time a child has a runny nose or a little fluid behind the ear. Doctors shouldn't just hand out a prescription because they are too busy to explain the situation to the parents," says Dr. Murray. "And parents need to be aware that the great majority of ear infections and respiratory infections in infants and young children are viral, not bacterial. Antibiotics should not be prescribed in these situations. Parents have to learn to advocate for their child in the doctor's office to protect them from improper prescriptions for antibiotics."
Dr. Murray suggests that parents of a child whose doctor wants to prescribe antibiotics should ask plenty of questions, including whether the illness is viral or bacterial and whether--even if it is bacterial--their child might safely recover without antibiotic use. Parents themselves can also learn more about how to tell the difference between a simple cold and a true bacterial infection.
"A sticky nose, as opposed to a runny one, is more likely to be an infection," explains Dr. Murray. "And parents should ask for a throat culture before giving their child antibiotics for a sore throat. Even the most skilled pediatrician can't usually tell if a child has developed strep throat simply by looking. When it comes to fluid in the ear, a doctor needs to look for symptoms that the ear is actually infected before prescribing antibiotics. These can include a bright red eardrum, fever, irritability, crying. . . . The pediatrician should check the eardrum itself to see if it isn't moving."
After a parent has asked all the appropriate questions and feels confident that the antibiotics prescribed for her child are truly necessary, it's critical that she then make sure the child takes the medication exactly as ordered by the pediatrician. Children should finish the full course of antibiotics, even after they have begun to feel better. This ensures that all targeted bacteria are eradicated, with none surviving to become resistant. And parents should never self-treat a child's illness using another family member's antibiotic prescription. Antibiotics are developed to target specific bacteria. Using the wrong medication could actually strengthen strains of harmful bacteria in a child's body.
According to experts such as Dr. Murray, the second most common risk factor for antibiotic-resistance in children--after frequent exposure to antibiotics--is early attendance at group child care. At any given time, a significant percentage of young children in a group child-care setting are taking prescribed antibiotics, creating a hotbed for development and transmission of antibiotic-resistant strains of disease.
Duncan Hampton of Knoxville, Tennessee, says that his fourteen-month-old son, Scott, was sick with a string of bacterial and viral illnesses from the time he was placed in child care at the age of six months until his first birthday, at which time his pediatrician strongly advised the Hamptons to remove him from group care to avoid the risk of future antibiotic resistance.
"Our baby was never sick with even a sniffle until he started day care. After that, he was basically on antibiotics for six months straight for one thing or another," says Hampton. "We must have tried eight different types of prescriptions to try to stop the constant ear infections, coughs, and diarrhea. It was only after it was clear that none of it was working that the doctor suggested we remove him from day care. I wish that he had explained how our son could develop resistance to antibiotics before we put him in day care. I think it's a sensitive subject and doctors don't want to seem judgmental about working mothers. At Scott's day care, so many babies were on antibiotics that there was actually a shelf full of bottles of it in his classroom. Almost every baby had his own prescription bottle at one time or another. Parents would talk about which antibiotic was working best for their child."
"Group child care, and particularly large group child-care settings, are often a breeding ground for resistant bacteria, as well as for viral illnesses, which are then sometimes improperly treated with antibiotics," explains Dr. Murray. "We as a society need to rethink putting babies and young children in these child-care centers and increasing their chance of experiencing antibiotic resistance. Parents need to be told about the risks."
Despite his concerns and those of the other members of the AAP's Committee on Infectious Disease, Dr. Murray says he believes the message regarding lowering children's risk for antibiotic-resistant illness is beginning to get out.
"Pediatricians are starting to understand the seriousness of this situation and soon, parents will too," says Dr. Murray. "I am optimistic that attitudes are changing concerning antibiotics. After all, used properly, antibiotics can save a child's life, but used in a less-than-judicious way, they have the potential to do great harm."
Katie Allison Granju is a regular contributor to Minnesota Parent.
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