Principles of Antibiotics Prescription
Antibiotics should only be used for infections caused by bacteria. In hospitals with severe and life-threatening infectious diseases (such as meningitis – inflammation of meninges, pneumonia – lungs inflammation, etc.) responsibility for correct choice of drugs lies entirely on the doctor, who bases on observation data of the patient (clinical picture) and results of special studies.
At lung infections treated in «home» (outpatient) conditions, situation is fundamentally different. The doctor examines a child and prescribes medication; sometimes it is accompanied by explanations and answers to questions, sometimes – not. Often, parents are asking doctors to prescribe antibiotics. In such situations, for pediatrician sometimes it is psychologically easier to write a prescription than to risk his reputation and spend time explaining inexpediency of such prescription.
In any case, physician must follow two basic principles of antibiotic therapy:
- fast assignment of the most effective drugs in cases where their effect is proved;
- minimal use of antimicrobial drugs in all other cases.
Reliable external signs or simple and cheap laboratory methods to distinguish between viral and bacterial origin of respiratory tract infections, unfortunately, do not exist. At the same time it is known that acute rhinitis (runny nose) and acute bronchitis (inflammation of bronchial mucous membrane) are almost always caused by viruses, and tonsillitis (inflammation of tonsils and throat), acute otitis media (ear infection) and sinusitis (inflammation of paranasal sinuses mucosa) in large part of cases – by bacteria.
It is natural to assume that approaches to antibiotic therapy of individual acute upper respiratory tract infections must be different.
Runny nose and Bronchitis
At acute rhinitis (runny nose) and bronchitis antibiotics are not prescribed. In practice, it occurs in another way: during one or two days of high temperature and cough in a child parents usually do not give their baby antibiotics. But then they start to fear that bronchitis is complicated with pneumonia and decide to use antibiotics. It is worth noting that this complication is possible, but it almost does not depend on preceding antimicrobials intake. The main signs of pneumonia is deterioration (further increase in body temperature, increased cough, dyspnea appearance). In such situations it is necessary to immediately call a doctor who will decide whether treatment should be adjusted.
If condition is not deteriorating, but does not significantly improve, there is no apparent reason for assigning antibacterial drugs. However, some parents just do not stand up in this period and begin to give children drugs «just in case».
Of particular note is that a very popular criterion for giving a child antibiotics for viral infections – preservation of high body temperature within 3 days – is absolutely groundless. The natural duration of febrile period for viral respiratory tract infections in children varies considerably, fluctuations in 3 to 7 days and sometimes longer are possible. Longer preservation of so-called low grade temperature (37,0 – 37,5°C) is not necessarily linked to development of bacterial complications and may be explained by very different reasons. In such situations, use of antibiotics is doomed to failure.
A typical sign of viral infection is persisting cough with improvement of general condition and normalization of body temperature. Keep in mind that antibiotics are not antitussives. Parents in this situation have ample scope of traditional remedies for application. Coughing is natural defense mechanism and disappears the last of all the symptoms of the disease. However, if your child has intense cough persisting for more than 3 – 4 weeks, it is necessary to look for the cause.
At acute otitis tactics of antibiotic therapy is different, since probability of bacterial origin of the disease reaches 40 – 60%. Given that, until recently, antibiotics were administered to all patients.
As practice shows, acute otitis media is characterized by intense pain in first 24 – 48 hours, then majority of children feel significant improvement and the disease disappears on its own. After 48 hours symptoms persist only in a third of young patients. There are interesting My Canadian Pharmacy statistics showing that if antibiotics are given to all children with acute otitis media, they will help (decreased febrile period and duration of pain) only those patients who should not have recovered independently. That may be only 1 child out of 20.
What will happen to the rest of 19 children? When receiving modern drugs from penicillin group, such as antibiotics amoxicillin or augmentin, nothing really bad will happen. 2 – 3 children may obtain diarrhea or skin rashes, which rapidly disappear after treatment cessation, but recovery does not accelerate. As with bronchitis, appointment of antibacterial drugs for otitis does not prevent development of septic complications. Complicated forms of otitis media with the same frequency develop in both children who received and who have not received antibiotics.
To date, a new tactic appointment of antibacterial drugs for acute otitis media is developed. Antibacterials are appropriate to prescribe to all children under the age of 6 months, even in case of doubtful diagnosis of acute otitis media (finding out that a child suffers from exactly ear pain is not so easy).
At the age of 6 months to 2 years at questionable diagnosis (or less severe course) of acute otitis media antibiotics can be delayed, limiting to observing a child – the so-called watchful waiting. Naturally, during observation children should be given painkillers and, if necessary, antipyretics. If within 24 – 48 hours condition does not improve, you need to start antibiotic therapy.
Of course, in this case, parents face increased requirements. First of all, they need to discuss with their doctor when to give antibiotics, and clarify, which signs of the disease they should pay attention to. The main thing is to be able to objectively assess pain dynamics, its enhancement or reduction and timely notice appearance of new symptoms of the disease – cough, rash, etc. Parents should be able to contact doctor on the phone and have prescription for antibiotic.
In children older than 2 years waiting and watching for 48 hours is the preferred tactic, except for cases of severe disease course (temperature above 39,0, intense pain).
In case of diagnosis of pneumonia or serious suspicion for this pathology tactics of antibiotic therapy differs from the two previous cases.
For certain age groups of children some features of predominant pathogens are characteristic. Thus, in the age of 5 – 6 years, according to some researchers, up to 50% of cases of pneumonia can be caused by viruses. At older ages, probability of viral pneumonia is significantly reduced and role of bacteria (pneumococci) in development of pneumonia increases. However, in all age groups common cause of this disease is Streptococcus pneumoniae, which causes severe course of the disease. That is why appearance of pneumonia symptoms is an absolute indication for antibiotic therapy.
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