VIRUSES, ANTIBIOTICS AND PHYSICIAN CONFIDENCE

The majority of childhood infections are caused by viruses and do not require antibiotic treatment. The misuse and overuse of antibiotics has resulted in a dramatic increase in antibiotic resistance to Streptococcus Pneumoniae (Pneumococcus) which is the most common bacteria to cause both mild and severe infections in children. Researchers, studying pre-school children in Toronto Day-care Centers recently found that approximately half of the 1300 children studied were colonized with Pneumococcus. Fourteen percent of the bacteria from these children were partly resistant to penicillin and 3% were very resistant to penicillin. Forty percent of the children were receiving antibiotics or had received antibiotics in the previous month. The onus is on both physicians and parents to reduce the use of antibiotics in order to prevent this increasing resistance.

What can parents do to reduce antibiotic usage?

Parents should not assume their children automatically need antibiotics and should not routinely ask for them when their children are sick. There are several reasons why parents may try to pressure physicians into prescribing antibiotics. They may, incorrectly, assume that antibiotics are effective against viruses. They may want an instant cure for their child who is not well, in discomfort, irritable and febrile. They may be more concerned with their own needs in being unable to deal with a sick child, lack of their own sleep and their need to have the child cured as soon as possible in order that they may return to work. Parents may be pressured by their spouse to have the child put on antibiotics. Often parents are going away on a well deserved vacation and desire antibiotics for their ailing child in order not to have their holiday spoiled. "Friday afternoon medicine" is a phenomenon well known to physicians; parents wish to have their children checked prior to the weekend in case the child is coming down with an ear infection and they will not be able to see their own doctor until Monday. All of these circumstances, consciously and unconsciously, prey on the physician to be sympathetic to the parents, caregiver and their child to prescribe antibiotics.

Why do physicians prescribe antibiotics unnecessarily?

Physicians basically want to make their patients feel better. Often if the diagnosis is not clear they will err on the side of administering antibiotics rather than waiting , since they feel they may lose favor with the parent or patient if there is any deterioration in the child's condition because of the avoidance of antibiotics. Many physicians feel that there is very little to lose by prescribing antibiotics since the side effects are mild and rare and the patient may just get better on medication rather than off medication. Some physicians are too busy, too rushed and do not have the time to work through the discussion and dialogue that is required in describing to the parent the nature of the child's condition, and the increasing incidence of antibiotic resistant bacteria due to the overuse of antibiotics. It is far easier to prescribe an antibiotic and move on to the next patient for some physicians. Sometimes it is just impossible for the physician to distinguish viral from bacterial infections and with all the good intentions in the world, antibiotics may be prescribed unnecessarily.

When a child presents with a fever, how can the physician determine whether the child has a benign viremia or a more serious underlying illness?

Febrile infants and young children present clinically in two ways; "wet or dry". The "wet" infants characteristically have rhinorrhea, stuffiness, cough or congestion; they may have the odd loose stool and may spit up. These infants usually have a viral illness which can be complicated by otitis media. The "dry" infants often have a fever without any other symptoms and almost never have otitis media. These "dry" infants are more likely to have a viral exanthem such as roseola or possibly a urinary tract infection. In the older school-age child streptococcal tonsillitis often presents as a classic "dry fever" with a sore throat but no other respiratory symptoms. Both "wet" and "dry" infants may have non-specific symptoms such as irritability, fussiness, lethargy and anorexia and at the same time have an underlying serious illness such as pneumonia (more common in "wet" infants) or pyelonephritis (more common in "dry" infants).

Does the height of the fever help the physician distinguish viral from bacterial infections?

No. How sick the child looks is far more important than how the high the fever is reported. In fact it is always best always to treat the child and not the thermometer (except for the infant less than 3 months of age where the usual clinical signs of serious illness may be absent). It is well recognized that viral illnesses such as roseola often present with a high fever of over 40oC and while these children may be miserable and unhappy, they are not sick or toxic and do not require antibiotics. On the other hand pneumonia, bacteremia and meningitis may occur in children with a significantly lower temperature, however these children usually looks sick, or frankly septic and antibiotics are clearly indicated in these situations.

How does the physician decide, with regard to specific type respiratory tract infections, which child to treat with antibiotics?

A recent metaanalysis evaluation of treatment for otitis media in children indicated that 81% of otitis media will resolve spontaneously without antibiotics. Therefore the practicing physician must now become selective in whom to treat with antibiotics and whom to treat only symptomatically with watchful expectation and no antibiotics. Otitis media with effusion (serous otitis media, non-purulent) should not be treated with antibiotics. There is also a growing tendency to recommend that mild ear infections not be treated with antibiotics, particularly in older children where there is a very high likelihood of spontaneous resolution. The key to avoidance of antibiotics is to explain to the parents what you are doing, why you are avoiding antibiotic usage, and ensuring that there is good follow up 7-14 days later. This strategy works best in community physicians' offices but may not work well in walk in clinics and emergency rooms where follow -up and continuity of care is uncertain.

Viral pharyngitis usually presents in a child, of any age, with a "wet" fever, who has a sore throat, coryza and cough and does not require antibiotic treatment. Symptomatic treatment with fluids, analgesia and antipyretics, as necessary, are all that is required. Streptococcal tonsillitis on the other hand, is usually seen in school-aged children (it is extremely rare under two years of age), who have a "dry" fever, sore throat, but no cough, coryza or congestion and should be treated with antibiotics (in the presence of a positive throat culture).

Sinusitis is in fact extremely rare in childhood and is thought to occur in less than 5% of cases. It should be remembered that a normal viral cold proceeds three phases. In the first phase there is a clear mucoid coryza. In the second phase, the mucous may become yellowish or greenish for a few days and then it reverts back to a clear nasal discharge in the final phase of the cold, which then resolves spontaneously. The simple presence of a green mucousy discharge for a few days, in a child who is playful, eating, sleeping and behaving normally, is not a reason to treat a child with antibiotics. Antibiotics should only be used if the child becomes sick or toxic, extremely listless or irritable, refuses to eat or drink, has significant facial pain or has had a purulent nasal discharge for 7 to 10 days or more.

Croup or tracheitis is a classical viral illness caused by Parainfluenza virus and does not require antibiotic treatment. It manifests itself with a bark or seal like cough, resolves spontaneously with the help of steam, cold air, or a vaporizer and occasionally may require the use of dexamethasone anti-inflammatory treatment. Antibiotics are not required except in the very rare form of bacterial croup where the infants and children often present in a febrile, toxic state.

Bronchiolitis is caused by respiratory syncitial virus (RSV), occurs in early infancy usually before 1 year of age, manifests with a productive chesty cough and wheezing and does not require antibiotic treatment. Bronchitis is often of the "wheezy" variety in toddlers and young children and if treated at all, may require bronchodilators and anti-inflammatory medications rather than antibiotics. Age is the best predictor of the cause of pediatric pneumonia, viral pneumonia being the most common during the first two years of life. Antibiotics are rarely needed unless the infant is distressed, hypoxic, toxic, and less than 6 months of age. As age increases and the incidence of pneumonia decreases, bacterial pathogens, including S.pneumoniae and Mycoplasma pneumoniae, become more prevalent.

How does the physician distinguish the seriously ill child with a possible septicemia from the child of a more benign viral illness?

The child who is playful, alert, has good coloring, interacts well with his caregiver, even in the presence of a high fever, is not a seriously ill child. On the other hand, the child who is lethargic, not playful, not very interested in interacting with his environment, pale and dehydrated, with or without a high fever, is clearly a sick child and needs more urgent intervention.