Medications

My Love-Hate Relationship with Antibiotics

Antibiotics are amazing. They can save lives. They can prevent horrible complications of infections, like rheumatic heart disease as a complication of strep infection. I prescribe antibiotics regularly. However, I also have many conversations about why I do not recommend antibiotics for various illnesses. I have to say, these conversations are generally longer and more difficult than writing a simple prescription for antibiotics. And when patients or parents (or my own parents!) give me confused or frustrated looks, I remind myself that my job is to do no harm and more and more we are learning that antibiotics are doing harm.

As you have no doubt heard, our use of antibiotics has swung to an unforeseen level. Our animals are fed antibiotics and this enters our food supply. Patients and parents feel like they need antibiotics to “get better faster” or “just in case.” Doctors fear they will lose patient satisfaction if they do not give prescriptions.

I am not against antibiotics. I just think that we all need to consider when antibiotics are truly necessary and when a tincture of time might do the trick. Here are a few things to consider next time you or your child or your parent feels under the weather:

Antibiotics kill the good along with the bad. When you take antibiotics to kill off unhealthy bacteria, your gut’s healthy bacteria suffers collateral damage. We rely on these bacteria for more than simple gut health—our gut microbiome shapes our immune system, effects mental health, obesity, and heart health. Recent data suggests autoimmune illnesses such at inflammatory bowel disease and juvenile idiopathic arthritis are related to antibiotic exposure in childhood. In extreme cases, the balance is so upset that secondary infections like C. difficile aka C. diff can arise from antibiotic use. The importance of healthy gut bacteria is so great that treatment for C. diff infections now includes fecal transplant, ingesting another person’s healthy microbiome to restore the healthy balance. Fecal transplant is now being studied for all sorts of ailments, from metabolic syndrome/obesity to cancer to resistant infection.

Resistance. I will not go into this too much as most people are familiar with this concept. Simply stated, bacteria can develop properties to resist the antibiotics used against them. When our bodies are exposed to antibiotics, we then harbor antibiotic-resistant bacteria, at least for transient periods of time. We have antibiotics that can defeat some of the known resistant bacteria but certainly not all. This is especially problematic in older patients or people with chronic illnesses who are repeatedly exposed to antibiotics. In cases when antibiotics are a must, consider discussing course duration (more and more we are learning that we can do shorter courses) may help minimize exposure.

Viruses are normal. Most illnesses, adult and pediatric, are viral. Viruses help develop our immune systems, which is especially important for children. Antibiotics will have no effect on a viral infection since antibiotics work against bacteria, not viruses.

Time can heal many things. Ear infections, for example. We know that we over treat ear infections. Data shows that many ear infections are viral. Even pneumonias appear to be mostly viral. However, as physicians, we cannot always distinguish between viral and bacterial infections. As a patient or a parent, you can ask your doctor or health care provider about “watch and wait” options. You can also read about home remedies and ideas for prevention for common cold symptoms.

Prevent illness. Vaccinate your child. The most important reason we can offer more antibiotic-free options for kids is because of vaccines. Many of the bacteria (like pneumococcus in the Prevnar vaccine), that caused more significant ear infections and complications of ear infections, are just not around thanks to the vaccines.

Tell your doctor you would like to avoid antibiotics if possible. It is fast and easy to write a prescription and many doctors feel that patients come expecting antibiotics. In my own practice, parents often come in saying their doctor gave them antibiotics, implying that the child has the same need. This is a very difficult situation. Data on over-prescription of antibiotics, especially in the adult population, is frightening. Over-prescription in pediatrics seems to be improving (though I only found data from 2002). Perhaps because parents worry more about their children’s gut health and immune health than their own. Or perhaps it is because of adult doctors’ perceptions of their patient satisfaction. In pediatrics, an old but nice study involving kids with upper respiratory infections (colds) reveals that parents actually leave more satisfied without a prescription for antibiotics, as long as the doctor outlined a contingency plan. I think an open and educated discussion with your health care provider is always worth the extra few minute.

Replenish your gut. If exposed to antibiotics, our gut can restore itself. It takes time (1 month to 2 years). Eating fresh foods, high fiber foods (natural fiber, like vegetables, fruits), cultured foods (like yogurt), and fermented foods (like kimchee, sauerkraut) can help keep your gut fill itself with a variety of species. Exposure to animals and dirt probably helps as well. I generally recommend taking probiotics when on antibiotics. Lactobacillus rhamnosus aka LGG is readily available over the counter. In studies, it seems to help some people with antibiotic-associated diarrhea and stomach upset. For patients taking multiple courses of antibiotics or very strong antibiotics, I may recommend a blend of probiotics to help prevent C. diff. For those of you interested in more on the gut and microbiome, try The Good Gut.