October 1997
LOS ANGELES — "In the words of Walt Kelly and Pogo, ‘we have met the enemy and he is us,'" said S. Michael Marcy, MD, clinical professor of pediatrics at the University of California, Los Angles, regarding the worldwide problem of antibiotic overuse.
To further describe the problem, Marcy cited the Earth Day slogan — "When each of us does a little, all of us do a lot." When individual physicians prescribe antibiotics that aren't really needed, they are contributing to the problem. According to the 1992 National Ambulatory Medical Care (NAMC) survey, more than 85 million prescriptions for antibiotics are filled annually. Most prescriptions were written for five common conditions: colds, bronchitis, pharyngitis, sinusitis and otitis media. All were uncomplicated upper respiratory infections that are often viral in origin.
By the same token, if each physician restricted the number of antibiotics they prescribe, they would be contributing to a solution.
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"It's worth noting that in one study over 50% of children who entered an office with a simple viral URI, left with an antibiotic," Marcy said. However, there is no evidence of therapeutic or prophylactic benefit from antimicrobial treatment for colds.
No decongestant medications, including over-the-counter products, have been shown to have much effect. However, Marcy said over-the-counter products might be used as a placebo to empower parents.
Antibiotics will also not hasten the resolution of purulent rhinitis. One study showed that clinical evaluation of patients with rhinitis five to seven days after treatment showed no significant difference between placebo and cephaloxin in nasal discharge, the rate of complications or parent satisfaction.
Bronchitis is a viral or allergic cough illness. There is no benefit to antibiotic therapy in otherwise healthy children. A prolonged cough is occasionally due to pertussis, which requires erythromycin. Dextromethorphan may be recommended for a severe cough that is non-productive. But in general, antimicrobials are inappropriate for the treatment of bronchitis, Marcy said.
According to the NAMC survey, 13 million prescriptions for pharyngitis were written in 1992. A study in Kentucky showed that about 66% of children with sore throats left a physician's office with no throat culture, but with an antibiotic. Proper treatment requires a throat culture, and antibiotics should only be prescribed if group A b-hemolytic streptococci are found, he said.
A proper throat culture is obtained by swabbing both tonsils and the posterior pharynx, without touching the uvula, tongue or buccal mucosa. The lab should use an antigen detection test or 5% sheep's blood agar with a bacitracin disk for identification of GAS. Properly done cultures result in 20% to 25% positivity, according to a longitudinal series conducted in Rochester, N.Y.
The two treatment options for sinusitis are symptomatic therapy and antimicrobial therapy, and there is little evidence to show that antibiotics are of any benefit. Some studies show that the common cold is a rhinosinusitis, Marcy said. "Sinusitis is usually just a part of the common cold. It is not a separate entity which requires treatment."
For a child with minimal symptoms of less than 10 to 14 days, Marcy recommends observation and symptomatic therapy. Initial antimicrobial therapy is indicated for a child with severe symptoms, such as periorbital cellulitis or sudden onset of mucopurulent rhinitis, accompanied by high fever. Treatment should continue until all signs and symptoms resolve, usually seven asymptomatic days or 10 days.
With 23.3 million prescriptions written annually for otitis media, it is the condition that receives the most antibiotic therapy. Like sinusitis, it is also a condition that can often be treated symptomatically, with observation, which is the way it is managed in much of Europe. And, studies have shown that 85% of acute otitis media (AOM) resolves without treatment.
The clinical diagnosis for AOM is often uncertain, Marcy said. A bulging tympanic membrane, bright red color and loss of landmarks are signs of AOM. However, otitis media with effusion (OME) is an inflammatory condition that presents with a pink tympanic membrane. Studies have shown that up to 25% to 30% of cases considered AOM are really OME, which does not generally require antibiotic treatment.
If the diagnosis is AOM rather than OME the treatment is amoxicillin, with infants and toddlers receiving a seven- to 10-day course; and children over 24 months receiving a five-day course. These shorter courses reduce pressure on the flora and, therefore, slow the development of resistant organisms, Marcy said.
A study in Iceland showed that levels of pneumococcal resistance fell following an education program about antibiotic overuse. Another study of parent focus groups conducted by the Centers for Disease Control and Prevention showed that 84% of parents would accept not receiving an antibiotic if the physician told them the reason. "If each of us does a little to resolve this problem, all of us can do a lot," Marcy said.
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