The dark black clouds loomed ominously across the sky giving the impression that it was late in the day. The wind blew constantly, making it uncomfortable to walk in the light rain that had just started to fall. It was hard to believe that it was ten o’clock in the morning on a late October day in Southern California. With no noticeable transition, summer was just a fleeting memory. Fall was upon us, and with it came the seasonal respiratory tract infections. It seems as if it was just yesterday that the office was filled with children needing their school and sports physicals. Now the office was full of children with coughs, colds and fevers.
Fifteen-year-old Ryan came to the office complaining of fever, headache and sore throat. He did have a temperature of 102 degrees, and upon examination his throat was fiery red. Although there was no stiffness to the neck, the swollen glands were prominent. The ears were clear, and in spite of a raspy voice and cough, the lungs were also clear. The rest of his exam was unremarkable. I did a strep test and a mono test, both of which were negative. This meant that Ryan did NOT have strep throat nor mononucleosis. Ryan’s mom said, "Well, that’s good news. Now which antibiotic are you going to put him on?" I could sense his mother start to bristle when I explained why I thought that Ryan did not need an antibiotic. I explained that Ryan most likely had a viral infection since the strep test was negative and the rest of his exam was normal. I was sure that he did not have mononucleosis and this was good news as well. She then rebutted, "But he is so sick...surely he needs Amoxicillin...or something!" I explained that there was no question that Ryan had a sore throat, tonsillopharyngitis to be exact, but because it was caused by a virus, antibiotics would be a waste of time and resources. He would definitely not get better any sooner. I told her what to do for his symptoms to make him comfortable, and I did tell her that if he was not better in 48 hours that I should recheck him to be sure that a secondary bacterial infection had not developed. This was reassuring to her and she understood the rationale behind this.
I called Ryan’s mom two days later to see how he was doing. She thanked me for calling and informed me that he was much better...so much so that she was just going out the door to watch him play water polo as he is one of the better players on the high school sophomore team. As a passing thought, she made the observation, "Had you put Ryan on antibiotics, he would have gotten better no matter what. And I would have thought it was the antibiotics...and he would have received a full 10 days of medicine for nothing, huh?"
Ann is an 18-month-old little girl who has just about caught everything she has been exposed to in day care. Mom brought her in because she has had a cough and runny nose for close to a week. Mom has tried over-the-counter medications, run a humidifier, and even has rubbed a mentholated gel on her chest...all to no avail. "I figured it has gone on long enough," she said in a resigned voice. "I think you need to put her on antibiotics!" Ann did not have a fever, and was quite playful and happy in the office despite a clear runny nose and a slight hacky cough. Her ear drums were clear and there was no redness to the throat. The post nasal drainage in the back of her throat was a bit thick, but was clear in color. Although there was congestion in the chest, her lungs were clear. "When I hold her next to me I can feel the rattliness in her little chest," mom protested. "I’m afraid that she might have pneumonia!", she went on. I explained to her that Ann had mucus and congestion in the large upper airway bronchioles and that it was this mucus that was causing the rattle in her chest. We can cough, hack and clear the mucus into the back of our throats, but someone Ann’s age is unable to do this effectively, thus they sort of "percolate" with each breath. This was so with Ann when I listened to her lungs. In trying to take deep breaths, Ann had a brief coughing jag and coughed up quite a bit of phlegm. When I listened to her lungs afterwards, they were crystal clear. I told mom that when one has a pneumonia, the classic noise one hears with the stethoscope are called rales, which are fine crackles heard best at the end of a deep breath. These crackles are a "fixed" noise meaning that they do not clear or move around the chest with coughing or clearing one’s throat.
Feeling confident that Ann did not have a pneumonia, ear infection, infected throat or any other sign of a bacterial infection I told mom that Ann would not need antibiotics...at least not yet. She caught me by surprise when she said, "Whew!!! I hate the thought of having to be on antibiotics unless it is absolutely necessary."
This fall and winter, many patients will be seen in doctors offices across the country for a myriad of illnesses ranging from colds, to runny noses, to coughs, to ear infections to pneumonias. A certain percentage of these patients will require antibiotics to treat the infections. A large number of patients, those with a viral infection, will not. It is the responsibility and obligation of the physician to appropriately discern which patients warrant antibiotics and which don’t. This decision is often times an unpopular one among the parents. It too, however, is the duty and responsibility of the parents to ask questions about their child’s health. If antibiotics are not felt to be warranted, the parents should have the doctor explain why this is so. And if antibiotics are prescribed, the parents should have no question in their minds as to why they are being started. Communication is critical between parent and doctor.
There is a growing problem in this country with bacteria that are becoming resistant to many of the standard antibiotics that we use to fight bacterial infections. A major cause of this is the overuse and indiscriminate use of antibiotics. Another cause is the incomplete use of antibiotics. Often times an antibiotic will be prescribed for a ten-day course. But as the child gets much better by the third or fourth day, the antibiotics are inadvertently stopped. This greatly contributes to the selecting out of a resistant bacteria because the weaker and more susceptible bacteria are killed leaving the hardier and stronger ones behind.
This fall and winter, if your child becomes ill and you take him/her to the doctor, listen carefully to what the doctor has to say. If it is decided that antibiotics are needed, be sure that in your mind you know exactly why. Don’t be afraid to ask the doctor questions. If it is determined that antibiotics are NOT required at that time, ask the doctor at what point should you be concerned, or when should the child be reexamined. Not only does this make the physician's job easier, and the parents more comfortable with the plan of action, but above all, the child’s well-being is best served.