Antibiotics – A Magic Bullet; But, Not For All!

The word Antibiotics comes from the Greek words ‘anti’, meaning ‘against’, and ‘biotikos’, meaning ‘concerning life’.  Antibiotics are mainly active against bacteria.  They do not cure infections caused by viruses or parasites or fungi, though some antibiotics may act against parasites.  Looking at the second part – “biotikos”, whose life is at concern?  It’s not just the life of bacteria, our lives too!  Antibiotic usage goes with the idiom ‘double edged sword’ – something that can be seen as a benefit and a liability.’ A diligent restrained use of antibiotics is a must for a secure tomorrow!

Antibiotics are one of the most commonly prescribed medicines only next to paracetamol!  There are several reasons for this (ab)use.  To list a few –

  • Parental anxiety/Parental pressure/Parental Misconception– A common scenario found in most of the outpatient clinics.  Any child with high fever, a runny nose, loose stools, vomiting etc., parents’ first remark would be, “Doctor, my child is having an infection, please give him some antibiotics to make him feel better as early as possible!”
  • Physician’s anxiety – Mostly seen with young or newly started physicians.  “What if I don’t write an antibiotic and this child doesn’t get better?  What if the child is taken elsewhere and doesn’t come back?  I may lose more patients because of this one parent who may say to others – ‘this doctor is not good.  He did not prescribe antibiotics and my child’s condition deteriorated’ and so on.”
  • Pharmaceutical companies – They pressurize the health care professionals to meet the target or to move the products in exchange for some incentives.
  • Luxury of insurance coverage This has been trending over the last few years.  It is commonly heard from parents – “Doctor we have insurance.  Please write the best possible antibiotic.”
  • Corporate or Private Health center’s pressure – A pharmacist or the supervisor walking into the doctors’ chambers saying “Doctor, look at this list of antibiotics, not moved at all…expiring in next few months!”
  • Weekend Syndrome – This syndrome owes its origins to the busy life schedules of the modern world. A busy parent may think, “Today is friday/saturday!  Doctor may not be available for the next 1-2 days.  What if my child doesn’t recover?  Better to take an antibiotic.”  A Doctor’s thought, “Let me give them antibiotics, just in case?”  Both these thought processes aid each other – with the end result being an antibiotic prescription.
Living weekend to weekend - causes tremendous pressure among working couple
Living weekend to weekend – causes tremendous pressure among working couple
  • Lengthy Line – Lack of Time Syndrome – This mostly happens with busy practitioners.  To evaluate any child with fever, it takes at least 10-15 minutes.  If there is a line of 60-80 children, the evaluation time can range anywhere between 10-12 hours nonstop.  Practically impossible for a human mind to focus on such extended periods of time.  The easiest option would be to prescribe anti-biotic – thereby saving time.
  • Play safe policy – “Why take chances?”
  • Let’s make others happy attitude!  Quick antibiotic – Parents are happy.  Pharmacists and pharmaceutical companies are happy. It all looks like a win-win situation.  
  •  Lack of forethought – Not thinking of what will happen if the antibiotic becomes useless tomorrow due to development of resistance, which by the way is not a farfetched idea. The devil is just around the corner.
  • “Quack – Quack” Found mostly in sub urban or rural areas.  In many rural areas where there is dearth of qualified doctors, unqualified practitioners prescribe anti-biotics as quick fix – without understanding the consequences. In many cases these “Doctors” acquire their knowledge through internet and through “Medical Representatives’ University”.
  • Working parents’ apprehension: More the number of days lost in taking care of a sick child, more to lose at the workplace.  They end up pestering the doctor for antibiotics.

Myth Busters –Clinical scenarios commonly we come across

  1. Myth: Fever = Bacterial infection.  Many parents believe that fevers are due to bacteria and don’t get cured without antibiotics. 

Buster:  Most of the fevers in pediatrics are viral and don’t need antibiotics.  Good nutrition and hydration, fever control and adequate rest are all that is required.

  1. Myth: Loose stools (diarrhea), vomiting, abdominal pain = Food poisoning due to bacteria and an antibiotic is a must.

Buster: Most of the gastrointestinal symptoms are either due to a virus or preformed toxins or self-limiting bacterial infection.  A good (re)hydration with ORS or tender coconut supported by proper nutrition, adequate rest, probiotics (benefit of doubt) – yoghurt or commercially available probiotics and other micronutrients like Zinc should suffice and/or anti-emetics.

  1. Myth: Runny nose, fever, throat pain = Throat infection due to bacteria.  Better to start antibiotics early!

Buster: Most of the upper respiratory infections are due to viral etiology, unless proved otherwise.  Supportive care should work most of the time.

  1. Myth: Injury/ Wound = Antibiotic is needed to prevent further infection.

Buster: Unless it is case of major or contaminated wounds – proper cleaning and local care should do the trick.

  1. Myth:  Too much cough = Severe bacterial infection.

Buster: Most kids cough either due to a viral infection or some allergy which should be taken care of without anti-biotics.

  1. Myth: Fever has disappeared after 2 days of antibiotic; So why take it for a prescribed number of days?  Let’s save it for the next fever/infection!

Buster: Properly diagnosed and treated bacterial infection usually responds to antibiotics in 48-72 hours.  That doesn’t mean the infection is totally cleared.  It is necessary to complete the prescribed course to eradicate the infection completely.  

  1. Myth: I have the same symptoms as last month – so I bought the same medicines from pharmacy – but it’s not working this time- what’s wrong?

Buster: There are several bacteria which can cause similar symptoms; Let the doctor do his assessment. A doctor is professionally trained to identify these subtle differences and prescribe suitable medicine. Do not try to be a doctor! 

  1. Myth: “Doctor!  The antibiotic you gave worked like magic.  One dose and I’m alright.”

Buster: Effectively treated an infection responds quickly; if the response is so quick with one dose, it is most unlikely a bacterial one.

With an effort to supervise judicious prescription of antibiotics by clinicians and followed adequately by the patient/parents,Antibiotic Stewardship program was brought into existence.  Stewardship program would guide us to use antibiotics diligently, in a restrained manner for securing tomorrow’s concern while treating infections.

To Be Continued…

Disclaimer:  The above article is only to create awareness regarding antibiotic use.  The given information should not be used as a substitute for doctor’s consultation in case of any clinical symptoms mentioned above.

An eight year old was brought to the emergency room of a hospital in a stage of shock. She had a short duration illness with fever, skin rash, red eyes with vomiting and diarrhea. The child was given intravenous fluids and oxygen and rushed to the pediatric intensive care unit. She was started on antibiotics and supportive treatment. When the history was reviewed, it was noted that she had come in contact with a relative with COVID-19 infection three to four weeks before. She was diagnosed to have Pediatric inflammatory multisystem syndrome (PIMS) – temporally related to COVID-19 (PIMS-TS) or Multisystem inflammatory syndrome in children (MIS-C) – temporally related to COVID-19.

Pediatric inflammatory multisystem syndrome– temporally related to COVID-19 (PIMS-TS) is a newly described condition with the first reports in the journals about a few months ago.

Year 2020 has had this dubious distinction of being a year of turmoil. The COVID-19 pandemic has been an event which happens once in a century. Last such event which affected the world as we know it, was way back in 1918 when the Spanish flu wreaked havoc across the whole world.  Children have been reported to be affected very mildly as compared to adults and elderly. 

Initial Reports

In the month of April 2020, there started emanating reports in medical literature of children who were previously well presenting with illness, fever, red eyes and swelling of glands in the neck. This description resembled a condition known as Kawasaki disease. But what made it worse was that these children presented with hypotension (low blood pressure). 60-100% of children had features of vomiting, abdominal pain, and diarrhea. About 60% of children had features of brain fever.  They were managed in the emergency room because the blood pressure had fallen significantly. Some of these children also had decreased heart function and swelling of coronary arteries which supply the muscles of the heart with oxygen rich blood which could have led to a circulatory shock. These reports from the United Kingdom were followed by reports from Italy, USA and recently from India too. 

The unique phenomenon which was noticed by epidemiologists was that the areas from which these patients were being reported were from those geographic areas which had witnessed a surge of COVID-19 infections three to four weeks prior. This has led to some experts suggesting a temporal association of COVID-19 infection with this multisystem inflammatory syndrome.

Symptoms & Treatment

The usual age of children being affected by this condition is about 8 to 10 years. These children present with fever for 3 to 4 days associated with redness of eyes, mouth and lips with skin rashes and presence of tender nodes in the neck. They have a sudden deterioration in the form of low blood pressure, cold clammy extremities and feeling faint with decreased urine output. These children need admission to the intensive care unit most of the times. The children need to be resuscitated with fluids and drugs to improve their blood pressure. Supportive treatment is very important. Drugs like intravenous immunoglobulin and steroids can be used to control the inflammation in the various organs of their body.

High fever in children, in contact with Covid-19 patients, could be due to PIMS-TS
High fever in children, in contact with Covid-19 patients, could be due to PIMS-TS

Many of these children according to the literature when evaluated for COVID-19 antibodies were found to be positive. This would substantiate the claims of temporal association of this condition with COVID-19 infection. The knowledge about this condition is still in a stage of evolution as more and more cases across the globe are being reported. There have already been reports of this condition from the cities hit by the COVID-19 infection like Delhi, Mumbai, Chennai and Pune. This condition has been reported in those geographic areas which have had a surge of COVID-19 cases about 4 to 6 weeks prior. The most important aspect is recognition of this condition early and early initiation of treatment. However the condition thankfully is associated with low mortality.  

Summary Pediatric Inflammatory Multisystem Syndrome – temporally related to COVID-19:

  • Predominantly seen in older children rather than infants or toddlers.
  • Suspect if child is febrile with skin rashes, red eyes and gland swelling in the neck.
  • Loose stools, vomiting and abdominal pain can be the presenting symptoms.
  • If the child is acutely ill with disorientation and cold hands and feet, he needs to be seen by a health care provider as soon as possible.
  • Treatment is available and mortality is very low when treated adequately on time.