In the December 2013 issue of Pediatrics, a clinical report on the use of antibiotics for upper respiratory tract infections caught my eye ("Principles of Judicious Antibiotic Prescribing for Upper Respiratory Tract Infections in Pediatrics," Pediatrics 2013;132:1146-54), both because of the clear applicability to my daily practice as a primary care provider and the considerable media attention surrounding it in the lay press.
While I (and the primary care providers I practice with) try to be very thoughtful and deliberate in our decision making about when and how we use antibiotics in the ambulatory setting, there is no question that parent education is an important and sometimes difficult part of implementing these treatment plans. I also was struck by the fact that in the same issue of the journal, there was an article describing a decline in emergency department visits for adverse events from the ingestion of cough and cold medications since the voluntary manufacturer withdrawal (of infant) and labeling revision (for all) of these over-the-counter pediatric medications ("Cough and Cold Medication Adverse Events After Market Withdrawal and Labeling Revision," Pediatrics 2013;132:1047-54).
While most of these events now are related to the unsupervised ingestion of medications, there still are many parents giving over-the-counter cough and cold medications to their young children, counter to recommendations. These two articles remind me that, while as medical providers we are understandably focused on recommending the safest and most effective treatment for children with viral upper respiratory tract (URI) infections, parents are understandably focused on how to make their miserable children feel better!
The principles for judicious antibiotic use laid out by Hersh et al. are clear and straightforward: Determine the likelihood of a bacterial infection, weigh the benefits versus the harms of antibiotic use, and then implement prescribing strategies, with consideration given to watchful waiting if appropriate. Putting these recommendations into practice, and importantly communicating them to families, is a trickier but worthy business. Numerous studies – and the clinical experience of myself and my colleagues – suggest that parents are generally less convinced that they need antibiotics or cough and cold medicines than that they need to do something to make their children feel better. These studies and experience also suggest that explaining why you are treating without antibiotics can happen within the same time that it takes to prescribe and give instructions on how to use an antibiotic, including administration, dosage, and side effects.
Everyone has their own personal style, but I find that framing my communications with families using the same principles I consider when deciding whether or not to prescribe an antibiotic is fast and effective.
As I am conducting my exam and determining the likelihood of a bacterial infection, I describe to the parents what I am doing. "Oh good," I may say, "even though I can hear a lot of congestion in the nose, I don’t hear anything in the lungs and little Johnny has a normal amount of oxygen in his blood ... These are both great signs that he does not have pneumonia or an infection deep in his lungs." I find that – no matter what the family member’s level of education or medical sophistication – hearing me talk through my thought process is infinitely more reassuring than watching me do an exam and then saying, "Well, looks like he has a cold."
Once I have diagnosed a viral infection, I take the family through my thought process of why antibiotics aren’t helpful. "It looks like he has a virus causing a really bad cold," I continue. "There is good and bad news about this – the good news is that these infections are usually not very serious and will go away on their own. The bad news is that they have to go away on their own, and this may take a little time. I know he feels pretty crummy now. While there aren’t any medicines to make this go away faster, there are things we can do to make little Johnny feel better and more comfortable while his body is doing its job." And then I tell them what those things are. As I was researching this article, I came across one medical group that had preprinted "prescriptions" for treating a viral URI that providers could fill out and give to families – a fun and fast way to share information.
Lastly, I look forward a little bit and communicate that part of the judicious use of antibiotics is knowing when you should use them. I explain that at any time things may change, and that if little Johnny seems to be getting worse or isn’t better within the expected time frame, the family should call the office or bring him in, and we may consider a different plan if indeed there have been changes. This simple act of explicitly letting families know that the evaluation of their child’s illness doesn’t end with the office visit goes a long way toward validating the family’s concerns, and making sure that as a provider I really am helping the child get better – even if I’m not giving antibiotics.