The antibiotic debate is a big one for several good reasons. One of those reasons is that times have changed and change can be challenging. Antibiotics were used liberally by previous generations of clinicians. We and our patients now find ourselves in a world where antibiotics are being used less often. This culture change is a major contributor to the conflict that arises due to expectation of antibiotics as a treatment for sore throats and painful ears in young children.
The good news is that if you are prescribing fewer antibiotics then you are part of a growing trend. In the UK and many other countries, antibiotics prescribing rates have fallen over the past few years. This means a lot more children are benefiting from symptomatic treatment without the added side effects of antibiotics. So far the evidence is that this reduction has not been the cause of a rise in bacterial complications such as peritonsillar abscess and rheumatic fever.(1)
If you work in a country with a low incidence of complications of streptococcal infections, that tells you more about the pathogenicity of your local bacteria than about your prescribing rates. We therefore greatly rely on our Public Health team to facilitate the safety of the no-antibiotic approach to managing URTI/AOM/tonsillitis. The Public Health team monitors the rates of complications of streptococcal infection and alerts you when there is a more pathological strain of strep and will make recommendations regarding temporary changes in prescribing practices.
It's great to know that Public Health have our backs, but it's a little complicated to explain to patients and parents in the time restrictions of a consultation. Explaining the rationale for avoiding antibiotics for sore throats and ears can be tricky. While many of of us are finding that it is problematic less often than it used to be, it is still one of the most important skills that we should have. The question is, what can we do to make it likely that this discussion goes well and goes quickly?
The first thing to do is make sure that we're coming at this from the point of view of the best interests of the child. I understand the need for antibiotic guardianship but quite frankly when it comes to each clinical encounter, I'm always going to choose what will be best for my patient. If this is what is driving our avoidance of antibiotics then the parents will hopefully sense that we want what they want -their child to be as well as possible as soon as possible. What this child centred approach achieves is that we then have the right attitude towards the subject of antibiotics. We don't come across as having a hidden agenda. It's all about the child and wee hope that parents will respond well to that.
When we have the discussion it is important to be considered when choosing our words. If we talk about "not needing" antibiotics, it might come across as them not having fulfilled the criteria for what they see as the ultimate treatment. Instead, talk in terms of antibiotics not helping.
It is fairly standard at this point to mention the side effects of antibiotics. I don't tend to mention allergic reactions, partly because they are not that common and partly because we are trying to get away from parents thinking that everything that happens while taking antibiotics is an allergic reaction. What I do emphasise is that common side effects are abdominal pain, vomiting and diarrhoea. I make sure that the parents know that the main reason for wanting to avoid antibiotics is that I don't want to do that to the child and I don't want to make life harder for the parents.
Because most people don't seek a medical opinion about what not to do, this is the ideal time to discuss what does work. Analgesia is key and parents will sometimes need encouragement in this regard. One thing that causes much confusion is the issue of what the medicine is for. There has been an unhealthy emphasis on controlling temperature which sometimes means that paracetamol (acetominophen) and ibuprofen are not used as analgesia when the child is afebrile but refusing to drink.
This is all important information and yet at the same time it is way too much information for a parent. In many ways, the complexity of the information is part of what perpetuates the overuse of antibiotics. It is far simpler for the parents and the clinician to simply say, "Your child needs antibiotics." Unfortunately this is the illusion of simplicity.
So what we need are strategies to simplify the complicated. A leaflet is a very good way to achieve this. We know what the questions that most people tend to ask, so why not give them some answers? Here is a simple leaflet, in a question and answer format:
You could even start the process in the waiting room. A poster that gives a bit of context might soften the ground for the discussion to be allowed to focus on more important things.
If you would like access to either the leaflet or the poster then please let me know and I can give you a fully editable copy. You will need to register a free account at canva.com When you have done that, either send me a direct message via social media or post a comment at the end of this blog. (You don't need to worry about anyone seeing the comment. I get to review all comments before they are published and if you start your comment with "not for publishing" I will keep it for my eyes only.) Give me your email address that you used to register the canva.com account and I will share the templates of the leaflets or poster if that is of use to you. You can then use these to edit and personalise.
There are lots of leaflets, posters and websites available. You should use them both to inform and to simplify. My view is that they should be basic but contain the important information.
Finally, make sure that the parents know that they need to be looking out for signs of secondary infection and sepsis. Complications of URTI are thankfully low where I practice but we should all be thinking of URTI as pre-sepsis. I think that this safety-netting discussion can actually be used to support the no-antibiotic element of the consultation. Parents need to know that the clinician realises that their child is genuinely ill. For that reason, we should avoid the phrase "just a virus". It may be meant as reassurance but is often perceived as dismissive. By completing the consultation with and explanation of signs of complicated URTI and when to re-attend we are helping the parent to see that we have taken the child's illness seriously.
Edward Snelson
Very Serious Doctor
@sailordoctor
Disclaimer: The online content of this blog may have been corrupted by pixies and as such the responsibility for anything that turns out to be wrong sits with the Fairy King.
Reference
The good news is that if you are prescribing fewer antibiotics then you are part of a growing trend. In the UK and many other countries, antibiotics prescribing rates have fallen over the past few years. This means a lot more children are benefiting from symptomatic treatment without the added side effects of antibiotics. So far the evidence is that this reduction has not been the cause of a rise in bacterial complications such as peritonsillar abscess and rheumatic fever.(1)
If you work in a country with a low incidence of complications of streptococcal infections, that tells you more about the pathogenicity of your local bacteria than about your prescribing rates. We therefore greatly rely on our Public Health team to facilitate the safety of the no-antibiotic approach to managing URTI/AOM/tonsillitis. The Public Health team monitors the rates of complications of streptococcal infection and alerts you when there is a more pathological strain of strep and will make recommendations regarding temporary changes in prescribing practices.
It's great to know that Public Health have our backs, but it's a little complicated to explain to patients and parents in the time restrictions of a consultation. Explaining the rationale for avoiding antibiotics for sore throats and ears can be tricky. While many of of us are finding that it is problematic less often than it used to be, it is still one of the most important skills that we should have. The question is, what can we do to make it likely that this discussion goes well and goes quickly?
The first thing to do is make sure that we're coming at this from the point of view of the best interests of the child. I understand the need for antibiotic guardianship but quite frankly when it comes to each clinical encounter, I'm always going to choose what will be best for my patient. If this is what is driving our avoidance of antibiotics then the parents will hopefully sense that we want what they want -their child to be as well as possible as soon as possible. What this child centred approach achieves is that we then have the right attitude towards the subject of antibiotics. We don't come across as having a hidden agenda. It's all about the child and wee hope that parents will respond well to that.
When we have the discussion it is important to be considered when choosing our words. If we talk about "not needing" antibiotics, it might come across as them not having fulfilled the criteria for what they see as the ultimate treatment. Instead, talk in terms of antibiotics not helping.
It is fairly standard at this point to mention the side effects of antibiotics. I don't tend to mention allergic reactions, partly because they are not that common and partly because we are trying to get away from parents thinking that everything that happens while taking antibiotics is an allergic reaction. What I do emphasise is that common side effects are abdominal pain, vomiting and diarrhoea. I make sure that the parents know that the main reason for wanting to avoid antibiotics is that I don't want to do that to the child and I don't want to make life harder for the parents.
Because most people don't seek a medical opinion about what not to do, this is the ideal time to discuss what does work. Analgesia is key and parents will sometimes need encouragement in this regard. One thing that causes much confusion is the issue of what the medicine is for. There has been an unhealthy emphasis on controlling temperature which sometimes means that paracetamol (acetominophen) and ibuprofen are not used as analgesia when the child is afebrile but refusing to drink.
This is all important information and yet at the same time it is way too much information for a parent. In many ways, the complexity of the information is part of what perpetuates the overuse of antibiotics. It is far simpler for the parents and the clinician to simply say, "Your child needs antibiotics." Unfortunately this is the illusion of simplicity.
So what we need are strategies to simplify the complicated. A leaflet is a very good way to achieve this. We know what the questions that most people tend to ask, so why not give them some answers? Here is a simple leaflet, in a question and answer format:
There are lots of leaflets, posters and websites available. You should use them both to inform and to simplify. My view is that they should be basic but contain the important information.
Finally, make sure that the parents know that they need to be looking out for signs of secondary infection and sepsis. Complications of URTI are thankfully low where I practice but we should all be thinking of URTI as pre-sepsis. I think that this safety-netting discussion can actually be used to support the no-antibiotic element of the consultation. Parents need to know that the clinician realises that their child is genuinely ill. For that reason, we should avoid the phrase "just a virus". It may be meant as reassurance but is often perceived as dismissive. By completing the consultation with and explanation of signs of complicated URTI and when to re-attend we are helping the parent to see that we have taken the child's illness seriously.
Edward Snelson
Very Serious Doctor
@sailordoctor
Disclaimer: The online content of this blog may have been corrupted by pixies and as such the responsibility for anything that turns out to be wrong sits with the Fairy King.
