Before You Start Those Antibiotics! (Part 2) | Will it Make a Difference?
In a previous article, we discussed the importance for patients to think critically when prescribed medications. Starting with antibiotics, there are certainly great benefits but also some harms. How do we go about making a decision on whether to use antibiotics?
Is it Cause by Bacteria?
One difficulty in knowing when to prescribe antibiotics is due to the fact that the same condition can be caused by both viruses and bacteria. In many cases it can be difficult to distinguish between the two.
For example, the colour of phlegm was commonly used to aid the decision on whether a cough is bacterial. However, apart from maybe those with specific chronic lung disease or long-term cough, coloured phlegm cannot reliably predict whether illness is caused by bacterial infection.
GPs who care about appropriate use of antibiotics are excellent at distinguishing between viral or bacterial disease. This comes from observing clinical features which are more likely in bacterial or severe infection, allowing for appropriate early antibiotics. As well as having experience in treating a large number of patients and safely managing the majority without antibiotics.
If you are ever unsure about taking antibiotics, don't simply take the script and mull over the decision at home. Feel free to ask your GP about the factors which compelled them to prescribe, in addition to any other questions or concerns you may have.
Will it Make a Difference?
For some patients, there is the perception that antibiotics will definitely help regardless, such that there's no harm in taking it anyway. In contrast, the Australian Commission on Safety and Quality in Health Care provides interesting fact sheets which highlight the true difference antibiotics make in some cases.
Example 1: Middle ear infections typically last around 84 hours. Children who take antibiotics typically have earache for only 12 hours less than children who don't take antibiotics.
Example 2: In typical cases of acute cough which lasts an average of 7 days, those who take antibiotics have the cough 12 hours less than those who don't take antibiotics.
There is another fact sheet for sore throat (acute pharyngitis) as well.
The reason these numbers indicate antibiotics don't make much of a difference is not because antibiotics are ineffective, but rather that the majority of patients with these conditions have viral rather than bacterial infections.
It is still important to attend your GP early as it is their role to decide whether antibiotics will truly make a difference. Early antibiotic treatment will often be required in cases of severe disease or patients with certain co-morbidities.
Why Not Take Antibiotics Anyway?
At this stage you may be asking, "If antibiotics could help a bit anyway, why don't we take them regardless? 12 hours less is still a benefit."
This is where we have to take side effects into account. No treatment is without potential harms.
Taking the example of middle ear infections, since a majority of ear infections are self-limiting anyway, they would get better even without antibiotics. While 5 children out of 100 might get better sooner on antibiotics, 7 children out of 100 will get some side effect from antibiotics.
In other words, more children are harmed than helped! This is one of the reasons we always weigh benefits and risks carefully before deciding if and when to give antibiotics.
Past Experience of Harm
Perhaps you appreciate these facts and figures apply to the average patient, but you've had an experience where the doctor advised your child to wait and your child got so sick they had to go to hospital where antibiotics were given anyway. As a result, you have been very cautious to make sure your child receives antibiotics early to prevent that from ever happening again.
Or it seems like you or your child always crash hard when sick and you feel routine early antibiotics will prevent a devastating infection.
I truly empathise with patients or parents who have these concerns. Rest assured that GPs who have time to listen and understand your concerns will aim to individualise their management by taking unique patient factors into account. There are certainly valid reasons to give early antibiotics based on certain clues on history and examination. Meanwhile, there are also cases, particularly in mild disease, where it could be more appropriate to hold off.
There are many opinions, beliefs and experiences that colour our perception of the right approach, whether that be something as common as whether to give antibiotics, or perhaps a bigger medical decision.
Where there are questions or differences in opinion, I always see this as further opportunities for engagement and education. So next time you're given a script (or not given a script) and you're not fully certain, make sure to share your concerns.
Patient curiosity and openness to engage is so important. Our duty as GPs is to provide a listening ear to discuss your perspectives and ensure all your questions are answered.