UPDATE: According to a study in the October 2014 issue of Pediatrics, published online September 15, as many as 11.4 million antibiotic prescriptions written for kids and teens in the US each year “may be unnecessary.” The authors of the study concluded that doctors "urgently need" better diagnostic tools or tests to quickly distinguish viral illnesses from bacterial ones (similar to the rapid strep test for throat infections).
Before he had reached his second birthday, little Alexander Khalil* had been prescribed six different rounds of antibiotics, all to treat his chronic ear infections. Two different prescriptions gave him rashes—although a third worked without incident—and some of the medications have stained his teeth with little white spots. (Tetracycline and doxycycline can stain teeth in kids younger than eight.) His mom, Mouna Khalil,* is desperate to stop her son’s pain, but she also believes there has to be a better alternative to all these drugs. From her home in Montreal she’s seen scary news reports explaining that the more antibiotics you take, the more at risk you are for developing something called antimicrobial resistance (AMR)—a phenomenon in which some of the bacteria in our bodies develop resistance to treatment. This leads to even worse infections, because they don’t respond to any drugs on the market. Khalil wonders if the antibiotics she’s been giving her son could cause him serious long-term health problems—and add to a worldwide crisis.
The post-antibiotic era
While no one will deny the life-saving abilities of antibiotics, in April of this year the World Health Organization (WHO) announced that if we don’t change the way we produce, prescribe and use them, we will enter a “post-antibiotic era.” Margaret Chan, the general director of the WHO and a maternal and child-health doctor, explained what’s at stake during a keynote address at a conference on combatting antimicrobial resistance: “Things as common as strep throat or a child’s scratched knee could once again kill. Some sophisticated interventions, like hip replacements, organ transplants, cancer chemotherapy and care of preterm infants, would become far more difficult or even too dangerous to undertake.”
How does over-prescribing happen? When parents come to the doctor’s office or ER with a screaming child suffering from a sore throat or earache, it’s not immediately apparent whether they have a viral or bacterial infection. Considering antibiotics don’t work on viruses, and some bacterial infections will go away on their own, often the best course of action is to wait 24 to 48 hours to see whether the symptoms get better or worse. Yet, some doctors prescribe the antibiotic right away, feeling pressured by parents who just want their child to get better. Or, doctors worry that they won’t be able to schedule a follow-up within 48 hours, so they send families home with a prescription just in case, even if it’s not ultimately needed. Many of these drugs are “broad spectrum” instead of targeted—meaning they can wipe out many kinds of microbes indiscriminately, getting rid of the bad micro-organisms along with the trillions of good ones a healthy body needs. This is why the WHO is asking both doctors and patients around the world to use antibiotics only when absolutely necessary.
Khalil has been reading up on home remedies instead. “But I grew up in a completely medicated environment—my mom is a pharmacist—so when I talked to her about my concerns, she was pulling her hair out,” she says. A neurologist friend also counselled Khalil against withholding antibiotics from Alex. “She said, ‘Are you crazy? I’ve seen people die from infections. You have to treat it.’” Amid all the confusing advice, Khalil is also contemplating having tubes put in her son’s ears, which is often recommended for kids who suffer from multiple middle ear infections and are experiencing hearing loss or speech delay. Although she’s anxious about the surgery, she feels she needs to weigh those fears against the ramifications of antibiotic overuse.
Read more: The ear infection debate>
Who's getting sick?
AMR is now present around the world. Some of the antibiotics previously used to treat tuberculosis, HIV and pneumococcal meningitis are no longer working, reports the WHO. And, in at least 10 countries, there are now cases of gonorrhea that cannot be killed by any antibiotic on the market. While a gonorrhea or TB infection is not something most Canadian children are faced with, our kids are susceptible to “superbugs”—when bacteria that cause urinary tract infections, bloodstream infections, skin infections and more, have become resistant to multiple antibiotics. Many of these bugs started and remain in hospitals, but some, like methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile (C. diff), are spreading in communities. Most at risk are people with weakened immune systems, like the very young and the very old, and those who live in close quarters, like hospitals and nursing homes. Daycares and locker rooms are also breeding grounds.
For Claire Krawczyk, of Thornhill, Ont., two courses of broad-spectrum antibiotics wreaked havoc on her system during an already stressful time. When Krawczyk was undergoing IVF treatment, her fertility clinic prescribed her two different antibiotics. (Some fertility clinics use them during embryo transfers to prevent pelvic inflammation and uterine infection.) “I was taking so many drugs at that time,” she says. “This was just another one on the list.” While home on bedrest after her embryo transfer, Krawczyk began to experience continuous diarrhea, lasting for weeks. She was eventually diagnosed with antibiotic-associated C. difficile. (The C. diff spores lie dormant inside the colon until an antibiotic wipes out the other “good” bacteria that normally prevent C. diff from transforming into its infectious, disease-causing form.) Finding the right treatment was difficult. Not only is C. diff bacteria resistant to some antibiotics, those that do work aren’t recommended during pregnancy, and, by this time, Krawczyk had found out she was expecting. Between the diarrhea and morning sickness she couldn’t keep much down, and lost 15 pounds during her first trimester. “I really thought that the baby and I were not going to make it,” she says. Doctors gave her the antibiotic vancomycin to clear up the infection, but it wasn’t until the four-month mark, when Krawczyk’s brother-in-law suggested probiotics—dietary supplements of live micro-organisms that restore balance to the digestive system—that she was able to eat again without being sick. She recovered fully, and was relieved to deliver a healthy baby girl. She later learned not all clinics recommend antibiotics during IVF. Looking back, she says, “It was preventative overkill.”
There are alternatives to antibiotics, says Cecil Horwitz, an acupuncturist and herbologist with the Whole Family Health clinic in Edmonton. Although he doesn’t discount the need for antibiotics when appropriate, he often uses Chinese medicinal herbs and acupuncture to treat children’s ear and sinus infections, whether they are bacterial or viral. “Parents come in and tell me, ‘I have this prescription, but I don’t want to use it yet.’ Often one or two needles around the ear will help a child in pain.” Simple home remedies, like a warm tea bag held behind the ear, says Horwitz, can work wonders.
For those facing antibiotic-resistant bacterial infections in the gut, like Krawczyk, Horwitz also suggests his patients try taking probiotics, which you can buy at a health food shop or drugstore. “Often, I will first recommend eating fermented foods or non-sugared yogurt—great natural sources of good bacteria. Lay off sugar as well. Then I recommend a good quality live strain.” While there are plenty of contradicting studies about probiotics, they are considered safe during pregnancy, and three different strains (S. cerevisiae boulardii, Lactobacillus rhamnosus GG and Bacillus coagulans GBI-30) have been proven to reduce infection risk while taking antibiotics and shortly afterward.
What you can do
The WHO isn’t advising doctors to avoid prescribing antibiotics if and when a child truly needs them, but we can be more careful. The next step in AMR prevention is to ensure patients take the entire course of medication—something a third of Canadians fail to do. Why is this important? Because an incomplete antibiotic course may kill some, but not all, of the pathogenic bacteria—and the surviving bacteria can become resistant. “Those leftover antibiotic pills end up in the cupboard,” says Val Montessori, an infectious diseases specialist in Vancouver. “And then people give it to their cousin who has a cold—that drives me nuts.” A systemic review of studies on this topic also found that a quarter of patients have used old antibiotics from the medicine cabinet after self-diagnosing, without knowing whether their illness is bacterial or not. This is why doctors are hoping to decrease the amount of unused medication and antibiotic exposure by prescribing new, shorter antibiotic courses. Five-, three- or even one-day regimens—instead of the typical seven to 10 days—are now being tested. (This isn’t something you can improvise on your own, however. Always follow your doctor’s instructions and take the full course prescribed.)
Read more: Hands off the antibacterial soap!>
Montessori is also mom of three, and she has one key piece of advice for keeping your family bug-free. “I am fanatic about hand hygiene. We have hand sanitizer in all the cars, in the kids’ backpacks. We clean our hands 10 times a day. After the grocery store—clean. Home from church—clean; from school—clean. And those indoor play spaces—they make me shudder.” Use alcohol-based hand sanitizer, not the antibacterial kind, she says. “While alcohol-based rubs aren’t active against all microbes, the resistance isn’t the same as the resistance that results from antibiotics and anti-bacterial products. They don’t contribute to the same issue.”
Here in Canada
Canadian experts are assuring parents that the AMR situation here in Canada is far from dire. “It’s uncommon that a healthy person who hasn’t been in hospital—and who hasn’t been travelling in developing countries that have a high prevalence of resistant bacteria—will be infected,” says Nicole Le Saux, an Ottawa paediatrician and infectious diseases physician at the Children’s Hospital of Eastern Ontario. “The vast majority of infection in children is easy to treat with the antibiotics we use today.” She credits Canada’s high vaccination rate, strict regulation of medications and physicians who are judicious in how they prescribe for children. (In some other countries, antibiotics can be purchased without prescription.) “Although we have these fears that the WHO correctly puts out there,” says Le Saux, “it’s a warning signal.”
That may be the case in Canada, but the AMR horror stories are not as far away as you might think. In 2003, health officials in Texas became alarmed about the spread of MRSA in otherwise healthy people. While the MRSA bacteria can be found just about anywhere, including on skin and surfaces, it usually only causes infection in those who are immune-compromised.
Bethany Burke, a teenager from Austin, Texas, was an exception. One morning in 2010, she noticed a bump-like blemish on her head. “I was 15 years old, so I thought it was acne,” she says. Later that day, she and her family boarded a plane for a vacation to the coast of Oregon. An hour after landing in Portland, Bethany’s bump, along with two new ones on her nose and eyelid, had morphed into pus-filled abscesses and engulfed her face. They rushed to the closest hospital immediately. The doctors there suspected it was MRSA, took a culture and prescribed an oral antibiotic, then encouraged the Burkes to continue on with the vacation. But Bethany’s condition worsened over the next two days. They went back to the ER (in different towns) twice. She received two more antibiotics through an IV as the abscess on her eye threatened to cause permanent vision loss.
The Burkes flew back to Austin to see an infectious diseases expert, and received positive test results from the culture taken in the Portland ER: It was definitely MRSA. Bethany battled recurring infections from the summer of 2010 onward. Eventually, the MRSA was slowly brought under control, and doctors were able to save her eyesight. “But that was just the beginning,” says Bethany’s mother, Melissa Burke. For two years, Bethany was sick with various other undiagnosed illnesses: fevers, rashes, dizziness, problems with vision, lethargy, loss of appetite, sinus infections, joint pain and swelling. At times she couldn’t walk, and for a six-month period, she rarely left the house, except for doctors’ appointments. She was tested for mononucleosis, Lyme disease, rheumatoid arthritis, tumours and more. Melissa had to quit her job as a teacher, and Bethany had to repeat a year of school. When the tests came back negative or inconclusive, the doctors just kept prescribing antibiotics. It was Bethany who eventually took a stand and said, “I won’t take any more antibiotics.” And that’s when, over time, she started to get better. Under the direction of an osteopath, Bethany took vitamin and mineral IVs, was treated by massage therapists and acupuncturists, and changed her diet to include probiotic supplements and food with live cultures. Her symptoms improved within two months of stopping the antibiotics and then disappeared after six months. She has been symptom- and antibiotic-free for two years, and graduated from high school this summer.
Even if we all drastically reduced our antibiotic intake, exposure—through the environment and through the food we eat—will still be an issue. Resistant bacteria is already present in our water supply, thanks in part to people flushing medications and to the antimicrobials in soaps, hand sanitizers and detergents. Farm animals also develop resistant bacteria when they are fed antibiotics to promote growth and prevent illness, and that bacteria moves from farm to fork. Only this year have Canadian producers begun to phase out the use of antibiotics for animal growth promotion (almost a decade after the European Union banned it outright). Buying antibiotic-free pork, beef, poultry and dairy is one way to send a message to the agriculture industry that we don’t want antibiotics in our food. While doctors don’t yet know how much of a difference eating antibiotic-free makes to an individual’s health, says Montessori, “it’s good for the world.”
Meanwhile, researchers around the world are working to battle AMR. Faster bacterial screening tests being developed will allow doctors to give antibiotics only when needed. In May, University of British Columbia scientists announced they had discovered a molecule that can prevent many different kinds of bacteria (including antibiotic-resistant kinds) from bonding together, a frequent cause of infections. However, when it comes to the development of new antibiotics that could replace the older, ineffective ones, there are very few in the research and development pipeline—pharmaceutical companies de-prioritized that area of study years ago. “You can make a lot more money with a cardiac drug that someone is going to take every day for the next 30 years than an antibiotic that someone is going to take for a week,” says Montessori.
It’s debatable whether new drugs are even the answer. New antibiotics can be more expensive, may have more side effects and bacteria can develop resistance to them, too. For now, it seems, the onus is on us: Take antibiotics only when needed and always finish the full course. While the wait-and-see approach is much easier said than done when your child is sick or hurting, remember that when it comes to AMR, parents’ insistence on getting meds—and finding a swift solution—is a big part of the problem. Sometimes, we just have to be patient and let our kids heal.
*LAST NAME HAS BEEN CHANGED.
A version of this story originally appeared in the September 2014 print issue with the headline, "Bad medicine?" on p. 35.