When Do I Need Antibiotics?

Author: Ryan Hassan, MD, MPH, Boost Oregon's Medical Director and pediatrician working at Oregon Pediatrics in Happy Valley.

Antibiotics are a class of medication that kill bacteria. They can usually help us feel better from a bacterial infection within a couple of days, and allow us to treat severe illnesses of the brain, lungs, and blood that often used to be lethal. However, antibiotics only work to treat infections caused by bacteria. They are completely useless against viral illnesses, which cause the majority of illnesses that humans suffer from.

A large part of my job as a pediatrician is diagnosing and treating sick children. The most common illnesses I see in my clinic are colds, ear infections, intestinal tract infections, and eye infections. In over 90% of cases, these illnesses are best treated with rest, fluids, and pain management.

Unfortunately, many sick children receive antibiotics they don't need. In 1995, there were 1.2 antibiotics prescribed per child each year (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC450361/). Today, 30% of antibiotics prescribed outside of hospitals are unnecessary (https://pubmed.ncbi.nlm.nih.gov/29202142/).

So why are we prescribing so many antibiotics?

Because it's easy to do. When someone comes in feeling sick, it's easy to say, "here, take this medicine and you'll feel better soon," than to take the time to explain why they may be better off without a medicine, especially when patients expect to be prescribed something to make them feel better.

Additionally, our for-profit medical system heavily incentivizes overprescribing. Doctors and pharmacies make more money when patients take antibiotics. And if a patient needs antibiotics and doesn't get them, they could get worse later, which could lead to lawsuits. A doctor has little to gain and a lot to lose by taking extra time to explain to their patient that they'll probably be fine without an antibiotic, instead of just prescribing a pill and sending the patient on their way.

This is not to say that healthcare providers are intentionally prescribing unnecessary medications. Medicine is just as much art as it is science, and as such it is often difficult to know for certain whether an illness actually requires antibiotics are not. In this situation, many providers feel more comfortable prescribing an antibiotic to avoid the risk of a progressing bacterial illness.

Antibiotics also feel useful when we take them, even if they aren't. In children, viral illnesses tend to worsen for 3-5 days and then improve for the next 3-5 days. By the time patients come to my clinic, they've usually already been sick for 3-5 days. That means that whether I prescribe an antibiotic, recommend a homeopathic medicine, or tell them to read their horoscope, they will still get better in a few days. If I prescribe an antibiotic, though, it will kill a lot of the beneficial bacteria in their body, possibly cause diarrhea, and then get into our water and soil where it will contribute to the rapid spread of antibiotic resistance across the globe.

Why does this matter?

Besides wasting our time and money and giving us diarrhea, unnecessary antibiotic prescriptions are causing a significant amount of harm to our bodies and our planet that we still don't fully understand. In 1929, just one year after he discovered penicillin, Alexander Fleming warned that many bacteria were already resistant to it. In the century since then, we have dumped several billion pounds of synthetic, nonbiodegradable antibiotics into our planet's soil and water that have led to massive changes in the interconnected system of microorganisms that are essential to life as we know it (Frontiers | Antibiotics in the Soil Environment—Degradation and Their Impact on Microbial Activity and Diversity (frontiersin.org)). Bacteria have actively adapted to the antibiotics we have exposed them to in order to survive, and they are so good at it that by 1995, 95% of the bacteria staphylococcus aureus were resistant to penicillin, up from just 14% in 1945 (Plant Intelligence and the Imaginal Realm. Stephen Harrod Buhner. p 98). Antibiotic resistant infections are now the third leading cause of death in the US, and were associated with nearly 5 million deaths globally in 2019 (National Estimates for Antibiotic Resistance | CDC).

Should I decline antibiotics when my healthcare provider recommends them?

Not at all. Antibiotics can reduce the pain and duration of bacterial infections, and reduce the risk for complications, including hospitalization and death. The best way to decide whether you or your child should take an antibiotic for an illness is to have a conversation with a healthcare provider you trust, and talk through the risks and benefits together.