This article is part of a video series with Dr. Changa Kurukularatne, a specialist in infectious diseases and internal medicine; he is a father of four. Dr. Changa has worked in multiple countries from the U.S. to New Zealand and Singapore.
Dr. Linnea: You mentioned antibiotics, and I feel that sometimes we have a difficult time in understanding the healthcare provider’s decision on that topic. Sometimes when we feel that it’s necessary and the healthcare provider says, “No, let’s wait and see,” other times there’s a prescription for an antibiotic, and we feel like maybe it’s a little bit too much. So, how do we handle those situations?
Dr. Changa: Well, that’s a very, very, very real problem. And I used the word “problem” here quite consciously because antibiotic usage is a global problem. Mostly because it’s overprescribed but there are some situations where antibiotic use should have been initiated a lot sooner. So, in both directions, if you use too much of it, or if you’re too late in starting it, the consequences could be very bad. But, for the most part, and there are some caveats here, if it’s a child with a normal…maybe normal is not a good word in anything. I’m trying to delete that word from my vocabulary.
But if it’s a child or it’s a functioning, robust immune system…so there are no immune-deficiencies that the child is born with, so certain genetic conditions, or HIV, or chemotherapy, all of those things, certain autoimmune conditions, they alter the immune system. So if we just set those cases aside, if we’re just speaking in general terms of children with functioning immune systems, most infections, I would say 9 times out of 10, are due to viruses. And for viruses, the vast majority of them, you don’t need any antibiotics.
Now, providers are trained, hopefully, to identify based on their experiences as well as some criteria whether the given infection is a virus or bacteria. I personally take it one step further. My own internal algorithm is, “Okay, this could be a virus, this could be a bacteria,” but what I’m really keen on is, is this infection either life-threatening or has the potential to have bad consequences?
And why I choose that is that there are some bacterial infections that we are able to clear without antibiotics, and I’ve done this myself. I’ve had very bad sinus infections where just out of curiosity, I’ve done a sinus consult on myself and it’s loaded with a certain kind of bacteria, and if you open most textbooks it will say, I’ll treat with this antibiotic. But because my immune system, thankfully, is working reasonably well and I had created my own sinus infections that have been proven to be bacteria without antibiotics. And I would do steam ventilation and really focus on the plumbing aspects of the disease.
So, the message here is that antibiotics are extremely important in certain situations. I don’t think anyone would appreciate that more than an infection specialist because we have seen how devastating infections can become. But at the same time, we also see the consequences of antibiotic misuse. So, what I would suggest parents do is to have an open dialogue with your provider about this issue.
This is too complex to “teach” a mom or a dad to figure out, does your child need antibiotics or not? I think that would be not ideal for us to do. But what is ideal is to convey the message that not all infections need antibiotics. And that in fact, the majority of infections that we encounter in childhood, the vast majority of them, especially if many people in the same family or the school come down with it, they have viruses, and for viruses, it’s usually supporting therapy, nutrition, and hydration.
So, it’s very difficult even for experts to discern sometimes. And I’ll give you a very, very life-example of meningitis. Meningitis, it’s a brain infection. The days before meningitis, everything looks like a regular viral infection. So that’s when we must fall back on those green light things. If your activity is normal, if your consciousness is normal, if the child is drinking well, peeing well, then you’re fine, but if any of those things change, then that’s the time to think about, should we go to the doctors now?
Along those lines, I encourage people to find healthcare providers that are willing to engage with you in these conversations. If your doctor or your practitioner is too busy to explain this to you, or to kind of go through the rationale, which doesn’t take too much time, it just takes a little bit of engagement, and if that’s not your satisfaction, and then I say find a provider who is willing to go over these with you and to answer your questions as a parent. And, a lot of times, in my own practice, parents have requested antibiotics and I have withheld, and that takes a lot of dedication on the part of, “This is why I don’t think we need antibiotics now. That may change in three days but if we give antibiotics at this stage, these are the things that will happen.”
There’s a lot of emphasis on the microbiome. That’s our ecosystem of other living things in our body, on our body. And if we take either by cell count or dry weight, actually there are more bacterial mass in our body than human cells, so we are actually more germ than human. So, if someone’s goal is to get rid of germs, then that really goes against our very existence. So managing this microbiome, invested in it is recognized now more than ever. And even a single course of antibiotics has the potential to alter this microbiome and sometimes permanently.
So, I want people to think of the good guys, the good bacteria that live on your skin, that live in your mouth, that live in your intestines, they are there to keep you healthy. And yes, the bad guys can take over sometimes, and yes, sometimes you will need antibiotics, but every other time that you take antibiotics that you don’t need, you’re killing the good guys, and you’re setting up the opportunity for bad guys to get even stronger and take over.
I’m using the words “good and bad,” so that people can understand, In real life it’s a spectrum. But managing your microbiome is now more important than ever. And the other day someone asked me about the appendix, “Well, it’s useless, right, we can just take it out?” And I said, “Well, there’s a school of thought, and I subscribe to that school of thought, that the appendix actually works as a mini-storage unit that stores representative bacteria from your own intestines so that, after an episode of diarrhea, the appendix will then help repopulate your intestines with your unique fingerprint of your gut microbiome. So I want everyone to think along these lines. And that will really help in the journey and the discussion around antibiotics.