What is so dangerous about the excessive usage of antibiotics?
First of all, the danger applies to the patient. Excessive use of antibiotics can upset the intestinal microflora as well as affect the overall organism in general. If we administer antibiotics without thought or unnecessarily, the sensitivity of various microorganisms to antibiotics decreases. This is something that has been happening for a long time and has become a major problem. According to the National Antibiotics Program, which was launched in 2009, the effectiveness of antibiotics severely impacts the quickly spreading resistance of the microbes which in turn increases mortality rates and the safety of patients.
However, this is not the only problem. Antibiotics affect the intestinal microflora and, according to the latest studies, using antibiotics in children up to one year of age increases the likelihood of intestinal inflammation five-fold and also demonstrates that a one-week treatment with antibiotics can cause a decrease in the numbers and spectrum of beneficial bacteria forming in the microflora. Furthermore, there is the danger of inflammation of the colon known as colitis, which is caused by the Clostridium difficile bacteria. Further allergies can also form as a result. It is therefore important to prescribe antibiotics with care and both the medical community and the public should be better informed. More than 90% of all antibiotics are prescribed at the primary care stage and often unnecessarily. The responsibility for preventing complications often lies with pediatricians and general practitioners.
There is much talk today about the bulk of the immune system residing in the intestines. Is that true?
Yes, this is why we recommend administering probiotics as they not only affect the intestinal microflora after antibiotic treatment but rather impact the entire body. Allergists recommend using probiotics to strengthen the immune system, primarily with children.
Can you explain better the connection between intestinal microflora and the immune system?
The intestines serve not only to digest food, but must also fight pathogens, which are ingested with food. Their connection to the immune system is therefore clear. The intestines by themselves are a complex organ. In fact, they are 7–10 meters long; their surface area is the size of a tennis court and the bacteria that inhabit it weigh approximately 1 kilogram. These bacteria are referred to as the human microbiome and are essential to one’s health. Without any exaggeration, we can state that these “good” bacteria are an essential component of ourselves, serving many crucial functions. The human microbiome is composed of 100 billion microorganisms, which is more that 10x more than the amount of cells in our body. Together these organisms contain 100x more genes than the human genome itself. The human microbiome is not only found in our intestines but also on our skin, in our respiratory system or in the genitourinary system and saliva. For example, one milliliter of saliva has approximately 1 billion bacteria. All of these essential bacteria are, of course, negatively affected by antibiotics.
What do these “good” bacteria contribute to?
For example, if they exist in the correct balance, they produce the K and B12 vitamins which have an irreplaceable role in the digestive process and in the immune reactions of the entire organism. They prevent the formation of pathogens. Deviations in the number of these organisms affect the regulatory immunity mechanisms and lead to allergies, autoimmune diseases and also to obesity. Much of it has yet to be discovered. The human microbiome is undergoing heavy observation. Continued research should help us better understand what particular bacteria are associated with which disease.
What to do to make sure that the beneficial bacteria functions correctly?
Caring for the human microbiome begins at birth and early childhood. For example, an important aspect is vaginal birth itself. In the womb, the environment is sterile and the intestines of a baby are also sterile. Through birth, the colonization of bacteria begins and the process jumpstarts the process of the immune system. Breastfeeding also plays an important role. Children who were breastfed have differently composed bacteria colonies than those who were fed formula. Yet another factor is a healthy diet. Preservatives not only kill bacteria in food products, but can also affect the bacteria in the body. A negative impact can also be observed with antibiotics and their application should be approached with care.
As far as intestinal microflora is concerned, what implications can antibiotics have on practical health?
It can affect the immune system, the intestinal microflora, a superinfection of a different bacteria can occur which becomes very difficult and complicated in terms of treatment. In some cases, states where inflammation or autoimmune processes occur can signify long-term health problems. In general, it can be said that excessive use of antibiotics in early childhood can result in inflammations and other disease such as Crohn's disease in adulthood. Sometimes, due to excessive use of antibiotics, the beneficial bacteria colonies are wiped off and other non-desired bacteria flourish. In normal circumstances, these would not be able to establish themselves. These can then result in significant problems – major inflammation, bleeding and diarrhea.
Can you provide an example from your practice where you came across the side effects of antibiotics?
Last year, a 12-year-old boy, was diagnosed with a joint infection and suffered from high fever. He was hospitalized and subjected to a relatively intense and comprehensive antibiotic treatment. Approximately three weeks after the problem seemed to have been solved, the boy started having bloody diarrhea and cramps in the stomach, was losing weight and pale. A thorough examination revealed that the boy was suffering from inflammation of the intestines. The cause of this was a dangerous spread of the Clostridium difficile, which is considered the most common cause of diarrhea associated with antibiotic use. These bacteria commonly occur in the human organism, but when they overbreed, the bacteria start releasing toxins, which can cause bloating, constipation and diarrhea associated with major pain in the stomach. The boy went through very much and it was very difficult to get rid of the bacteria. The treatment took several months and we had to order a drug from abroad that cost tens of thousands of Czech crowns and which was not paid for by the insurance company. The medication worked, but it was a very uncomfortable and complicated situation.
Why are the risks associated with the excessive use of antibiotics higher in children than in adults and how much greater are the risks for children?
The risks are higher because the intestinal microflora is more sensitive in children than in adults and the usage of antibiotics can have more long-lasting effects. With small patients, we have to be more careful – with the antibiotic indications, the length of time, the type of antibiotics and how often the antibiotics should be given.
Why have antibiotics become so popular?
In our hectic times, the fastest and simplest solution for all of the infections which the patient encounters may appear to be the use of antibiotic treatment. This, however, is not the case. Often, adults prefer to be prescribed antibiotics instead of trying to treat the disease and get well by staying at home in bed and trying to cure illness with the standard resources available in the home. As a result, these people prefer a quick solution that is not correct.
Does the unease of doctors and mothers play a role in perceiving antibiotics for children as a “certainty”?
Yes, definitely. Our task is to make sure that such perceptions are negated and inform everyone that common infections such as a cold, coughs, bronchitis and inflammation of the middle ear are usually viral. Application of antibiotics in such cases is therefore not effective at all and this should not be the case.
If antibiotics are prescribed for a disease for which they are not required, for example a common flu or a cold, is it entirely unnecessary to use them? Does that mean that the body heals itself?
Yes, it is unnecessary. The only case in which this should be considered is if we fear a superinfection – meaning, that as a result of a viral disease, a bacterial infection also occurs and causes complications. In such cases, antibiotics are often used. Otherwise, they should not be.
What options does the doctor have to make sure he/she administers them correctly?
Here, two options should be considered. First of all, the decision whether to implement antibiotics and use it as part of the treatment. The second is what type of antibiotics should be used – there are many narrow-spectrum and wide-spectrum options available.
The first choice is derived from the history of the disease, i.e. the clinical findings at the day when he/she undergoes an examination and the overall health state, followed by some form of check-up. This depends on the doctor’s own judgment. The best option is to carry out a CRP, CBC, sedimentation test, a streptococcus test and other related tests. These are quick tests where the results are known either immediately, or on the same day. These can form the basis for deciding whether antibiotics are suitable or not. The second choice depends on whether this is a recurring disease or whether the patient does not suffer from allergies and the like.
In what cases, when the child falls ill, is it necessary to prescribe antibiotics?
This is not easy to answer. This depends on how old the child is, what the health condition is, etc. There are many factors that play a role. However, it could be said that for children up to one year of age, antibiotics should only be used in rare cases, supported by tests to ensure that the antibiotics are truly needed. With children in their school years, most illnesses they undergo are viral in nature. Yet again, antibiotics should be applied only when needed and when it is supported by one or two tests to ensure that the need is there to use them.
If normal treatment does not seem to be helping and only repeated antibiotics application does, what approach would you recommend? Are further check-ups recommended?
Definitely, such a child should undergo a basic examination by a pediatrician but also an immunological examination to make sure that there is not a problem with the child’s immune system which results in the need for repeated antibiotics use. With healthy children, this does not tend to be the case. With repeat infections, such as throat streptococcus, we also examine other members of the family to ensure that they are not carriers.
Do you associate disharmony in the family with an increased rate of sickness of your child?
It is very difficult to find a clear correlation between an acute infection and a certain psychosomatic cause. Such a connection should be considered with small children who suffer from repeated head, stomach and joint pains…in cases where all other possible causes have been eliminated and a psychological problem appears to be the problem.
Do parents pressure you to prescribe antibiotics to their child?
This usually only occurs in situations where the parents have a plan of some sort – i.e. need to leave somewhere and do not want to risk the child being ill or that the disease will become a bacterial infection etc. I always try to make sure that antibiotics are only used in the cases where they are needed and not simply just in case. If the need is not there, parents tend to go with more conservative approaches – i.e. have the option to call me during the day or at night, possibly even on the weekend. With older children, the situation is different.
Parents usually want the child to be healthy as soon as possible to make sure that he/she does not miss school. It is common however, that doctors depend on their experience and the clinical symptoms, but do not check whether antibiotics are needed. When antibiotics are not administered, it can mean that it requires more time, effort and attention. This translates to more responsibility for the doctor. However, the long-term health is important to consider as well.
Children in their pre-school years tend to be sick more often. What should parents consider to be normal and when should they start to worry?
The general rule of thumb is 10 infections per year, which to many parents is a shocking number. In fact, some form of an infection occurs almost each month. Generally, this applies to the first two years after attending school as well. At first, most parents who have not seen their children ill are confused and worried. This usually leads them to seek out a doctor often, but later learn to cope better. With an otherwise healthy child, it is advisable to stay at home for the first couple of days, checking the temperature and treating the symptoms (cold, cough) with resources available at home. A doctor will usually not prescribe anything different.
What are the most common child diseases and what treatment should be chosen?
A pediatrician usually encounters infectious diseases of the respiratory system, the digestive system or the urinary tract. This is what we encounter most of the times. It is important to have a clear-cut opinion on this and to have a clear methodology, always trying to eliminate the negative impact of various medicines and to prevent any unnecessary harm. It is equally important to ensure that children pass through this period without any complications.
What would you recommend as prevention to mothers whose children are ill often?
It is difficult to give general recommendations because the answers depend on multiple factors – what the age is, what the general state of health is and whether there are other children in the family as well. If the child is ill often, we usually recommend that the child does not frequent public places to make sure that the immune system has the time to recover. In awhile, the child can try meeting other children again. If these illnesses are frequent and require antibiotics, further examinations to shed light on any possible problems should be carried out. Toughening of the children, suitable diet, frequent physical activity and fresh air are common recommendations which have and will always play a major role.
What is your opinion of the various dietary supplements for children?
We recommend probiotics and substances to strengthen the immune systems of children that are frequently ill, do not have any immunity defect and for those who we need to slightly strengthen their body’s immune system. Probiotics and immunomodulators have a good impact and usually have very few side-effects. For a child that is suffering from certain problems, it is usually much better to treat it with such supportive medicine and substances than to apply complex drugs which have multiple side-effects. With a healthy child, we do not recommend any supplement use.
Would you recommend using probiotics and immunomodulators for children who have been treated with antibiotics?
We often prescribe probiotics along with the antibiotics and recommend that the probiotics are applied while undergoing treatment as well after the treatment has stopped. This option is used when we apply wide-spectrum antibiotics and where we know that the negative effect on intestinal microflora will be adverse because of the length of time these will be used for. We also recommend probiotics with children that suffer from repeat infections. Immunomodulators and other substances, which strengthen the immune system, should be applied during periods when the children are healthy and we are trying to jumpstart the immune system to prevent any further illness from occurring.
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