Managing patients' antibiotic expectations

Five-year-old Billy is a Pākehā boy, who lives with his parents and eight-year-old brother on a small, lifestyle block in Canterbury. Billy has a five-day history of sneezing, runny nose, nasal congestion and sore throat. For the past three days he’s had a cough, which was initially dry but is now productive with yellowish sputum. Billy's mum has administered several rapid antigen tests, which have all returned negative results. The family received COVID-19 and influenza vaccinations two months ago.

Mum tells you they are all going camping for a week and she thinks Billy should start on antibiotics “just in case” he has an infection that could worsen while they are away.

On examination, Billy has erythema of the posterior pharynx with tonsillar enlargement but no exudates. The tympanic membranes are mildly erythematous bilaterally, with no evidence of fluid or retraction. There is no palpable lymphadenopathy in his neck, and lung auscultation reveals only a few scattered expiratory wheezes bilaterally. He does not have a fever.

Billy’s signs and symptoms show strong evidence of a viral respiratory tract infection. There are no signs suggestive of bacterial infection at this time, so you are of the opinion he does not require antibiotics.

How do you explain to Billy’s mum that antibiotics are not needed, given her expectation for them?

Reassure Billy’s mum that he has a cold that is caused by a virus, and that viral cold infections get better of their own accord, usually within a week.

Billy does not have any features of a bacterial infection – his sore throat will be due to his cold. Explain that antibiotics are not effective against viruses and will not reduce the time taken for Billy to get better. However, he may benefit from some rest and symptom relief such as:^1,2

• warm honey and/or lemon drinks
• ice blocks or cool drinks
• paracetamol or ibuprofen (these should be dosed by weight)
• gargling with a warm saline solution (1 teaspoon salt in 250ml water) if Billy is capable of gargling
• throat sprays, if appropriate for Billy.

Medicated throat lozenges may not be appropriate in a child of Billy’ age because of choking risk.

Together with Billy’s mum, devise a clear plan of action. Provide a printout of advice and red flag information, such as that from Health Navigator or KidsHealth. Let her know that these patient handouts include the Healthline number (0800 611 116), which is a 24-hour, seven-days-a-week service providing free health advice.

Stress that the development of red flag symptoms is highly unlikely but if any were to occur, she should take Billy to the nearest hospital. Red flags for children with viral respiratory tract infections include:^1,2

• drooling/dribbling – indicates difficulty in swallowing saliva
• difficulty breathing – struggling or grunting when trying to breathe
• bluish lips or tongue
• stiff neck
• extreme drowsiness or confusion.

Additionally, Billy’s mum should seek out a healthcare provider for review if Billy:^1,2

• develops a very high temperature
• is unable to drink much or has a dry mouth, difficulty swallowing or reduced urine output
• develops severe pain at the back of his throat
• breaks out in a rash
• has increased snoring episodes or stops breathing occasionally while asleep
• has a cough lasting more than four weeks
• has no improvement in symptoms after 48 hours.

Billy’s mum is still not convinced that antibiotics are not needed, and asks if it could be strep throat?

Explain to Billy’s mum that he has features of a cold (caused by a virus) such as a runny nose and a productive cough, and these symptoms would be unusual in strep throat, which is caused by bacteria. Additionally, antibiotics would be used for strep throat only if he was at high risk of developing rheumatic fever - a rare complication of a strep throat infection. Given that Billy’s risk of rheumatic fever is very low and he is not significantly unwell, he doesn’t require a throat swab to check for strep.^3,4

Explain that it is important to use antibiotics only when needed to avoid possibly experiencing adverse effects such as diarrhoea, and to limit the development of resistance and safeguard their usefulness.

Billy is of European ethnicity; how would his management change if he were of Māori or Pacific ethnicity? What other history would be important?

Māori or Pacific children are at increased risk of developing rheumatic fever, relative to children of other ethnicities. Risk criteria for rheumatic fever include:³

Personal, family or household history of rheumatic fever or two or more of:

• Māori or Pacific ethnicity
• aged 3–35 years (with emphasis on children and adolescents)
• living in poor or crowded living conditions.

If Billy was a Māori or Pacific child, he would have two of the high-risk criteria (age and ethnicity). Early treatment of his sore throat would be needed as antibiotics can stop the development of rheumatic fever following infections caused by Group A Streptococcus. Billy’s throat would be swabbed to check for GAS and he would need a prescription for 10 days of empiric penicillin or amoxicillin. If the swab was positive for GAS, Billy would need to be isolated at home for 24 hours after starting the antibiotics, which should be continued for the 10 days. If the swab was negative, the antibiotics would be stopped.³

It would be important to know if anyone else in the household or family was sick. Strep throat is spread through coughing and sneezing, and sharing cups and utensils. The incubation period is between two days and one week. If someone in the family has strep throat, often others in the household are also infected, so it is recommended that all symptomatic household members have their throats swabbed, especially if they are children or adolescents.³

Prescribers, including pharmacist and nurse prescribers, can use the EPiC dashboard to freely access their own prescribing data. They can compare their data with practice data and national data. Non-prescribers can also access the online EPiC dashboard to explore national dispensing data.

Amoxicillin + clavulanic acid dispensing is high

The addition of clavulanic acid to amoxicillin extends amoxicillin’s spectrum of activity, adding cover against anaerobic and gram-negative bacteria. In primary care, amoxicillin + clavulanic acid is recommended first-line for only a small number of clinical indications.⁶ Generally, these are:

• human and animal bites
• diabetic foot ulcer
• mastitis in males and non-lactating females.

Given these few first-line indications, low levels of amoxicillin + clavulanic acid dispensing in the community would be expected. However, data from the EPiC Antibiotics dashboard clearly show high use of amoxicillin + clavulanic acid in Aotearoa New Zealand. In fact, this drug combination remains the second most used antibiotic after amoxicillin.⁷

There is a seasonal shift in prescribing

The EPiC dashboard also shows a seasonal shift in antibiotic prescribing, indicating they are likely being used inappropriately, and possibly for viral illnesses, over the winter months.⁷

Amoxicillin + clavulanic acid should not be used to treat community-acquired pneumonia; this condition is most commonly a result of gram-positive bacteria. Treatment guidelines suggest community-acquired pneumonia can usually be sufficiently treated with amoxicillin alone.⁶

Including indications on prescriptions may reduce use

Before prescribers provide a script for amoxicillin + clavulanic acid, they should be considering whether this extended cover is required for the infection they are treating.

One of the World Antimicrobial Awareness Week recommendations, from a WHO initiative, is for prescribers to add a meaningful indication to a prescription for antibiotics. This prompts the prescriber to reflect on their choice of antibiotic and facilitates communication between healthcare providers and patients.⁸

Infectious diarrhoea is more likely

Nearly all antibiotics can increase susceptibility to colonisation and overgrowth of toxin-secreting Clostridioides difficile (previously called Clostridium difficile) but amoxicillin + clavulanic acid along with cephalosporins, fluoroquinolones and clindamycin increase risk to the greatest extent.⁹