Courtney Collen (Host): Hello, welcome to our new medical series ‘Called to Care’ by Sanford Health. I’m your host, Courtney Collen, with Sanford Health News. Called to Care brings forward medical experts who can give fellow clinicians some advice and guidance they can use in their primary care practice and information about when it’s time to refer patients and families to more specialized care.
Joining me for six episodes, focusing on children’s care is Joseph Segeleon, MD. He’s the vice president and medical officer for Sanford Children’s Hospital and a leader in pediatric critical care. Glad to have you here, Dr. Segeleon.
In this episode specifically, we’re talking about decreasing antibiotic usage in urgent and primary care. Dr. Segeleon, first, tell us why you chose this topic.
Dr. Joseph Segeleon: Well, I think anybody who takes care of children and importantly takes care of children’s parents often have the issue of does my child need antibiotics or don’t they need antibiotics and that can be a real difficult judgment call. I think that our expert today will really help narrow that down and provide some valuable guidance.
Host: And speaking of, let’s welcome Dr. Fernando Bula Rudas to the conversation today. Good to see you.
Dr. Fernando Bula-Rudas: Good to see you. And thank you for having me here.
Dr. Segeleon: At Sanford Children’s, we’re really just incredibly fortunate to have some, some great pediatric infectious disease physicians who really are the experts in, in febrile illnesses and infectious illnesses for children, both in the hospital and also as an outpatient. And so that’s why I thought that Dr. Bula-Rudas’ expertise would be a great way to tip off this series and it gives some great advice for providers. Dr. Bula-Rudas, maybe perhaps we’ll start by just saying, what is a pediatric infectious disease specialist? What kind of training have you had?
Dr. Bula-Rudas: So just as he says we treat mainly infectious diseases in children. We treat both outpatient and inpatient. We combine both of our settings complicated infections in the hospital. Also we do infection prevention, the strategies to prevent healthcare associated infections and also we manage the outpatient setting, kids that do not need to be admitted and can be managed as an outpatient.
Dr. Segeleon: Thanks. I know with with my own children and certainly when you talk to other parents it seems like kids are sick a lot, especially when they’re young. And there’s a fair amount of pressure when kids have febrile illnesses, especially with whether it’s getting back to daycare, parents going back to work permission to go back to school. So I can feel for our providers on the call who really get pressured a fair amount about antibiotics. What guidance could you give, first to our providers, on when is it appropriate to give antibiotics or I think I suspect where you’re going to go more approach more importantly, when is it not appropriate?
Dr. Bula-Rudas: Correct. So it is a very valid concern for parents to think that, okay, ‘what is wrong with my child? I just feel that my child or my baby’s sick all the time, especially if a child is going to, to daycare and being exposed to too many viruses’. I take it as sometimes as being sign off like as a sign of being healthy. That means that your immune system is responding to agents, foreign agents that are coming in contact with, with that infant. And then they’re responding, you know, in a way is to say that they’re creating that immunity. So as long as they were like non-complicated in viral infections that the child, once the fever is down, is back to normal self and, and playing, that is a very reassuring sign. But I can understand the, the valid concern that the parents can have and, especially if my child is well for, you know, one week, then I feel like it’s, you know, just like boogers and you know, a runny nose for the whole winter.
Dr. Segeleon: So, I take it, you’re talking about upper respiratory infections, which kids get a fair amount of. So how do I, if I’m a provider and I see a parent and they have a URI, and there really is pressure to get back to school or where there really is pressure to get back to the daycare, how do I make the visit less transactional and lower their expectations that an antibiotic is going to one make their child better right away? And two is, is the right thing to do?
Dr. Bula-Rudas: Correct. So these type of illnesses, as I mentioned, they were mostly viral, they were mostly caused by a virus and so antibiotics are not the treatment for, for viruses. So the parent is concerned and I think one of the very important issues to manage in this type of visit is to communicate well with parents. Give them the reassurance that yes, your child is sick at this moment, may not feel well, may have like some fevers, not being in the best state of health. I acknowledge that there are some symptoms that I can manage, like the fever, like the runny nose, maybe if there’s like some cough, how to help parents manage that. But also reassure them that antibiotics would not make them feel better or would not treat the specific viral infection that they have.
Dr. Segeleon: And this is specifically after you do an exam and rule out any specific signs of bacterial infection, correct?
Dr. Bula-Rudas: Exactly. We’re talking probably with a child that about our child that the physical exam does not point into a complicated or, you know, a more serious bacterial infection.
Dr. Segeleon: Now, what about, I often get asked about temperatures, right? Fever. Is there a certain temperature that you know, parents, especially if the fever is quite high, parents get more nervous about an illness. Does temperature at all weigh into the decision about antibiotics?
Dr. Bula-Rudas: Exactly. So well, first of all, is one of the things is to have a fever. We make the recommendation of temperature above 100.4-degrees Fahrenheit. That becomes a fever. So then parents can say, ‘well, my child has, has a fever’, any temperature below that we can like probably, you know, ask the parent if they gave like any antibiotic or any medication to to lower the fever, to make sure that there was no fever at home. And then by the time they get seen, the fever has, has gone down.
Dr. Segeleon: A lot of times you do hear patients talk about that, you know, we’ve, we’ve seen children that have been on a lot of antibiotics. I think some of the things that can be used to advise parents is that antibiotics are not without their own consequences and side effects, right? So what are some of the things that we can tell our parents so that they’re more educated about the, the potential negative side effects and aspects of antibiotic use?
Dr. Bula-Rudas: Exactly. Joe, I wanted to mention some numbers to show the importance of the antibiotic prescription. So a study that was conducted by the Pew Trusts and the CDC found that in the United States, approximately 150 million visits a year and then adults and children have at least one antibiotic being prescribed in those visits. That accounts for 13% of all visits for, for outpatient visits in the U.S. And they also found it that 30% of these antibiotics that were prescribed were considered unnecessary or not indicated, based on the clinical findings on that. So, it is important to know that there is an antibiotic over-prescription in this case. And antibiotics are by no means, you know, a 100% benign medication. They carry side effects as any other medication can have. And this side effects can be, in the short term, can present in the short term adverse events, more commonly seen are rashes or GI disturbances, like abdominal pain diarrhea. The frequent use of antibiotics can develop to a more serious condition, which is the clostridium difficile colitis which is a more serious condition. But also can affect the blood cells decreasing the, the neutrophils. Some antibiotics have the risk of creating renal problems. So they are by no means benign. And then in the long term, what we are seeing as the problem of anti-microbial resistance, that superbugs…
Dr. Segeleon: Superbugs.
Dr. Bula-Rudas: Superbugs, yeah. What are the called the superbugs and one of the, you know, interesting data about, about the antibiotic prescription in the U.S. is that basically any child by the age of two, like about like one child or every child in the U.S.by the age of two would have received at least one prescription for antibiotics and in their lifetime.
Dr. Segeleon: Yeah. And I, I know the superbugs and the resistance we read about that quite a bit. I also, I know I’ve read research on how really is the single episode or a single course of antibiotics can affect the microbiome is as well. Is that right?
Dr. Bula-Rudas: Exactly. There are many studies on the, on the microbiome and especially those have been done in newborns, in premature babies, that receive antibiotics in the NICU. And these works have shown that the colonization with this microbiome, or what we call the good bacteria, is completely different than those babies that have received antibiotics early in life. To this extent, we are not quite sure what will be the impact of, of that, but certainly those differences are, are, you know, are going to create like some sort of consequences. And also, you know, and as I said in the long-term, we’re probably seeing the children that are being exposed very early in their lives to multi-drug resistant to bacteria, to the superbugs. So those are children that are going to need you know, very specific antibiotic to treat multi-drug resistant infections.
Dr. Segeleon: Well, thanks. Yeah. I, I mean, you, you can’t really pick up a magazine without reading about microbiome and the importance of your, your own flora in your gut, and certainly antibiotics disturb and can change that so I appreciate that insight. Thanks. And I think that helps give our providers who are listening information that they can use with parents because really that’s throughout the lay literature.
Okay. Let’s shift gears. We talked about when not to give antibiotics. So what are some of the things you can offer to the providers listening… What are some of the indications to give antibiotics? And if you want to do that by either severity or grade of illness, or if you want to go through some specific conditions, that’d be awesome as well.
Dr. Bula-Rudas: So you’re absolutely right. I mean we know that for example, in children, vaccines have caused a decrease in the bacterial causes of infection. I’m talking specifically about acute otitis media, about ear infections. Mainly the pneumococcal vaccine and Haemophilus influenza type vaccine have created a major impact in decreasing like this type of infections. So mostly those ear infections are going to be viral. However, there are specific indications where we want to give antibiotics in this particular situation. For example, when there is an infant, when there’s a child, less than two years of age, we have to be more cautious because of the severity and the complications that that can cause. So if we have a bilateral ear infection, that is an indication of treating with antibiotics in an infant. If we have you know, for example, a urinary tract infection that is going to be an indication to treat with, with an antibiotic.
Dr. Segeleon: What about fluid behind the ears?
Dr. Bula-Rudas: So fluid behind the ears depends on like the clinical exam. It it takes skills to make that diagnosis and to be able to visualize, and then also the severity of the, of the illness. If we have fever for more than 48 hours, if we have pain, we have to check that the child for example, is as immunized or if there’s a guarantee of good compliance and, and follow-up. So parents still can be instructed in this type of situations on like when we can wait and we can watch, and you can have a follow-up in a couple of days, and I can check the status of the ear to see if the patient needs antibiotics.
Dr. Segeleon: Great. Well, thank you. I know our in both the acute care world, as well as primary care often see children with sore throats, and the question is ‘strep or not strep … tonsillitis or not tonsillitis’? Frequently the discussion of antibiotics comes up when it comes to sore throats. Can you get shine some light on it for us, for our providers that are listening?
Dr. Bula-Rudas: Yes. So absolutely as I have mentioned, you know, many times, and in this conversation is like the number one cause of pharyngitis is a virus is like viral pharyngitis. In school age, children, and, and mainly those like four years of age and older, then they start having the classic strep throat. And that presents of course, with classic signs and symptoms that are not consistent or that do not represent a viral illness of viral pharyngitis. So when we have like this type of clinical presentation than a basic simple test, that is the, the strep test, the rapid strep test would give us like valuable information in this patient to start the antibiotic or not. So we basically have the means to, to have an answer in a couple of minutes in order to start or to prescribe an antibiotic in this specific situation. On the contrary, kids that are less than three years of age is not routinely recommended to do this test. We know for many reasons that these patients, these children do not get, or do not have the receptors to create the complications of these infections so then antibiotics or the tests are not recommended.
Dr. Segeleon: So that’s, that’s good to know. So children, less than age three routinely should not be checked for strep throat. Is that what I heard?
Dr. Bula-Rudas: Yes, that is correct.
Dr. Segeleon: Great. Okay. And what about, are there other symptoms that would lead you away from doing a rapid strep or a strep throat or throat culture?
Dr. Bula-Rudas: Cough? The nasal discharge and symptoms are mainly consistent with with a viral upper respiratory infection.
Dr. Segeleon: Great. Thank you. I guess the last thing I would want to cover is blood cultures, or when do you culture, particularly for our colleagues who are working in urgent cares or perhaps ERs, is there an indication for a blood culture in a certain population or a certain degree of illness? And do you give antibiotics when you culture? Can you, can you shed a little light on that information?
Dr. Bula-Rudas: Yeah, so that will depend especially on a specific specific situations and mainly the age of the, of the child is one important factor to consider there. Then the next factor I would say is the, the severity of the illness, how the child is presenting are the vital signs abnormal? How many days of fevers have, have there been there? Blood cultures can be very valuable in patients, immunocompromised patients who have central lines and they present to an acute care setting to determine if there is a line infection or if there’s another bacteria causing more trouble there. They’re not routinely recommended for example, a patient that that has clear signs of, of a viral URI and the fever is caused, or the fever is caused by an ear infection, we don’t necessarily need to get blood cultures in this type of situation. So to summarize, I would say mainly the age: we want to get a blood culture along with all the tests in newborns and in particular cases in some infants and toddlers, depending on the severity and the age as well.
Dr. Segeleon: Oh, I know when I, when I trained, which was just a little bit, little, few years ago, I guess when I trained we use that eight weeks, you know, a true fever in a child less than eight weeks was was a cause for alarm and some real significant evaluations. Do we still use the eight weeks or has that shifted lower?
Dr. Bula-Rudas: So as, as of now, they’re like, you know, every institution manages based on their risk, they establish their own criteria. But I would say that caught off where no one has any doubt about it as the four weeks and below, but then, you know, we have, okay, what is a five week old baby? What if the baby was not born full term, we’re dealing with some situations that, yes, we probably need to get a blood culture and further evaluation.
Dr. Segeleon: So really use your clinical judgment, especially with those infants is what it sounds like.
Dr. Bula-Rudas: Exactly.
Dr. Segeleon: Great. Well, really thank you for the information. I feel like we could talk about UTI and VCU, GS and bronchitis and pneumonia, and I think the list could go on and on, but really appreciate your insight. I know this is the pressure about to antibiotics is really a real one that affects many of our providers, and they often have those somewhat difficult conversations with parents about why they’re not prescribing an antibiotic. I guess to close up, I would ask you when should a provider refer a patient specifically for an evaluation by a pediatric infectious disease physician like yourself?
Dr. Bula-Rudas: Yes, Joe. I want to hold on that question just to you know, follow up on a comment that you just, just that you just made in terms of providers probably feeling the pressure from the parents on, on one end on antibiotics. I would say to providers that parents want your expertise, or they’re looking for your expertise and your expert advice, and they would follow most of the times, whatever, you know, a provider has to say and education and the language to communicate is key into reassuring the parents and saying your child is ill right now, but I don’t think your child needs antibiotics and offer that follow up opportunity, an alternative gave me a call in a couple of days, or I want to see you in a couple of days and see how things are going. And we’ll determine if there is the need for antibiotic.
Now going back to your question yes, we do see, you know, referrals from our community. One of the main things that, that we see is like prolonged fevers or recurrent infections. With prolonged fevers, what we see in disease referrals are patients, children who have more than one week of fever and despite laboratory workup imaging multiple physical exams, there’s no clear evidence or where this infection is coming from. So, we might be dealing with a more serious situation. And then yes, we would like to evaluate and and see what are the risks and what are the potential infections or causes for, for these fevers. Then with the recurrent infections, as we talked about that child that is probably sick all the time, sometimes those recurrent viral infections are not that concerning, but if my child is having positive blood cultures, if my child is having recurrent urinary infections or recurrent confirmed pneumonias with x-rays, then that’s something that can raise a concern. There is my child dealing with with an immunodeficiency or there’s something wrong with the immune system that they’re not able to respond well or it’s causing this recurrent infections. In the region that we live, we have infections that are transmitted by animals and by insects and those infections sometimes require like specific laboratory workup or a specific imaging and we would like to help into those infections to treat with the right antibiotic and establish the appropriate risk for that patient.
Dr. Segeleon: Good information. Thank you.
Host: Dr. Segeleon and Dr. Bula-Rudas, thank you so much for your expertise on this topic.
Our Called to Care podcast series focusing on children continues with topics from appendicitis to joint payments and many more right here with our Sanford Health experts. Thank you both for being here and for all that you do. We’ll see you soon.