Should pneumonia be treated with antibiotics?
Many children are given antibiotics for pneumonia unnecessarily. Antibiotics only work for bacterial infections and most cases of pneumonia are caused by viruses.
What does general practitioner do when a worried father or mother comes in with a child they fear has pneumonia? The doctor needs to make a diagnosis and start treatment as soon as possible. Should the child be given antibiotics, or not?
Pneumonia can be caused by bacteria, but also by viruses, fungi or other types of parasites. Bacteria have been considered the most common cause for a long time.
However, new research carried out at Akershus University Hospital indicates that the share of pneumonias caused by bacteria is decreasing. Now, a virus is probably the culprit in most of the pneumonia cases among children and adolescents.
The researchers are apprehensive about the overuse of antibiotics, which can contribute to making mounting strains of bacteria resistant to the drugs.
Vaccinated against bacteria
Are Stuwitz Berg, the researcher behind the study, thinks the reduction of bacterial infections is linked to the vaccine against pneumococci which was incorporated in Norway’s vaccination scheme for children in 2006. Pneumococci are a type of bacteria which can cause infections in the brain (pneumococcal meningitis) and the blood stream (pneumococcal septicaemia). The national vaccination programme included this vaccination to help prevent these serious maladies.
But pneumococci are the most common causes of bacterial infections in the lungs.
“As a result of the vaccination, among other factors, the total share of bacterial pneumonias has declined among children and adolescents,” says Berg.
The children in the study were otherwise healthy but were thought to have contracted pneumonia. After a thorough x-ray examination, close to two-thirds of them were diagnosed with the infection. Then Berg and his associates charted the microbiological causes of the pneumonias. In other words, they ascertained whether the instigators were bacteria or viruses and which kinds of these were in action.
Only 12 percent of those with pneumonia had bacterial infections. The assumption used to be that up to 40 percent of pneumonias were bacterial.
“This means that there is a much larger chance than before that the pneumonias are caused by viruses. This is an important finding and indicates that doctors might need to cut down on their use of antibiotics to treat pneumonia,” says Berg.
Hard to find the cause
The Norwegian Directorate of Health’s guidelines of 2013 specify the use of antibiotics for bacterial pneumonia. But the diagnosis is often wrongly made and it is hard to find out whether the lung infection is caused by a bacteria or a virus.
“When a general practitioner treats pneumonia, the issue of whether it is bacterial or viral is one of the key questions, and much of the job involves answering that question. But it can be tricky to arrive at a definite answer with the equipment a GP has at his or her office,” says Sigurd
Høye of the University of Oslo, who researches the use of antibiotics in the primary health services.
Methods exist for ascertaining whether an infection is from a bacteria or a virus.
“But with these methods it often takes days to get an answer. When it comes to pneumonia among children, the doctor’s challenge is to initiate treatment as soon as possible,” says Høye.
He adds that even making a diagnosis of pneumonia is not that simple. It can easily be mistaken for bronchitis, which is a viral infection.
“Many are diagnosed with pneumonia, even though it’s bronchitis – and this appears to lead to an enormous overuse of antibiotics.”
Antibiotics when needed
As a result, many children are over-treated. Are Berg and his colleagues found signs that many children were being needlessly given antibiotics.
“As a kind of measurement of this we received 66 patients directly from general practitioners in the study. A criterion for sending them to the hospital was that the GP had decided to start treating the pneumonia with antibiotics. Only a few of them actually needed antibiotics,” explains Berg.
But he points out that it can be hard to determine how often family doctors generally treat pneumonia with antibiotics.
“Antibiotics are only good if you really have a bacterial infection,” says Trude Flo, a professor of immunology at the Norwegian University of Science and Technology (NTNU).
She says antibiotics can have an array of unfortunate effects on the body. One of them is wiping out many benign bacteria in the intestines which are necessary for staving off fungal infections or keeping harmful bacteria from getting a foot-hold.
“The gut flora is important. It works in collaboration with the immune system. After an antibiotic cure it can take a long time for the gut flora to re-stabilise, and this can lead to a person becoming more vulnerable to other infections later.”
Lack of treatment can have an impact
On the other hand, the consequences of neglecting to get antibiotics when such medication is called for are potentially greater.
“Some harmful repercussions, for example a hearing impairment, can result in cases where children should be given antibiotics but have not received them,” says Flo.
The risk of neglecting to treat those who need the medication can outweigh the negative consequences of needlessly prescribing antibiotics.
“Pneumonia can be a fatal condition, unlike other respiratory infections. It is better to treat children with pneumonia with too much than too little,” says Høye.
Nevertheless, he agrees with Berg that this is an area in which doctors in the future will need to be more careful about prescribing antibiotics.
Read the Norwegian version of this article at forskning.no
Translated by: Glenn Ostling
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