When it really is a virus

I joke that, as a Peds ID doc, it is my duty to say this at least once a day…

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Ok, I may not literally be slapping people upside the head, but there are certainly times when I’m doing it in my mind. The situation is common enough – a patient, parent or doctor, faced with symptoms consistent with an infectious disease, considers using antibiotics to treat bacteria. After all, we know that bacteria kill people, right? But in many of these situations the patient really has a viral infection – and viruses aren’t affected by antibiotics. So at the very least we’re wasting money and drugs. Worst case scenario? We’re promoting drug-resistant bacteria, antibiotic allergies and side effects – that in some cases can be life-threatening.

But aren’t there clues to help us make the distinction? Real clinical signs and symptoms? Well, lets review a few.

White pus on the tonsils
Everyone is familiar with the feeling of an awful sore throat, and having a doctor peer down and having you say “Ahhhh…” What are they looking for. Probably something like this:

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This is a classic appearance of “Strep Throat” – a bacterial infection that aside from being painful in its own right can go on to lead to serious complications, such as rheumatic heart disease, kidney disease, a form of arthritis and a weird neurologic disorder called “Sydenham’s Chorea”. Fortunately it has no drug resistance so simple penicillin/amoxicillin will kill it (so if your doc tries to give you “stronger” antibiotics please feel free to slap them).

The trouble is, this isn’t a picture of strep throat. I grabbed this from an article on “Mono”. Infectious Mononucleosis can be indistinguishable from strep throat, but antibiotics do nothing for it. The “pus” you see isn’t really pus, it’s just a nasty-looking white gunk your tonsils make. A bad sore throat can be caused by influenza, adenovirus, RSV, metapneumovirus, rhinovirus….you get the idea. It can be hard to tell strep throat from any of the other many possibilities, but in general if you DON’T have a runny nose or a cough, and the lymph nodes in your neck hurt then it’s PROBABLY strep. But it could be a virus. Strep tests and cultures help – and holding off on treatment until the test comes back is a sensible plan.

Red eardrums
What about ear infections? Another common bane of pediatrics (almost every young child I see with a prolonged illness has at some point been diagnosed with an “ear infection” before arriving at the correct diagnosis – I once saw a kid with a brain tumor get that diagnosis…). The symptoms are notoriously non-specific (ear pulling, fussiness, fever) and a good ear exam in a small, squirming child can be difficult! A crying baby can turn their ear drums pink…and voila! An ear infection! But even assuming your exam is good and the ear drum really does look nasty, how do we know its a bacterial infection? Despite the appearance of a rip-roaring otitis media (bright red, bulging ear drum, fluid behind it) it can be a viral infection too. Most of what you see is the BODY’S response to the infection remember. Clinical trials of antibiotic use have shown with without antibiotics, ear infections tend to get better just as quickly as with them. Complications from untreated bacterial infections do exist, and can be quite serious, but are rare. It is prudent to consider a “wait and see” approach to ear infections to see if it gets better by itself. I don’t want your kid to get mastoiditis any more than you do, but if it does happen I want it to be treatable with the best antibiotics!

Most of the time when we’re treating ear infections we’re not even treating the child…we’re allowing the adults in the house to get a good nights sleep…;-)

Cough, fever, patches on chest x-ray
Pneumonia? Guess what. Usually a virus, at least in kids, before they become immune to everything. Without proper testing though this can be harder to tell apart, and we’re getting into the realm of “sick kid” here. Almost every doc will feel a little weird ignoring a possible bacterial pneumonia, even if they really do think its viral. But the high rate of viral infections, along with the risk of increasing drug resistance, is why the current recommendations for antibiotic treatment of pneumonia in children start with plain old amoxicillin. RSV, metapneumovirus, influenza, adenovirus – they can all cause pneumonia. In the Bad Old Days viruses like measles and varicella could also do it, and they were quite nasty! With symptoms like a runny nose, rash, lots of sick contacts, the chances of it being a viral infection are quite high. Sitting it out for a few days is again a reasonable option – because you know if you see a doc and get a chest x ray they’ll start you on antibiotics, and we don’t want that, right?

Very high fevers, difficulty breathing, chest pain with pneumonia, coughing up junk – always worth getting checked out.

Green snot
All of us have at some point experienced symptoms of a sinus infection. Fever, pressure, tons of snot, headache. They are truly miserable things. I hear all the time how “we knew it was bacterial because he had green snot”. Sorry, but that’s not all that helpful. The greenness of snot comes from the cells your body is sending in to kill the infection, which will tend to be neutrophils whether it’s a virus or bacteria. (Neutrophils don’t really kill viruses, but they’re just reacting to the inflammation there). Neutrophils have the awesome ability to create highly-reactive chemicals, one of which is called “superoxide” which gets converted to hydrogen peroxide which then reacts with chloride ions in salt to produce….bleach. The green color you see is actually the neutrophils and the enzyme they are using to create the bleach (myeloperoxidase), not the infection itself. You’ll get green snot regardless of what’s causing the infection, and it’s a good sign – a sign that your immune system is in full swing.

Severe sinusitis will produce lots of snot, for sure, but lots of snot doesn’t necessarily mean its a severe sinusitis, and certainly doesn’t prove it’s bacterial. If symptoms have lasted for a couple of weeks with no improvement, that’s a red flag for something non-viral.

High Fever
Fever is a normal immune response which effectively suppresses bacterial and viral infections. It hurts them far more than it hurts the patient. A fever by itself won’t necessarily cause any harm at all – and high fever may or may not indicate bacterial infection. A fever is just a clue – a reason to look and figure out what’s going on. One you’ve figure out it’s a virus based on symptoms (runny nose, viral rash etc) then you’re good. And don’t worry if fever keeps coming back, it will do that until the infection is gone, which may take a week or more.

The height of the fever is only slightly predictive of the risk of bacterial infection – but influenza, adenovirus, EBV can all cause pretty good-going fevers of 102F and up. I’m far more interested in what ELSE is going on in addition to the fever.

Febrile seizures, convulsions caused by fevers in young children, are more closely associated with a rapidly rising fever than a high fever itself. If your child has a fever of 104.5F and has sat there for an hour, chances are good they’re not going to seize from that.

Addendum – Mark Crislip recently posted on fevers over at Science Based Medicine!

Summary
So that’s a rough overview of the various common viral infections. It really is surprising how often we do get sick from something that will simply run its course. Our immune system is pretty robust. That’s not to say that in exceptional circumstances viruses can’t or shouldn’t be treated (herpes, influenza, chickenpox, measles, adenovirus, CMV and EBV all have some form of treatment to try even if the therapies are nowhere near as effective as antibiotics are on bacteria) but for respiratory infections in particular we would be far better served by reassurance that our symptoms are more consistent with a virus than a bacteria, and that most of the time it will sort itself out. A large chunk of the inappropriate usage of antibiotics stems from over-treatment of viral respiratory infections – so next time you see your doctor for something like this consider asking about tips for symptomatic relief rather than an antibiotic prescription.

A few other studies: prescribing antibiotics doesn’t necessarily save time.
Antibiotic overuse, even based on physician diagnosis, worse with criteria-based diagnosis.
Understanding why physicians overprescribe – many different reasons.

Good advice can be found on the CDC website.

I have been told that I must credit my wife for originally coming up with the idea for the “IT’S A VIRUS” slapping Batman meme, and Quickmeme helped me create it.

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  1. #1 by R. Copley on December 22, 2012 - 11:53

    Great post Dr. Bennett. Very informative. As you can imagine, this topic is often discussed and disagreed upon in my household. As an example, all 5 of us got pretty wiped out with an “illness” that was sweeping through town last week. Productive cough, low grade fever, green snot (especially in the shower!), etc. 4 of us went on ABX and 1 of us did not.

    Wait for it, wait for it…….. We all got better at the same time! BOOM! 1 of us didn’t have to endure any GI side effects of ABX or even the nasty taste or large pills.

    Will this small, in-home experiment change anything the next time this comes around? I hope so, but I a wont be betting on it.

    Great post. As always, thanks for sharing your knowledge.

    • #2 by Nick Bennett on December 22, 2012 - 11:59

      I’ve seen influenza, adenovirus and RSV circulating recently. Could have been any one of those, or something else! Glad to hear you all survived :-)

      The CDC says that about 1/3 of the influenza B circulating is non-vaccine. That’s going to be a problem…

  2. #3 by Kaytee on December 23, 2012 - 23:22

    Thank you once again – I routinely share your articles with my co-workers and the Pediatric Hospitalists. Great article!

    • #4 by Nick Bennett on December 23, 2012 - 23:24

      Thanks – happy to be of help!

  3. #5 by Seth Trueger on December 24, 2012 - 10:51

    great post! there are also those who have compelling arguments against treating strep throat at allhttp://www.smartem.org/podcasts/treatment-acute-pharyngitis

    • #6 by Nick Bennett on December 24, 2012 - 12:05

      Not sure I would go that far – strep complications are often hard to spot and it is at least easily treated.

      • #7 by Seth Trueger on December 24, 2012 - 14:06

        The argument is that the treatment isn’t so helpful. It shortens pharyngitis symptoms by something like 6 hours (over a week) while 1/6 patients get diarrhea and 1/6 get yeast infections. NNT to avoid a PTA is slightly above 100. PSGN is probably not avoidable with antibiotics. And in modern, developed nations, the NNT to avoid rheumatic fever is probably 40,000, suggesting that 4 people will drop dead from anaphylaxis to prevent 1 case of RF.

      • #8 by Nick Bennett on December 24, 2012 - 14:09

        Interesting stats…I wonder why the RF is lower in developed countries. One argument I’ve heard is we over treat otitis so much we are inadvertently treating group A strep along the way.

      • #9 by Seth Trueger on December 24, 2012 - 14:31

        The argument I’ve heard is that the strains in developed nations with modern hygiene are less likely to cause RF? See esp fig 2 here: http://www.ncbi.nlm.nih.gov/pubmed/8403347 — the drop in RF started BEFORE antibiotics were introduced.

  4. #10 by maturinuk on December 29, 2012 - 11:25

    Reblogged this on Broken_Heart Blog and commented:
    Thank you to Nick Bennett [@peds_id_doc] Assistant Professor in Pediatric Infectious Disease for permitting me to repost here. The message is many febrile illnesses in our community are due to viruses for which there are generally no effective treatments. If you or your children have a fever it may last up to three weeks and this is not affected by the use of oral antibiotics. So, in almost all cases treat the symptoms – fever control, pain management, light diet with plenty of fluids. [A Cochrane review for basis of this approach in case of respiratory tract infections – http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004417.pub3/full%5D

  5. #11 by maturinuk on December 29, 2012 - 11:26

    Thank you an excellent post

  6. #12 by mommycall on December 29, 2012 - 21:19

    I agree that many often overuse antibiotics for likely viral illnesses. When faced with a distraught parent and miserable child in the office though, I understand the desire to offer them some remedy for relief (although I don’t give them antibiotics for my own selfish desires). I wish that there were more options for supportive care than rest, fluids, humidifiers, and nasal saline.
    mommycall.wordpress.com

  7. #13 by Barbara Owdziej on January 18, 2013 - 13:00

    Great article! And I would argue that antibiotic rx’ing is as much for the provider than it is for the parents. So many times a provider collapses under the pressure. I appreciate your comment about “my own selfish desire” .

  8. #14 by Chris on January 21, 2013 - 19:40

    Thanks for the article! Very informative. Cleared up something I’ve been a little unsure of for a while now.

  9. #15 by InternetMedicine.com (@Internetmeds) on February 27, 2013 - 14:26

    Hi NIck
    I don’t know how I stumbled on your great blog, but glad I did. This is an age old issue, that I wrestle with too. As you know, many times we treat the mom and not the child. In the ER, she came for Antibiotics, and will not be happy if you don’t give it. And, if you like your job as an ER doc, you don’t want people constantly complaining about your “lack of compassion”.
    So, for many years, I was weak, and gave them. I guess it is pretty selfish on my part.
    John Bennett MD
    http://www.internetmedicine.com

    P.S. By the way, I put a link to your blog on my site in both the Pediatric Blog and Infectious Disease Blog sections at Internet Medicine.

    thanks

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