Is Amoxyl a cough medicine?

Why don’t you give her an antibiotic, then she can come back to school?
This extraordinary advice was given to one of my nurses when her child missed school due to a cough. Now let’s leave aside the ethics of school teachers giving health advice to nurses, but where on earth did the idea come from that antibiotics help children with coughs?

Let us go back to the 1930’s and Alexander Fleming working in my old Alma Mater St Mary’s hospital. He was culturing some bacteria, went away for some days, and came back and found the plates spoilt. Some mould, probably from the damp walls, had contaminated the plates. He was about to throw them away when he noted that the bacteria had died in the areas where the mould was. He did not “discover” penicillin. Moulds, penicillin or otherwise, were already known. Nor did he really discover antibiotics: in fact he did nothing for some years, thinking it was only of academic interest, and the bactericidal mould was useful for helping to identify different bacteria. It took Dr Foley, an American, to realize it’s clinical potential, just in time for the 2nd world war.

The realization that penicillin, a fungus that grew on mouldy bread, could be injected into humans and treat wound infections, was one of the greatest scientific discoveries of the last century. Streptomycin, one of many soil fungi discovered in the 50’s brought TB under control. Doctors thought they were out of a job. Modification of the molecules made oral treatment possible, and soon Doctors were giving these new wonder drugs for every infection.

Big Mistake!

Antibiotics kill bacteria. That is all they do. They do not stop coughs, nor do they stop diarrhoea, nor do they bring down fevers, reduce pain, make you healthier, make you live longer or make you better looking. They kill bacteria. Full stop
Not all bacteria are bad for us. Our bodies are teeming with bacteria, also viruses, yeasts, other fungi and various parasites. Some are actually essential for health. Almost all the bacteria that live on us and in our intestines are harmless, and by taking up residence prevent other microorganisms living there instead. As all ladies know, kill the lactobacillus and you get thrush!

In the ‘60’s Doctors gave penicillin or the new wonder drug ampicillin to every child with a fever hoping it would wipe out streptococcus and make rheumatic heart disease history. So a child has a virus. Dr. sees a fever and a red throat and gives a penicillin. Being a virus, a few days later the child gets a rash. Oh! Says the Dr. You’re allergic to penicillin! Wrong again. In my generation, it has now been shown that 9 out of 10 of us who were told we are allergic to penicillin are not. We were victims or a knee jerk reaction of giving antibiotics for every infection.

The sad thing is that now, 40 years later, history repeats itself. A new generation of doctors, and even old codgers like myself who should know better are giving antibiotics to anyone with an infection. Kampala has just had a new flu virus hit us like a tidal wave. Hundreds of children and adults with high fevers, often up to 40 degrees, sore throats, red eyes and a cough. Half of them are told it is malaria and are given artemether if they are lucky, and injection quinine if they are not, the rest are taking antibiotics. I have lost count of the parents coming in who have told me the child had a cough so they went to a pharmacy and were given amoxyl syrup. I didn’t know antibiotic syrups were “over the counter” drugs. One was even given cipro.

So why have we regressed to the 60’s when scientific knowledge is supposed to be growing?

Are antibiotics ever necessary in people with a cough?

Almost all coughs are viral. They do not need antibiotics. Babies can be very ill indeed with a viral pneumonia but they still do not need antibiotics.
A few have asthma or allergies. They may be very ill indeed. They may need admission, nebulized salbutamol and big doses of steroids. They do not need antibiotics.
Some may have weird causes, for example bilharzia often causes a chronic cough. They do not need antibiotics.
Some may have T. B. They need specific treatment.
Some may have very serious causes, e.g. heart failure or lung cancer. They probably do not need antibiotics.

Some have a bacterial infection. Not very many, and not even all of them need antibiotics. Sometimes the bacteria are simply growing in the mucous produced by the bronchi in response to the virus. So bacteria may be cultured but it is not causing the cough. However in those few cases where a bacteria is causing a problem, such as pneumonia or a sore throat, (e.g.strep. throat) antibiotics are indicated.
So why, with all these many causes of cough, do so many people (and so many pharmacies, it seems) give antibiotics for anyone with a cough?
We need to look at two more questions

Should we give antibiotics to everyone just in case a bacterium is playing a role and it might help?

Do antibiotics prevent bacterial infections in people with very bad viral infections, for example SARS and Bird flu?

The answer is no. There have been many very good studies done and published in the BMJ or the American physicians association newsletter, that show that antibiotics do not help and may harm. The latest overview by WHO published just last month in the BMJ showed that antibiotics given routinely to people with bad chest infections in bird flu did not help, unless there was a clear secondary bacterial infection.

So if there is no help, what is the harm?

First, antibiotics kill the bacteria that live harmlessly in us and on us, and therefore something else will grow in their place. That may be a yeast, a more harmful bacteria, or even the virus itself may be better able to exploit the vacated niche. In most antibiotic uses, it is not really a big deal. So if a child really does have an ear infection for example, 5 to 7 days of Pen V or amoxyl is not going to do that much harm. However give an antibiotic every time a child gets cough and certainly the commensal bacteria are going to be replaced by their antibiotic resistance cousins.

More importantly some of the newer broad-spectrum antibiotics can cause much more damage to the commensals, especially in the gut. Parents will often tell me the child has a cough, they gave amoxyl and it didn’t get better (of course it didn’t!) and he now needs a “stronger” antibiotic. Well here’s news for you. We do not grade antibiotics by strength, but by spectrum. Augmentin is not stronger than amoxyl. Simply a slightly broader spectrum, very seldom of any greater use, but always of a much higher price! Some such as cipro and most of it’s family are actually a lot less active against the species of bacteria that are the usual cause of bacterial sore throats, and therefore are really of little use in most respiratory infections. However they can certainly cause a lot more harm.

So what is the message?

Antibiotics are not “cough medicine” they should only be used for specific bacterial infections.
Antibiotics are not over the counter drugs, and should not be offered by pharmacies as routine medicine for coughs.
Do not self prescribe antibiotics for yourself or your children for sore throats and coughs unless you have a very specific reason, for example rheumatic heart disease.
Do not try and cajole your doctor to give antibiotics just because the cough is “bad”. “Getting worse” or not getting better.
In the EU it has been estimated by Health ministries that 80% of prescriptions for antibiotics for respiratory infections are unnecessary. I think that in Kampala we can try and do better than that.