Doctor ordered to temporarily stop prescribing antibiotics, antifungal medication to children after specialists complain

SINGAPORE: A doctor has been ordered to not “recommend, prescribe or administer” an antibiotic and an antifungal medication for the next 18 months to children aged seven or under, after complaints from four hospital specialists.

Dr Erwin Kay Aih Boon, a general practitioner in private practice at Healthwerkz Medical Centre, had prescribed antibiotic Vancomycin and antifungal medication Fluconazole – trade name Diflucan – to children with autism.

The Singapore Medical Council (SMC) said these were “strong” medications, which are potentially dangerous and harmful if prescribed “without scientific basis”.

According to the grounds of decision published on Thursday (Sep 2), the Interim Orders Committee has ordered Dr Kay to temporarily stop prescribing the two medications to children.

It comes after four paediatricians in a hospital, which was unnamed in the grounds, complained to the Singapore Medical Council (SMC) about Dr Kay’s management of children with autism.

They said his management of the children were “not based on evidence”, the grounds read.

“Hospital A’s paediatricians were of the view the use of antibiotics and antifungal agents for the treatment of children with (autism spectrum disorders) was unnecessary and had the potential for harm,” said the committee in its grounds.

The paediatricians requested SMC to investigate Dr Kay’s practices further, and stated that he “may not be adhering to the current recommended clinical practice guidelines for the investigation and treatment of children with autism spectrum disorders”.

They said there was “no evidence” to support treatment with antibiotics or other alternative therapies.

A complaints committee found that at least three children with autism or suspected autism who were treated by Dr Kay had been prescribed antibiotics and antifungal medications.

Two children – aged three and five – were prescribed both medications, while the third, who was three, was given five bottles of the antibiotic.

Dr Kay, who has been a general practitioner for 25 years, defended his actions and said the committee did not need to make such an order.

He said both medications are “therapeutic products locally registered” with the Health Sciences Authority, and that both are safe and approved for use in children.

He added that he did not treat these patients’ autism spectrum disorder as they were already being seen at Hospital A for that condition.

The general practitioner told the committee he had treated their “co-occurring medical conditions” associated with autism spectrum disorder.

That included prescribing antibiotics and antifungal agents to treat the bacterial overgrowth or infections, and yeast or fungal overgrowth or infections respectively.

NOT RECOMMENDED IN PRE-SCHOOL CHILDREN WITH AUTISM

SMC said according to the clinical practice guidelines, antibiotics and anti-yeast medications are “complementary alternative therapies” that are not recommended in pre-school children with autism spectrum disorder because of insufficient evidence for efficacy and potential harm or adverse effects.

Evidence on the antibiotic’s efficacy in children with autism was “inconclusive”, said the council, adding that there are “serious adverse effects” associated with the “indiscriminate use of antibiotics”.

This includes the emergence of antibiotics-resistant bacteria.

“Chronic use of anti-fungal therapy is associated with hepatotoxicity and exfoliative dermatitis,” said the SMC, according to the grounds.

Two of the three patients were children on follow up in Hospital A for autism spectrum disorders. Hospital A assesses and manages children from birth to seven years of age with a range of learning, behavioural and developmental needs, including autism.

When they were seen by a paediatrician there, the two patients were ordered to stop taking the medications.

“Hospital A’s paediatricians’ allegations are serious and if true, that is that Dr Kay is prescribing antibiotic and antifungal medications unnecessarily without scientific basis, would mean that Dr Kay is needlessly subjecting young children with (autism spectrum disorders) to the harm that the consumption of Vancomycin and/or Fluconazole may cause,” said the SMC.

“Given the vulnerability of these children, the consequences of the risk materialising would be severe.”

The SMC asked for an interim order to stop Dr Kay from prescribing the medications for 18 months, as the complaint was still pending before the complaints committee.

The complaints committee has yet to determine if the case should be referred for formal inquiry by a disciplinary tribunal.

The SMC said that it is not up to interim orders committee to determine if harm was caused by the prescription of Vancomycin and Fluconazole, but it has to consider the risk and the nature of the harm to the public.

DID NOT TREAT PATIENTS’ AUTISM

Dr Kay maintained that he did not treat the patients’ autism spectrum disorders, but he did treat their other medical conditions.

He said his prescription of the medications to the children was “clinically indicated” and that it was “supported by scientific evidence and safe”, according to the grounds.

He said there were “clear medical grounds”, arrived at through sufficient clinical information, “obtained through history-taking, clinical findings, and relevant investigations”.

The general practitioner detailed the patients’ cases. In the case of the two-year-old child, who was diagnosed with severe autism, his mother told Dr Kay he had eczema, poor immune status, constipation and behavioural issues, such as hyperactivity, irritability and frequent meltdowns.

“Dr Kay suspected a gastrointestinal issue given its prevalence in children with autism spectrum disorders,” said the grounds.

“Patient B was also noted to exhibit inappropriate laughing, giggling, inattention, high pitched squealing, sugar cravings and skin rashes, which were symptoms suggestive of a yeast infection. These are generally accepted signs and symptoms of yeast overgrowth and consistent with observations.”

He said he had explained the risks of both medications to the child’s parents, and that they understood the risk and benefits. The boy was given the antibiotics and antifungal medication, and his health condition “improved notably”, said the grounds.

Another patient who has autism had aberrant eating behaviour, hyperactivity, and sleeping problems. The patient’s mother reported acutely increased inappropriate laughter and “silly behaviour suggestive of yeast symptoms”, said the grounds.

Dr Kay suspected a gastrointestinal disorder and a possible yeast infection, and ordered a test which showed markers of bacterial and yeast metabolites, indicating dysbiosis.

He offered various options to the patient’s mother and she chose to go for a short course of antibiotics and antifungal agents, said the grounds, adding that “notable improvements” were reported.

The parents of the third patient also agreed to a trial of the antibiotics, after Dr Kay diagnosed her with acute gut bacterial infection.

She eventually stopped crying without reason and her sleep improved.

With all three patients, their parents provided testimonials, said the grounds. None of the three patients suffered any side effects due to the antibiotics and “instead benefited from the medication”, Dr Kay said, according to the grounds.

Dr Kay said his prescription with the medications was according to “best practices” he learnt from training by attending various accredited conferences and training programmes, adding that there was no evidence he posed any risk to the public.

RISKS OF POTENTIAL HARM: COMMITTEE

The interim orders committee said it is of the view that there will be “risks of potential harm” to the public if Dr Kay is not restricted from prescribing Fluconazole and Vancomycin to young children below the age of seven.

This is pending the complaint committee’s proceedings, and if the complaint is referred to the disciplinary tribunal.

Lawyers on both sides agree it is not for the committee to decide if Dr Kay’s prescription of the medications were based on scientific evidence or is generally acceptable medical practice.

The committee said it agrees that public trust and confidence in the medical profession “may be undermined” if it is made known that four specialists in paediatric medicine had raised concerns regarding Dr Kay’s conduct, yet he was allowed to continue without restrictions.

“On the other hand, Dr Kay’s current practice would face little disruption if he is simply prohibited from prescribing such medication to children below the age of seven,” said the grounds.