Credit: Wikimedia Commons
Credit: Wikimedia Commons

“The waiting is the hardest part.”
— Tom Petty

Over 100 million doctor visits in the US each year result in a prescription for antibiotics. Over a third of those visits are for respiratory infections. A large fraction of the antibiotics prescribed yield absolutely no benefit to the patient. The issue is much more severe than just unnecessary spending on ineffective medication. As I’ve written before, antibiotic overuse is a major cause of emerging antibiotic resistance and of dangerous infections like Clostridium difficile. Antibiotics also can cause unpleasant side effects and (albeit rarely) life-threatening side effects.

Minimizing antibiotic misuse is becoming a major public health priority. In November, Annals of Internal Medicine published an article reviewing the current evidence on the role of antibiotics in the most common respiratory infections. The recommendations are summarized below.

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Symptoms: Cough that lasts up to 6 weeks with mild fever and aches.
Causes: Most cases are caused by viruses.
Role for antibiotics: None, unless pneumonia is present.

A generation ago we thought that colored phlegm was a sign of a bacterial infection. Now we know that the yellow or green phlegm is due to airway inflammation that can be caused by viruses or bacteria. Studies have shown that antibiotics for bronchitis don’t decrease the duration of cough and increase the rates of adverse events. If a doctor’s examination rules out pneumonia, antibiotics should be avoided.

Symptoms: Sore throat, pain swallowing, sometimes with fever.
Causes: Usually caused by viruses. Some bacteria can also cause sore throats, most importantly Streptococcus.
Role for antibiotics: Should only be prescribed if a Strep test is positive (with rare but important exceptions in adolescents and young adults).

The presence of cough, nasal congestion, pink eye, hoarseness, diarrhea, or cold sores make a viral cause much more likely. Even in cases in which the physical examination is consistent with Strep, many patient have a viral infection. So Strep should always be confirmed by culture or rapid testing before antibiotics are prescribed.

Symptoms: Nasal congestion with thick drainage, upper tooth pain, facial pain or pressure, fever, fatigue, ear pressure or fullness. Symptoms can last from a few days to a month.
Causes: Most cases are caused by viruses, allergies, or irritants. Fewer than 2% of cases are bacterial.
Role for antibiotics: Antibiotics should be prescribed if symptoms last more than 10 days, or severe or worsening symptoms last for 3 days.

Even in bacterial sinus infections, drainage of the sinuses frequently results in resolution of the illness. So decongestants like pseudoephedrine (Sudafed) or ipratropium (Atrovent) nasal spray are essential and usually curative. Antibiotics are a second line treatment if the decongestants alone don’t work.

Symptoms: Sneezing, runny nose, sore throat, cough, low grade fever, headache, and malaise lasting up to 14 days.
Causes: All colds are caused by viruses.
Role for antibiotics: None.

Antibiotics don’t help colds. Zinc supplements have been shown to modestly reduce the duration of cold symptoms if taken less than 24 hours after symptom onset, but it can cause nausea and a bad taste. There is no evidence that vitamins (like C) and herbal remedies (like Echinacea) have any effect.

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On this issue, societal interest and the welfare of individual patients are aligned. No one is asking patients to forego helpful medications for the sake of preserving the benefit of antibiotics for the future. On the contrary, patients are exposing themselves to harm and harming society when they take antibiotics for illnesses for which they have no benefit. So why are so many inappropriate antibiotic prescriptions written, and why do so many patients take them?

First, lots of patients grew up in an era when antibiotics were routinely prescribed for bronchitis and for sinus infections. We just didn’t know better then. The patients improved after taking these antibiotics (as they would have had they taken carrot soup or Tylenol or nothing) and are understandably convinced that antibiotics are required in these cases. Doctors have to educate these patients despite their entrenched expectations. Many doctors find that writing a prescription is faster than taking the time to teach.

Second, antibiotics give patients the (false) impression that they are doing something to hasten their recovery. The alternative – treating symptoms and waiting – can be very difficult when one is miserable. Doctors who are fully aware that antibiotics will be ineffective sometimes relent and prescribe them because it buys us ten days during which the patient accepts he’s on the road to recovery.

So patients owe it to themselves to be educated about when antibiotics work and when they don’t. And doctors owe patients an explanation about why antibiotics won’t help and how long it will take to recover. And then patients have to do the hard part and wait. That’s why we call you patients.

Learn more:
Got a Respiratory Infection? Why Your Doctor Shouldn’t Prescribe Antibiotics (Consumer Reports)
Appropriate Antibiotic Use for Acute Respiratory Tract Infection in Adults (Annals of Internal Medicine summary for patients)
Appropriate Antibiotic Use for Acute Respiratory Tract Infection in Adults (Annals of Internal Medicine article)

My previous posts about antibiotic misuse:
CDC Sounds the Alarm about Antibiotic Resistance
Relearning What We Knew: Antibiotics Don’t Help In Sinus Infections
Clostridium difficile Infections on the Increase
Azithromycin Might Kill You, but That’s Not Why You Shouldn’t Take It
Untreatable Gonorrhea – The Next Infectious Threat