21 November 2015
A Short History of Medicine:
2000 B.C. — “Here, eat this root.”
1000 B.C. — “That root is heathen, say this prayer.”
1850 A.D. — “That prayer is superstition, drink this potion.”
1940 A.D. — “That potion is snake oil, swallow this pill.”
1985 A.D. — “That pill is ineffective, take this antibiotic.”
2000 A.D. — “That antibiotic is artificial. Here, eat this root.
Antibiotics should never be used unless they are absolutely needed to fight an infection
Back in 1999, my first year of private practice, the American Academy of Pediatrics published its first edition of the Judicious Use of Antibiotics in an effort to curtail their usage. It was an evidence based guideline intended to be used by doctors in order to support their decisions to either use or not use antibiotics. The guidelines were again updated in 2013 and I would encourage everyone to read them. (They are well written and you don’t need to be a professional to understand them.)
Between 1999 and 2013, not much in the guidelines had really changed. Disappointingly, it seems that not much has changed in the way most doctors are dispensing antibiotics, either. It seems as though many doctors are still giving out antibiotics as if they were harmless and are not adhering to the guidelines at all. In fact, approximately 50% of all antibiotics prescribed in the United States are given unnecessarily.
Therefore, I am appealing to the patients to get educated and realize that we need to save these powerful drugs for when they are really needed. I am appealing to my colleagues to cut down on overuse and the unnecessary prescribing of antibiotics. I’ll go through a few common infections mentioned in the report and some that aren’t, and discuss when, why, and if you need an antibiotic for them. Remember that every antibiotic prescription has the potential to create resistant organisms, and can cause many unwanted side effects, such as allergic reactions and GI upset.
One very important thing to keep in mind is that antibiotics only work for bacterial infections
They do not work for viruses. Upper respiratory tract infections (URI), aka ‘the common cold,’ are viral nearly 100% of the time, yet antibiotics are given for them more than any other infection. A cold can last anywhere from 1-2 weeks, can come with fever, green/yellow mucous, fatigue and a headache. Let me stress again: an antibiotic will not work for a URI. Do not ask for one, and do not accept one if the doctor you are seeing offers you one. It will not work, and will not help you to get better faster.
The one exception is a sinus infection
How do you know when you have a sinus infection? The current definition accepted by the overwhelming majority of health care organizations is: a URI with worsening symptoms after 7-10 days, or persistence of symptoms for greater than 10-14 days without showing signs of improvement. That’s it. No CT scan, scoping of sinuses or an MRI will tell you whether or not you have sinusitis. It’s just that guideline. You don’t need anything else. If you meet those criteria, then an antibiotic may be helpful (Amoxicillin should be the first line of treatment), but so might be a neti pot (nasal irrigation).
Doctors, I have noticed, are also fond of diagnosing and giving an antibiotic for acute bronchitis (typically Zithromax, aka the Z-Pak). Unless you smoke, or have cystic fibrosis, then you do not have bacterial bronchitis and an antibiotic will not help. Instead, you should stay hydrated and rest.
Any additional symptoms, such as wheezing or difficulty breathing, should be further evaluated, treated and certainly taken seriously. If you have a cough and congestion lasting 2 or more weeks, then maybe you have a sinus infection instead. Call your doctor. If, instead of bronchitis, you have pneumonia, then you will likely need an antibiotic. How can you tell the difference? Pneumonia could come with chest pain, rapid breathing, and persistently high fever. Hopefully your doctor can tell the difference, but diagnosing pneumonia is not always so straightforward and you may need to have a chest x-ray to find it.
What about tonsillitis?
When I was in residency, a study was conducted where doctors, including ENTs, were shown images of throat findings, and the residents were asked to identify the cause of the infection. If I remember correctly, they were only able to get it right about 30% of the time. There are many causes of a sore throat or tonsillitis. If the tonsillitis you have is not strep or an abscess of some kind, then it is not bacterial, no matter what it looks like. Some of the worst throat infections I have seen have been viral. Mononucelosis (mono), for example. For the most part, if it is not strep then you do not need an antibiotic. If your doctor says it looks like strep and decides to treat you with an antibiotic without a culture or a definitive diagnosis, that is not what is recommended and I would advise against it.
Ear infections: most will go away on their own
Ear infections are a more controversial subject, and many people, including doctors, are under the impression that you need an antibiotic to treat them. The fact is that about 80% of properly diagnosed ear infections will go away on their own without any antibiotics, and they will do so within 24-48 hours after the onset of symptoms.
The current approach and guidelines set forth by the AAP are what are known as “watchful waiting.” Basically, if you are a person older than 2 years of age and are diagnosed with an ear infection, we give a prescription and ask you to hold onto it. If, after 1-2 days you are still in pain and not improving, then cash in that prescription. While waiting for the infection to resolve, Motrin or Advil will help with the pain. This approach does not lead to any further complications, and in the 12 years we have followed it we have drastically cut our use of antibiotics. As a doctor and a patient, the first time you try this, it may be a bit unnerving, and you may not believe it, but it does work. I’ve even seen it happen with severe ear infections in my own children. Trust me, it works.
Swimmers ear, on the other hand, never needs an oral antibiotic unless, in the rare instance, the infection spreads beyond the ear canal. The bacteria which cause ear infections are resistant to all but the most powerful oral antibiotics (usually given IV), which is why strong topical antibiotics are the only treatment that works. Using the ear drops with a cotton ball, or a specially designed wick, works the best.
Gastroenteritis does not need an antibiotic
Another condition that never needs an antibiotic is acute gastroenteritis, aka stomach virus or stomach flu. You’re better off with a probiotic such as acidophilus or Culturelle. But, what if it is caused by a bacteria, such as Salmonella or E. coli. Even more reason not to take an antibiotic! Taking one when you have Salmonella can cause you to be a carrier, and taking one for E. coli could potentially cause kidney failure. It can be difficult to determine what you have without a stool culture. That is why when you don’t know the cause, do not take an antibiotic.
What if you’re traveling to a foreign country and are advised to take an antibiotic with you just in case?
I feel that this is a potentially dangerous practice, because who knows what you might have contracted, and taking an antibiotic can lead to more harm than good. Take a good supply of probiotics with you and you should be alright. If you are not alright and have bloody diarrhea, then seek medical attention, not drugs.
There is no question that antibiotics have changed medicine and the way we practice it
There is also no question that when prescribed responsibly, they are one of the most beneficial, helpful medications we have. In an effort to keep them working, and to keep bacteria from becoming resistant to them, we must continue to prescribe them only when needed.
A world where antibiotics no longer work would take us back to the pre 1930s era where people died of relatively minor injuries and conditions. Almost 100 years later we are headed in that direction, and should do all we can to prevent it. Judicious use of antibiotics, along with research and development of newer antibiotics, will help. Please do your part. Don’t demand antibiotics when not necessary, and don’t prescribe when not indicated. Remember, “He is the best physician that knows the worthlessness of the most medicines.”
 Pediatrics Vol. 132 No. 6 December 1, 2013, http://www.aappublications.org/content/34/12/1.1