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Prescribing antibiotics is not always the best medicine

Dr. Jim Holt • Dec 16, 2013 at 9:06 AM

One of the less-pleasant features of autumn and winter is the increase in acute viral illness, which we commonly call the cold and flu season. Nearly everyone has experienced a cold, a sore throat, sinus congestion and a cough. Most people develop favorite ways of treating these conditions, from what they eat to what they do. Sometimes, these preferences conflict with other concerns, as in the case of antibiotic use.In the early 1990s, family physicians and patients were on the same page. If a person, in the course of a cold, developed cloudy yellow or green mucus draining from the nose, it was called “purulent rhinitis” — Greek for “pus from a nasal infection” — and we doctors would treat with antibiotics. Coughing up similar yellow or green mucus from the chest was called “bronchitis” — Greek for inflammation of the large airways in the chest — also treated with antibiotics. Patients and doctors both seemed to be happy with this routine.Reality intruded in the form of really nasty infections. Streptococcus Pneumoniae, i.e. Pneumococcus was (and is) the most common cause of bacterial pneumonia, bacterial ear infection and bacterial sinus infection. My private practice was south of Charlotte, N.C. The Charlotte metropolitan area noted a change from virtually no Pneumococcus resistance to penicillin in 1985, to less than 40 percent resistance of Streptococcus Pneumoniae to penicillin in the mid 1990s. Most of the remaining Pneumococcal infections were partially resistant to penicillin. This was very bad, since penicillin and its derivatives were the safest and most effective antibiotics for Pneumococcus. Managed care companies, which were very powerful in the mid 1990s, did not like paying for treating these increasingly dangerous infections. They especially didn’t like paying for more expensive and less safe antibiotics. They initiated new research on the best way to treat common respiratory infections. Results have been coming in over the past 15 years. The results have changed how I practice.n A “cold,” limited to nose and throat, lasts 7 to 10 days, and then resolves. Colored nasal drainage can occur normally with the virus.n A “chest cold,” i.e. bronchitis, lasts two to three weeks in most people. Antibiotics only help significantly if the person also has COPD, smoker’s lung disease, or if it lasts beyond three weeks.n Sinus fullness is indeed a sinus infection, but in the first week, the infection is nearly always viral. Colored drainage is usually viral.n Many ear infections are viral, and most will clear up without using antibiotics. n Salt water cleansing of the sinuses, if done properly, resolves sinusitis and congestion symptoms much better than antibiotics.n For all the above infections, harmful effects of antibiotics exceed the benefits. n More severe infections in the sinuses, ears or chest are exceptions to these rules, and benefit from antibiotics often enough to warrant their use. These more severe infections are uncommon.When the research started coming out in the late 1990s, I had been in private practice in South Carolina for more than 10 years. My patients trusted me. So as I explained why I wasn’t giving antibiotics for purulent rhinitis and for bronchitis — the first research available — they tried the symptom-controlling treatments I suggested. And, even without antibiotics, they improved about the same time into the illness. Only the rare patient wanted antibiotics regardless of my recommendation.I joined the East Tennessee State University Family Medicine faculty in 2001. Here, too, most patients agree to treat symptoms only, but many do not agree. They want antibiotics, and are certain they will not get better unless they receive them. Not only that, I perceive they feel “disrespected” that I won’t provide antibiotics — that I am withholding a benefit I extend to my other patients. Even health care workers who know the research request antibiotics with similar emotion.Antibiotic use can speed up the improvement in drainage, as I’m sure my unhappy patients have noticed, but the average improvement is less than a day. On the other hand, between 12 and 25 percent of patients who take antibiotics will have a noticeable harmful effect. This doesn’t even address the severe resistant germs that develop from unnecessary antibiotic use, like the resistant Pneumococcus discussed above. Antibiotics for most colds, sore throats and bronchitis do more harm than good.Unfortunately, there are both patient and doctor incentives to give antibiotics for these viral infections. Antibiotics are prescribed more often than not, based on a research letter published in JAMA Internal Medicine in October: 60 percent for sore throats and 73 percent for bronchitis. The patient, or the parent, remembers improvement in previous infections a few days after starting antibiotics — after all, it took good research to discover that the infection would have improved anyway. If the doctor writes an antibiotic prescription, even if it won’t really benefit the patient, he saves time by not having to explain what helps and what does not.The Centers for Disease Control and Prevention in Atlanta is the U.S. government’s primary division that deals with infections. For several years, the CDC has directed a public-relations campaign to reduce use of antibiotics in viral infections, and in undifferentiated infections which resolve without antibiotics. If this topic interests you, take a few minutes to review what they have posted on the subject on their website: www.cdc.gov. It is ironic that the doctors who providing the best care appear to be unkind to their patients. Please at least consider the possibility that your doctor may really love you if he or she does not give you antibiotics.Dr. Jim Holt of Johnson City is a physician and faculty member at the Johnson City Family Medicine Residency.

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