By: Zachary Bloomgarden, MD
We are coming out of the winter “cold season,” a time when respiratory infections are most frequent. Antibiotics are among the most used medications – given to nearly one in seven people in the US every year. Antibiotics are prescribed to more people than medicines for cholesterol-lowering, pain, or breathing issues, only ranking behind blood pressure medicines. Should they be?
I treat people with diabetes, and I certainly worry about their developing infections. But I spend more time talking about not using antibiotics than I do writing prescriptions for them. The reasons have to do with two complex issues of antibiotic use in the US. First, antibiotics are of no benefit for the common cold, even with colored nasal discharge. Often the diagnoses of laryngitis, pharyngitis, and sinusitis are applied incorrectly to various manifestations of the common cold. For acute bronchitis, there is no practical way of distinguishing viral and bacterial infection, and the symptoms are typically self-limited. The Centers for Disease Control estimates that at least 30%, and perhaps as much as 50% of antibiotics prescribed during office or emergency room visits are unnecessary.
People with illness, and many physicians ask, Why not give antibiotics anyway? What if there is a bacterial infection? What’s the harm?
From the point of view of the community, giving antibiotics inappropriately leads to the development of resistant organisms, which then can be much more difficult to treat. An example is Methicillin-resistant Staphylococcus aureus (MRSA) infection, caused by a type of staph bacteria which has become resistant to many of the commonly used antibiotics, and can lead to severe, life-threatening infections.
There are many potential harms to people taking antibiotics. A common effect of antibiotics is gastrointestinal upset, including nausea and vomiting, diarrhea, or simple symptoms of “indigestion,” abdominal pain, or bloating, but sometimes with overgrowth of a specific type of bacteria in the intestine, Clostridioides difficile, which can cause diarrhea, sometimes with colitis, and which may respond poorly to antibiotics given to eradicate it. More subtly, antibiotics can favor the growth of intestinal microbes which appear to have long-term adverse metabolic side effects, contributing to obesity and diabetes.
Antibiotics can cause allergic reactions, sometimes a self-limited rash, but also throat tightness and wheezing interfering with breathing. As much as 15% of people report an antibiotic allergy, to penicillin and penicillin derivatives, including cephalosporins, to tetracyclines, to sulfa drugs (typically Bactrim or Septra), and to many other types. It’s not a minor issue, as sometimes these drugs are absolutely needed for severe infection, and an allergy which developed after inappropriate prescription may interfere with such treatment.
The commonly used fluoroquinolones, including levofloxacin (Levaquin), ciprofloxacin (Cipro), and moxifloxacin (Avelox), can cause a variety of abnormalities related to connective tissue, including tendonitis (sometimes with tendon rupture), retinal detachment, and arterial aneurysms. These drugs may also cause central and peripheral nervous system disorders, and hypoglycemia when given in combination with certain diabetes medicines.
So, what should we do? Many physicians feel that their patients “expect” to be given antibiotics for symptoms of a respiratory infection. It is reasonable to point out that antibiotic treatment simply does not help viral infection, and sensible “sick-day rules” of maintaining hydration and nutrition (with the time-honored bowl of chicken soup!) will be useful. The visit is not “wasted” if an antibiotic is not given – a careful examination to make sure there is no evidence of pneumonia, streptococcal pharyngitis, or middle ear infection helps the prescriber to know that the uncomfortable symptoms the patient is experiencing are not dangerous.
A reasonable approach if the doctor feels there is no immediate danger but that there may be a bacterial respiratory tract infection is to offer delayed antibiotics – providing an antibiotic prescription, but with advice to delay filling the prescription. The prescriber determines that immediate antibiotics are not required, expecting that symptoms will resolve without antibiotics. With this approach, studies have shown antibiotic use is reduced by two thirds – and sometimes the “art of medicine” is best practiced with this sort of solution.