“Doctor, I REALLY need those antibiotics!”

The other day I came across an article in one of the medical journals I subscribe to. It informed me that the FDA is now requiring stronger warning labels for the fluoroquinolone class of antibiotics* about their potential to cause plummeting blood sugar levels and adverse mental health effects. 

The new labeling will warn doctors that the low blood sugars may lead to coma, and the psychiatric side effects can include conditions such as attention disturbances, agitation, memory impairment, and delirium.  These adverse effects may occur after just one dose.  Most clinicians already know that this class of antibiotics can also cause tendon, joint, muscle, and nerve damage.

Reading this article drove home a point long known in the medical community: antibiotics, though life-saving, can be dangerous drugs when used recklessly. Doctors, nurses, and pharmacists know this.  But much of the public does not.

Antibiotic overuse is a big problem in medicine.  Though it’s something I discuss with patients almost every single day, reading that article compelled me to put my thoughts down in writing. 

One of the joys of practicing medicine is helping my patients become better advocates for their own health. Promoting the judicious use of antibiotics, especially in the setting of common viral upper respiratory infections (URI) is something I feel strongly about. Investing those few extra minutes during the appointment to help patients understand the basic concepts of “antimicrobial stewardship”, a term coined by John McGowan and Dale Gerding at Emory University in 1996,  gives me hope that this important message will spread one person at a time. 

Before I talk about the appropriate use of antibiotics, let me begin by expressing that as doctors, we understand that when you come to see us, you may be worried, scared, and physically uncomfortable. You may have taken time off work, arranged for childcare, or driven long distances to see us.  We get it: after all, we are patients too. We want you to leave the office feeling that you’ve been listened to and cared for. Most of us who chose medicine as a career operate from a place of empathy and a desire to serve. So when we sit down to talk to you, to understand your pain, we are deeply committed to helping you.

To do this, we start by taking a history.  This is our chance to hear your concerns, and to ask focused questions about your symptoms. I’ve listed some common questions and concerns that patients bring up at this point in the visit: 

“I’m worried that if I don’t get antibiotics today, this head cold will move into my chest and turn into bronchitis.  I always take azithromycin to prevent this from happening.”

“I’ve been getting the same antibiotics every year for this cough for the past 20 years and they work like a charm.  Nothing bad has happened to me so far.  I’ll make sure to eat lots of yogurt.”

“I have asthma.  So I need antibiotics every time I get a cold.”

“I’m pretty healthy. I never see the doctor, except when I get a sinus infection.  I usually go to the walk-in clinic at the drugstore and they send me home with antibiotics.  Can you do that for me today?”

“I’ve been miserable with fevers, and I’m coughing up yellow phlegm.  Now it’s turning green. Can I get on antibiotics?”

“I have pressure behind my eyes, sneezing, congestion, fevers, and a runny nose.  I know this is a sinus infection.  Antibiotics will fix it.”

Did any of them sound familiar to you?  

Before I went into medicine, I remember being a patient making similar statements to my own doctor.

The patient’s questions and concerns are followed by a thorough history-taking session and a physical exam.  Keeping the vital signs, patient’s story, and the physical exam in mind, the physician comes up with an actionable diagnosis.  But before coming to this definitive conclusion, the doctor considers a differential diagnosis— the larger range of probable diagnoses. Is the patient’s issue caused by a bacteria, fungus, or virus, or none of these factors? Is the patient in any danger? Does he need to be hospitalized? Does she need a chest x-ray?  Would a strep test be helpful to find the cause of this sore throat?

After considering the differential diagnosis, doctors arrive at a diagnostic conclusion and take appropriate action.  One of these actions may be to prescribe a course of oral or even intravenous antibiotics if the patient has a bacterial infection.  This is because antibiotics work only on bacteria. However, if it is determined that the patient has an infection caused by a virus, then an antibiotic simply will not work; and in fact, it may cause unintended side effects. 

Prescribing antibiotics is not necessarily a benign intervention. When these drugs are not indicated, their harms far outweigh their benefits. Responsible physicians who respect the concept of antimicrobial stewardship, and who are not trying to rush you out the door will think twice before prescribing them.  

One such overused antibiotic, the generic name of which is  Azithromycin, is commonly prescribed inappropriately for viral infections of the ear, sinus, and throat.  To be sure, this is a powerful and very useful drug. But with a memorable commercial name and convenient five-day dosing, it can be perceived as a friendly and harmless medication, and patients request it by name.  Who can really blame them?  Who doesn’t want to get better as quickly as possible? Most patients are not aware of the harms of unnecessary antibacterial therapy. Most are not aware that antibiotics only kill bacteria, not viruses.  And most are not aware that the average upper respiratory infection is caused by any one of a few hundred types of viruses, which are constantly mutating and dodging our immune system’s defenses. This is why we still haven’t cured the common cold, which can manifest as a simple runny nose, congestion, and sneezing—- or even as an illness that feels just like the flu.

Did you know that a five-day course of azithromycin stays in your system for about ten to fourteen days?  One usually gets better from a cold in about one to two weeks without antibiotics on board.  Think about it—we may attribute our improvement to the antibiotic, but what really makes us better? The medicine or the passage of time?

In this age of germophobia, we are scared into adopting extreme hygiene measures.  We have been made to believe that we must buy disinfectant wipes for our kitchen counters. We are convinced that our clothes need nanosilver particles woven into them, and that wiping down our grocery cart handles can save us from serious illness. We have been made to feel that hand sanitizer is superior to the primitive practice of washing hands with soap and water. We have become completely intolerant of “dirt”. So to ask for antibiotics is natural, because it is perfectly aligned with this very real panic.  In reality, our irrational fears are weakening our immunity and are making us more susceptible to those very infections we are trying to avoid. Antibiotics are excreted through our urine, and once in our wastewater, many are unfilterable by sewage treatment plants. The resulting effluent is then discharged into our lakes, streams and oceans. Antibiotics are so ubiquitous in modern life that whether humans ingest them as prescription medications or not, they enter the body through the consumption of the milk and meat of livestock that routinely receive antibiotics in their feed. 

Antibiotics are associated with antimicrobial resistance—both in the community (i.e., they help create “superbugs”), as well as within the individuals who consume them.  That is, they increase the risk of your own personal resistance to antibiotics when you do truly need them.  This is an alarming problem worldwide. Not uncommonly, they can disrupt the normal intestinal flora, which no yogurt or probiotic can quickly restore.  In addition, they can cause clostridium difficile colitis (which is potentially life-threatening), ringing in the ears, hearing loss, kidney damage, yeast infections, tendon rupture, skin rashes, and serious allergic reactions. They can interact with other prescription medications you take. They may also be associated with heart arrhythmias, which in some cases can even lead to death. And though it has several limitations, one study shows that antibiotics may play a role in increasing the risk of developing Type 2 Diabetes. Some of these side effects above are more common to certain classes of antibiotics than others. However, despite such dangers, patients all over the world continue to be inappropriately treated with antibiotics for colds, sinusitis, viral bronchitis, viral ear infections, and viral sore throats.  

What about that colorful mucus we cough up? Many patients will expectorate into a tissue during the visit to show me the contents.  It’s then that I remind them that most head colds eventually do become chest colds. This does not mean that the cold has turned into a pneumonia.  Green, yellow, or even brown mucus from the nose or upper airways does not necessarily indicate a bacterial infection. Neither does the presence of a fever.  Facial pressure or pain may indicate bacterial sinus infection, but in the vast majority of cases, these sinus infections are viral can can be treated with symptomatic care, nasal irrigation and observation. Since it can be confusing to interpret your symptoms yourself, leave it to your doctor make the determination of whether your illness is viral or bacterial. 

If your doctor tells you that you have a virus, trust her.  Please don’t be disappointed with the diagnosis. After all, it’s not just a prescription you are there for, it’s her medical expertise that you seek— her training in the science of ruling in and ruling out disease. If she diagnoses you with a viral illness and discourages antibiotic treatment, know that she is on your side. Know that she is protecting you from the adverse effects of an unneeded drug.  To be honest—writing a prescription for an antibiotic is the easier thing to do. It takes just a few seconds and makes for a conflict-free situation for both parties.  But if she is dissuading you from taking the drugs, consider this: despite the risk of disappointing you (even enough to earn her a bad review), she is trying to do the right thing. She is not withholding treatment.  Nor is she downplaying or dismissing your suffering.  She knows firsthand that viral infections can be miserable. If it’s cold and flu season, chances are high that she’s trying to fight a cold herself.

It is true, many people coming to see the doctor for a URI are expecting a tangible prescription.  But most of these same patients are just as happy with a prescription for a medicine that isn’t an antibiotic, especially if the doctor explains why he has chosen not to prescribe antibiotics.  Certain prescription drugs can help relieve coughs, chest congestion, and post-nasal drip (the latter can cause sore throat and a pesky, lingering cough). Of course, as all medications, these prescription drugs too have their own side effects, but I think that these risks are more acceptable.

Let me add here, at the other end of the spectrum, there are those who have serious symptoms of infection and who choose to treat themselves at home with herbs, salves,  teas, or folk remedies.  To them I give a heartfelt warning: please seek medical advice! Though Three Rivers Ayurveda is an integrative medical practice, I am a family physician first and foremost.  Let your doctor figure out what is ailing you. Because if you are harboring a serious infection, say a pneumonia, the first-line treatment will be antibiotics; not herbs, supplements, or a special diet.

Please help your doctor spread the word that antibiotics, like all drugs, can have serious side effects, and should be used sparingly. They should be reserved for cases of true bacterial infection. All this being said, if patients are concerned that they are still not getting better despite the care outlined by their doctor for a viral infection (rest, fluids, over-the-counter medicines, honey, teas, etc.) they need to go back to their doctor for re-evaluation.

There’s so much more I want to talk about.  Maybe in a future post I’ll talk about antibiotic overuse in viral pinkeye, minor abrasions and cuts, non-Group A Strep sore throats, and styes. Another scenario I want to talk about is when antibiotics are prescribed before dental procedures for those patients who do not need it.  But I’ll save this for another time.  

It is our natural instinct is to send you home with something worthwhile, making you feel that your time and money were “worth it.” However, as as a profession, we need to change how we do this.  We need do a better job of checking the urge to comply with every antibiotic request.  If we want to stay true to our Hippocratic Oath of first doing no harm, it behooves us doctors to actually take the few extra minutes to explain why antibiotics are not a good idea in many cases. When we do this, patients understand that we are keeping their best interests at heart while helping them navigate through the myths surrounding upper respiratory infections. To me, spending the time to talk to patients as equal partners in health care is important because together, we are the stewards of judicious antimicrobial use. 

For more information, check out: http://www.choosingwisely.org/resources/updates-from-the-field/avoiding-antibiotics-overuse/

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*A few examples of fluoroquinolones are ciprofloxacin, levofloxacin, and moxifloxacin.