HEALTHCARE
January 26, 2016

You Don't Need Antibiotics

Why do people go to the doctor hoping to make cold symptoms disappear when it doesn't work and can be dangerous?

The sneezes, sniffles, coughs and sore throats of winter send patients to their doctors looking for relief, usually in the from of a prescription for antibiotics to treat their symptoms. Are antibiotics always necessary? Absolutely not, though clinical practice often reflects otherwise.

Viruses cause most acute respiratory infections (ARTI), so they should not be treated with antibiotics, although they may benefit from treatment with medications aimed at relieving troubling symptoms while the viral infection runs its course.

Unfortunately, antibiotics continue to be overused for treatment of respiratory infections, due largely to patients' expectations and doctors' failure to comply with treatment guidelines. Not only is antibiotic treatment for respiratory infections usually unnecessary, it causes unwelcome problems for both individual patients and for public health.

Just as with any kind of drug, antibiotics should be prescribed with a careful consideration of the risks and benefits. They are not risk-free. People taking antibiotics may experience allergic reactions that range from rashes to life threatening anaphylaxis. Antibiotics also can destroy intestinal flora, your body's microbiota, causing annoying to debilitating diarrhea, or creating an imbalance in your gastrointestinal system to the point where a serious condition, clostridium difficile (c. diff) diarrhea develops.

Not only is antibiotic treatment for respiratory infections usually unnecessary, it causes unwelcome problems for both individual patients and for public health.

Antibiotic prescriptions are also expensive. They are a large consumer of health care spending. One study found that up to 50% of outpatient antibiotic prescriptions were unnecessary or inappropriate. This was estimated to equal $3 billion in costs. And widespread antibiotic use has contributed to the emergence of antibiotic resistance, strains of bacteria that no longer respond to common and necessary treatments.

Needed: More Realistic Expectations

What should a patient expect when they go to the doctor with a cold, sore throat, cough or sinus pain? Recent clinical guidelines published in the Annals of Internal Medicine outlined the standard of care for ARTIs, including bronchitis, pharyngitis, rhino-sinusitis and the common cold.

Bronchitis
Bronchitis is the most common condition for inappropriate antibiotic prescriptions in U.S. adults. It is an inflammation of the large airways which typically produces a cough which may last for as long as six weeks. Sputum may be clear or colored. Over 90% of cases of acute bronchitis are caused by a virus.

Symptoms of sinusitis include nasal congestion and obstruction, thick nasal drainage, tooth pain, facial pain and pressure, fever, fatigue, cough, changes in sense of smell, pressure and fullness in ears, cough, headache and bad breath. These can last as long as a month.

Unless a person's history and clinical exam suggest the possibility of pneumonia, the new clinical guidelines suggest that health care providers should not perform additional testing, or treat with antibiotics.

People with bronchitis may be helped by cough suppressants, expectorants, antihistamine, decongestants, and bronchodilators.

Pharyngitis
Pharyngitis is typically a benign illness whose primary symptom is a sore throat. It rarely leads to anything more serious.

Most sore throats are caused by viruses and last about a week. Patients may also have a cough, nasal congestion, conjunctivitis, hoarseness, diarrhea, and sores in their mouths. The presence of these symptoms increases the likelihood that the cause is viral.

Viral sore throats do not respond to or require antibiotics.

It is important to make sure that the cause of the sore throat is not group A streptococcus, better known as strep throat. This does require antibiotic treatment. Symptoms that suggest a bacterial cause include persistent fever, chills, night sweats, tender lymph nodes, and signs of infection on the tonsils and palate. If strep throat is suspected, patients can be tested with a rapid antigen test or a throat culture. If, and only if, streptococcus is confirmed, should patients be treated with antibiotics.

Most sore throat symptoms can be relieved with medications such as acetaminophen, NSAIDs (non-steroidal antinflammatories) or throat lozenges.

Rhino Sinusitis
Rhino sinusitis is an inflammation of the tissue that lines the nasal and sinus cavities. It can be caused by virus, allergy, or irritation. Symptoms of sinusitis include nasal congestion and obstruction, thick nasal drainage, tooth pain, facial pain and pressure, fever, fatigue, cough, changes in sense of smell, pressure and fullness in ears, cough, headache and bad breath. These symptoms can last as long as a month.

Antibiotics are often prescribed for acute rhino sinusitis because symptoms can linger but it is usually caused by viruses. Sometimes the initial viral infection makes it hard to get rid of mucous from the sinuses and a secondary bacterial infection can develop, but this is uncommon.

If there is no improvement in symptoms for 10 days, if there is fever greater than 39º Centigrade or 102.2º Fahrenheit, if there is deep yellow or greenish nasal discharge or facial pain lasting for more than three days in a row, or if symptoms begin to improve and then worsen again, a bacterial cause should be suspected.

Most cases of acute rhino sinusitis resolve without antibiotic treatment. In fact, because of adverse reactions to the antibiotics, antibiotic treatment can do more harm than good.

Treatment recommendations are for supportive care with analgesics for pain and fever, decongestants, nasal irrigation, intranasal corticosteroids, and antihistamines.

The Common Cold
Most people know the common cold with its sneezing, runny nose, sore throat, cough, low-grade fever, headache, and fatigue just needs time to go away. Even so, there are about 37 million doctor visits for the common cold, and about 30% result in treatment with antibiotics.

There is absolutely no role for antibiotics in the treatment of the common cold. Importantly, particularly for parents of children with colds, antibiotics do not prevent complications such as acute bacterial sinusitis, asthma exacerbations, or ear infections.

Symptoms can be managed with antihistamines, analgesics like aspirin or acetaminophen, decongestants, cough preparations, and zinc supplements.

The Bottom Line

Most acute respiratory tract infections do not require treatment with antibiotics. Using antibiotics for these conditions is not harmless. It puts people at risk for adverse side effects and contributes to the emergence of strains of bacteria that do not respond to currently available antibiotics. Unnecessary antibiotic use also costs millions of dollars in unnecessary health care spending.

When you go to your health care providers with symptoms of respiratory infections, do not automatically expect an antibiotic prescription. Go seeking a full clinical evaluation, careful attention to the history and symptoms of your illness, and an informed decision regarding treatment.

Unnecessary antibiotic use racks up millions of dollars in unnecessary health care spending.

In most cases, your symptoms will resolve on their own, even if more slowly than you would like. Symptoms may be relieved by medications that are available over-the-counter or by prescription.

Ask your health care provider what symptoms you might expect, the likely duration of your illness, and when you should come back for reevaluation if you are not improving.

The study is published in Annals of Internal Medicine.

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