Friday, April 17, 2015

What I want my patients to know about antibiotics

I saw a patient recently that had been very ill for quite some time with a variety of weird symptoms, some of which were very concerning. I recommended further testing to help us narrow down what the problem might be.

Her response: "Can't you just give me an antibiotic?"

Ohhhhhh no. I tried to explain that I can't just "give [someone] an antibiotic" if I don't know what disease I am trying to treat. I explained again that she needed more testing so we could figure that out, and maybe, if appropriate, start an antibiotic.

She never had the testing done. She wanted to start feeling better today.

Working in urgent care as I do, I prescribe antibiotics every day. People are often miserable when they come to see me and the request for antibiotics is frequent. They want a quick fix. I often hear, "Well, I have to do this huge presentation next week at work, so I want an antibiotic so I can be better by then."

The reality is, their immune system is the one that is going to have to dig them out of this miserable illness, and the best care I can give them is to try to alleviate their symptoms in the meantime.

Here are a few things I wish every patient knew about antibiotics.

1. Antibiotics aren't harmless

The most common side effects of antibiotics are nausea, diarrhea, and vomiting, along with allergic reactions. They are hard on your digestive system. There is also the risk of yeast infections among women, and pathological diarrhea, C. difficile, which can also result from antibiotics.

Then there is the risk of increasing the prevalence of antibiotic-resistant bacteria. These pathogens require the big guns to treat and there a few strains out there with no known antibiotic to treat them. Often these bacteria are kept in check by other bacteria in and on your body, but if the "good" or "less harmful" bacteria are frequently killed off by antibiotics, it increases the risk that these resistant bacteria will be allowed to flourish.

Last, there is a multitude of research coming out now about the Microbiome--the colonies of good bacteria living in your digestive tract. This research is interesting and exciting, because scientists are increasingly finding links to the types of bacteria in your gut to allergies, autoimmune diseases, digestive disorders, metabolic disorders (like obesity and diabetes), mental illness (believe it or not), and others.

There is a lot of need for more research in this area, but some studies are suggesting a possible link between early antibiotic use and childhood allergiesasthma, and inflammatory bowel diseases (like crohn's disease or ulcerative colitis).

[I don't want any parents out there freaking out about what I just said. We don't know for sure what the link might be. I'm just making a point that some caution is merited.]

2. Antibiotics aren't always necessary or even appropriate

The number one thing that I see in urgent care is upper respiratory illness: coughs, sore throats, colds,  and sinus infections.

The number one cause of upper respiratory illnesses is VIRUSES. Antibiotics treat bacterial infections. They do not treat viral illnesses, or illnesses caused by fungi, parasite, or protozoa.

Even if your snot is bright green, that doesn't necessarily mean you have a bacterial infection. The green color is caused by your immune system doing its job, and there hasn't been much correlation in the literature between mucous color and type of infection.

Antibiotics don't treat the common cold, most sinus infections, most coughs, or most sore throats, so I usually don't give people antibiotics for these.

I am frequently a heartbreaker.

To help you out, here are some of the guidelines I follow:

1) I never give antibiotics for the common cold
2) I try not to give antibiotics for sinus infections unless they are quite severe or have been going on close to 2 weeks
3) 75% of ear infections will clear up on their own within 7 days, and antibiotics usually only shorten the course of symptoms by 1 day. Current recommendations suggest waiting 48-72 hours to see if it will improve alone before starting antibiotics. The exception to this is young kids, especially less than 6 months old. The first treatment for ear infections is tylenol or ibuprofen for pain control.
4) I rarely give antibiotics for coughs (including bronchitis), unless I really suspect pneumonia. 90% of bronchitis is viral.
5) I rarely give antibiotics for sore throats unless someone tests positive for strep. If you have a sore throat with no fever and have a cough with it, there's a really good chance it's not strep.

3) Some times when you really should go to the doctor

That said, antibiotics, when used like they should be, are amazing! They save lives every single day. I'm not an antibiotic hater by any means.

Here are some times you really should get to the doctor:

1) You strongly suspect strep throat. Strep (the bacteria) can travel to other areas of the body and lodge there, including your heart (rheumatic fever) and your kidneys. If you truly have a full-blown infection, you need to treat it.

2) You have a raging UTI (urinary tract infection). Some UTIs will clear up on their own with lots of hydration. The ones that don't, however, may travel up to your kidneys, where they will make you incredibly sick. Sometimes once bacteria reaches your kidneys it has easy access to your bloodstream, which can cause sepsis (an infection in your bloodstream). By no means will every UTI do this, but they are worth treating.

3) You have a fever and a cough or your child's breathing scares you. If you have a fever and a cough together, there are two things I'm concerned about: influenza and pneumonia. You may not have either. But knowing you have influenza gives me the chance to get you on medication for it (if appropriate, especially for someone very young or with asthma) and also to tell you to stay the heck away from other people! Never go out in public or allow your kids to go to school with influenza. It kills thousands of people every year.

Pneumonia can also be very serious (sometimes life-threatening), and I always treat people with pneumonia.

If your child is having difficulty breathing or their cough is so bad it's freaking you out, COME IN! There are a couple of things we can do for that. Antibiotics may or not be on the list.

4) You have vomiting or diarrhea along with high fever, significant pain, dehydration, or bleeding. Most vomiting and diarrhea will clear up on its own, and diarrhea may linger for 2 weeks or so. Dehydration can be dangerous, however, and some types of bugs that cause stomach flu symptoms can also be dangerous. They are worth investigating if some of these "danger signs" are present.

5) You're worried about yourself or your child. There are hundreds of legitimate reasons to look for medical care, and my intent in writing this isn't to scare anyone off from coming to the doctor's office if they're sick or worried! Come. Sometimes I find people that felt reluctant about coming in are actually very seriously ill.

But remember this: if you go to the doctor, and you leave without a prescription for antibiotics, that's not always a bad thing.


  1. Thank you for all the information. It has taken us some time to finally have found a pediatrician who doesn't push antibiotics on us every time our kids are sick. Modern medicine is amazing and I'm glad we can get medications when we really need them.

  2. I love this post! I'm totally sharing it. I'm always shocked at how many of my friends truck their kids to the doctor and get antibiotics any time they're sniffly!

    I have a bit of a tangential question since you mentioned pneumonia - what do you consider pneumonia? I've realized in the last few years that it seems like every medical professional I encounter has a totally different definition...

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  4. The Microbiologist in me yells in glee! (Also, it has now been shown that once you take an antibiotic, it can take as long as 2 years to get your stomach microbiome similar to your pre-antibiotic medication). (I deleted the previous comment trying to get rid of that picture of myself with a bloody nose! Gross!)

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