Antibiotics Aren’t Always the Answer

Al-Azhar Park in Cairo, Egypt. (Dr. Noorali Bharwani)
Al-Azhar Park in Cairo, Egypt. (Dr. Noorali Bharwani)

Are we prescribing too many unnecessary antibiotics for cold, cough and sinusitis? Yes, says an article in the Journal of the American Medical Association (Internal Medicine: May 3, 2016).

The article is titled, “Prevalence of Inappropriate Antibiotic Prescriptions Among U.S. Ambulatory Care Visits, 2010-2011,” by Fleming-Dutra, Hersh and others.

The research comes amid ongoing concern about antibiotic resistance, which has been blamed for at least two million illnesses and 23,000 deaths annually, according to the US Centers for Disease Control and Prevention (CDC).

People with sore throats, ear infections and sinus infections get the wrong antibiotic at least half the time. When that happens patients are not cured and it helps drug-resistant “superbugs” evolve, says the article.

What is the most commonly misused drug?

Zithromax, also known as “Z-Pack” or azithromycin. “Z-Pack” is a name easy to remember, so patients ask for it.

“Overall, only 52 per cent of patients treated with antibiotics for sinus infections, middle ear infections and pharyngitis (sore throat) received the first-line treatments recommended by prescribing guidelines,” Dr. David Hyun, an infectious disease specialist at the Pew Charitable Trusts, told NBC News.

Research also shows at least a third of people who get antibiotics don’t even need them. There is lot of bad prescribing of antibiotics. Ear infections, sore throats and sinus infections generate 44 million antibiotic prescriptions a year.

Antibiotics are essential to treat certain conditions. Strep throat is easily treated with antibiotics, and if a child with a middle ear infection has pus oozing out, a pediatrician will usually give an antibiotic. Sinus infections that linger may be helped with antibiotics. Experts do not disagree on that.

Quite often infection is caused by viruses. In that situation, antibiotics will not help. When an antibiotic is called for, it should be a basic one – usually amoxicillin, according to Pew researchers. However, that’s not what people usually get.

If you are allergic to penicillin and have pharyngitis then Zithromax should be tried. But Zithromax is not recommended for sinus or middle ear infection.

The reason doctors end up prescribing Zithromax is because of the pressure from patients and the convenient dosage. Not to mention sleek packaging.

To prevent misuse of antibiotics, doctors and patients should ask whether antibiotics are really necessary and if yes then what is the correct antibiotic. Medical experts have been complaining about the misuse of antibiotics for two decades, but the message still is not getting through, says one of the experts.

“Antibiotics are lifesaving drugs, and if we continue down the road of inappropriate use we’ll lose the most powerful tool we have to fight life-threatening infections,” said CDC Director Dr. Tom Frieden.

Sinusitis was the single diagnosis associated with the most antibiotic prescriptions. Drugs are not usually needed to treat sinus infections, which are often caused by fungi that are not affected by antibiotics. Up to 70 per cent of people with acute sinusitis recover without any prescribed medications, the American Academy of Allergy, Asthma and Immunology says on its website.

The point is we should use antibiotics only when we really need it. Otherwise it’s just a waste of money. And dangerous to our health.

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A concerned mother has a question: My pediatrician recently told me that he no longer recommends that patients who are prescribed antibiotics finish their entire dose. He said that recent research shows that finishing the dose may lead to greater antibiotic resistance, not less. He also said that pediatricians are no longer automatically prescribing antibiotics for bacterial ear infections. Could you comment on these two points in one of your columns?

Sure, I can do that. The use of antibiotics and other agents is widespread among humans, animals, in agriculture and other industries. I don’t think there is a person or an animal who has not been prescribed antibiotics. Let us look back in time.

Canadian statistics show that in 1999, about 25 million prescriptions for oral antibiotics were dispensed and that, after cardiovascular and psychiatric drugs, antibiotics were the most commonly prescribed class of agents, says an article in the Canadian Medical Association Journal.

Seventy years ago, sulphonamides (popularly known as sulpha) was the first chemical agent discovered to kill bacteria. Until then molds had been used to fight infection for 2500 years, but its effect was unpredictable and sometimes toxic.

In 1928, a Scottish physician, Alexander Fleming, noticed that a small amount of mold growing on a Staph culture destroyed the bacteria. He named an extract of the mold penicillin. In early 1940s, penicillin was mass-produced by drug companies. Since then many anti-bacterial agents have arrived in the market.

There is no doubt that modern anti-bacterial therapy has considerably decreased illness and deaths from infections, has prevented disease, and has contributed significantly to the development of modern surgery, trauma therapy, and organ transplantation.

“The broad application of antimicrobial agents in modern medicine has not, however, been problem-free. These agents occasionally cause major adverse reactions, interact with other classes of pharmacologic agents, and exert a major selective pressure for widespread antimicrobial resistance among bacteria,” says one textbook of medicine.

So, how long should one take antibiotics for?

Just the right number of days! And there is no magic formula. Short therapy fails to cure the illness. And unnecessarily prolonged therapy leads to undesirable reactions. For most acute infections, it is a good idea to continue therapy for two to three days after the temperature has returned to normal and all signs of infection have gone. If in doubt, then ask your physician.

What about antibiotics for ear infection?

The diagnosis of middle ear infection has the distinction of being the single most common diagnosis reported from pediatric office practices, yet there is no consensus in the literature about optimal methods of diagnosis, prevention, treatment and follow-up, says some medical literature.

Ear infection can be viral or bacterial. Seventy-five percent of children experience at least one episode of middle ear infection by their third birthday. Almost half of these children will have three or more ear infections during their first 3 years.

The majority of uncomplicated cases of ear infection do not require antibiotics as they resolve spontaneously. Since there is so much confusion on how to care for ear infection, a clinician’s experience may be more important than actual scientific knowledge. So, follow your physician’s advice regarding use of antibiotics for this condition.

Finally, here is what Caskie Stinnett said about antibiotics:

“The trouble with being a hypochondriac these days is that antibiotics have cured all the good diseases.”

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!