I came back to LA about eight weeks ago from a visit in Israel and brought with me a bad upper respiratory tract infection. I know every sufferer’s first response (including my own … I couldn’t swallow and had a bad cough) is to get a prescription for antibiotics. I prudently waited a few days and did a throat culture which was negative. My symptoms initially got worse but they were clearly viral and required non antibiotic care. With time they are slowly resolving. So it was with great interest that I read the report in the Annals of Internal Medicine on appropriate antibiotic use for acute respiratory tract infection in adults. The report is 17 pages long but I will try to give a quick synopsis… after all, tis the season for all of us!
Acute respiratory tract infections include bronchitis, pharyngitis, rhinosinusitis and the common cold. They are the most common illnesses for acute outpatient office visits and antibiotic prescriptions in adults. According to the article, antibiotics are prescribed at more than 1 million adult ambulatory care visits annually and 41% of these prescriptions are for respiratory conditions.
Inappropriate use of antibiotics for these conditions can be dangerous. In the United States, at least 2 million antibiotic resistant illnesses and 23,000 deaths occur each year at a cost of at least $30 billion. Antibiotics are also responsible for the largest number of medication related events and are implicated in one of every five visits to emergency departments for adverse drug reactions. These can be serious (anaphylaxis or even sudden cardiac death, which is obviously extremely serious!) or mild (diarrhea or rash). An overgrowth of the bacteria called clostridium difficile can occur after normal bacteria are obliterated from the gut with antibiotics and this “wrong growth” causes severe difficult to treat diarrhea and can even be life threatening. Up to 500,000 adults develop this yearly and 29,300 deaths from clostridium difficile occur in the United States each year. All of these doom and gloom consequences, an estimated 50% of antibiotic prescriptions that are taken, are considered unnecessary or inappropriate!
So here is a brief summary of the recommendations for each type of acute respiratory infection:
Acute Uncomplicated Bronchitis: More than 90% of generally healthy patients with an acute cough have a syndrome caused by a virus. Even if there is yellow or green sputum it may not signify a bacterial infection. The changing color is due to the presence of inflammatory cells or cells that have sloughed off from the lining of the upper respiratory tract. Of course, with severe symptoms there is a concern about pneumonia, but in adults younger than 70 it is unlikely in the absence of a fast heartbeat, rapid respirations, fever or abnormal breathing sounds heard during an exam with a stethoscope. For most patients the treatment should be the use of cough suppressants, expectorants, antihistamines, decongestants and perhaps an inhaler such as albuterol. I guess those over-the-counter ads are for the most part are true…)
Pharyngitis: This is a sore throat that is worse with swallowing. It is unfortunately common and there are about 12 million visits to ambulatory care centers in the US annually for sore throat. Antibiotics are often unnecessary but are frequently prescribed. Again, in most cases, pharyngitis is due to a viral origin. If the sore throat is accompanied by cough, nasal congestion, conjunctivitis, hoarseness, diarrhea and muscle pain it is probably due to a viral illness. Most providers will rule out streptococcus infection with a rapid antigen test or a throat culture. If this is positive or if there are suspicious symptoms such as persistent fever, exudate (pus) and swollen tonsils, then antibiotics should be prescribed.
Acute Rhinosinusitis: The symptoms of this include nasal congestion and obstruction (stuffy nose), purulent nasal discharge, tooth pain, facial pain or pressure, fever, fatigue, cough, inability to smell, ear pressure, headache and bad breath. More than 4.3 million adults are diagnosed with sinusitis annually, and more than 80% get antibiotic prescriptions. Again most antibiotic prescriptions for this condition are considered unnecessary since the infections are most often caused by a virus. If however an infection continues with symptoms for more than 10 days without improvement or they become severe with onset of fever, the sinusitis may be from a bacterial cause and antibiotics could be necessary.
Common Cold: This is a benign, self-limited illness and is the most common acute illness in the United States. It usually includes sneezing, runny nose, sore throat, cough, low-grade fever, headache and a general sense of feeling ill. (I don’t think I have to define the symptoms but it makes me sound more authoritative.) Use of an antibiotic will not prevent complications. There are about 37 million ambulatory care visits each year for the common cold, and roughly 30% result in an antibiotic prescription. As we all know the best method to reduce spread is appropriate hand-washing. Treatment usually includes an antihistamine, an analgesic, and a decongestant and these may be in one product or several. Zinc supplements have been shown to reduce the duration of common cold symptoms in healthy persons if administered less than 24 hours after symptom onset.
I just sneezed over my iPad as I wrote this…pretty psychosomatic! In a germless summary, if you start to have any of these upper respiratory tract infection symptoms you might want to wait before you make that phone call to your medical provider with the message, “Help I need an antibiotic”. Not only will the antibiotic not cure the virus that is most likely causing your symptoms, inappropriate use may end up increasing antibiotic resistance and when you do need one it won’t work for you or for others!
I just read the following cartoon in the New Yorker and thought it would be appropriate to end this fairly long article.”Would you like to try some of our over-the-counter drugs while you wait for your prescription?”