Antibiotic resistance occurs when bacteria no longer respond to the drugs designed to kill them. For more than a decade, the Centers for Disease Control along with other national and international agencies has supported an initiative called “Antibiotic Stewardship” the hallmark of which is the judicious, appropriate use of antimicrobials.
It’s told in some sobering statistics from the CDC, World Health Organization, and Food and Drug Administration:
Patients and providers must take equal responsibility. When we get sick, we often feel we need an antibiotic right away. In fact, we often demand one. A study published in the New England Journal of Medicine in 2018 found that to achieve a patient satisfaction rating in the 90th percentile physicians needed to prescribe antibiotics 75% of the time. Is this the correct approach to therapy? Are we using antibiotics too readily? What are the consequences of profuse antibiotic use?
In which of the following situations are antibiotics warranted?
A. Cold symptoms (runny nose, sore throat, headache) with a fever of 101F for 2 days
B. Cold symptoms lasting 12 days with persistent stuffiness and headache
C. Cold symptoms for 3 days with yellow-green mucous discharge
D. all of the above
The correct answer is B. Let’s discuss the reasons. Symptoms experienced as part of the common cold can include green/yellow sputum, cough, runny nose, stuffiness, sore throat, headache, fever, and mild muscle aches. This illness is caused by a virus, most likely a rhinovirus. Currently, 160 identified strains of rhinovirus are know.
Antibiotics work to destroy bacteria, not viruses since they have no activity against viruses. Antibiotics target specific bacterial structures or functions. Common bacterial targets for antibiotics include the cell wall (amoxicillin), ribosome activity (azithromycin), and bacterial DNA (levofloxacin). All of those are lacking in the very primitive structure of a virus. So, you could sit in a bathtub full of penicillin and not cure your cold with an antibiotic because there is simply nothing for the antibiotic to destroy in the viral structure.
Why are antibiotics appropriate after 10 days with cold symptoms? The typical common cold lasts between five and ten days with symptoms peaking around three or four days and waning at day six. If symptoms are consistent or regress and then become worse it is likely a sign of bacterial superinfections (super = on top of).
Usually, we carry certain bacteria with us as part of our “normal flora”. The mouth, nasal passages, large intestines, and skin host the most bacteria in the body. These bacteria work with our body and provide various “services” including protection against other more dangerous bacteria, digestion of food, and production of vitamins. A viral infection disturbs the normal balance of bacteria, allowing for proliferation and subsequent bacterial infection.
Why should we be careful about antibiotic use?
Antibiotics are not innocuous substances. They have significant side effect profiles. Adverse drug reactions associated with antibiotics can be less severe and consist of mild rash or nausea. More serious reactions include heart arrhythmias, tendon rupture, Stevens Johnson Syndrome (severe skin rash resembling thermal burns), and liver and kidney damage. Remember – every drug – not only antibiotics – has the potential to cause unpredictable adverse reactions
The most compelling reason to be careful about antibiotic use is resistance. Each time bacteria are exposed to an antibiotic, some are destroyed but others adapt to resist the antibiotic and live to see another day (remember Darwin’s Survival of the Fittest?). Antibiotics are unique in that the more they are used, the less effective they become. When antibiotics are used inappropriately – not taking them on schedule, for the right duration, taking them for a viral illness – bacteria have a chance to adapt to overcome the antibiotic activity. The resistant bacteria may go on to set up a resistant infection in you or that bacteria may be transmitted to others.
There are several ways we can combat this problem according to the Joint Commission on Healthcare Accreditation 2020 Standards. It is important to identify the causative agent if possible.
For example, a sore throat should not be treated with antibiotics until a throat culture or rapid strep test is obtained and a bacterial cause is identified. According to the Infectious Disease Society of America, 90 percent of adult sore throats have a viral cause, not bacterial. Avoid unneeded clinic or urgent care visits and utilize OTC and non-drug measures to manage non-bacterial infection symptoms.
Mislabeled allergy status leads to more expensive, less optimal antibiotic choices, more complex administration, increased resistance rates, and more treatment failures. The most common listed drug allergy in the US is Penicillin. According to the CDC, 10% percent of patients reports an allergy, however, < 1% of patients have a true allergy precluding penicillin or penicillin-like agents (the biggest class of antibiotic agents).
Vaccines may prevent bacterial infections or prevent viral infections which will avert a bacterial superinfection. Here are two examples of where vaccines can lower antibiotic use. The pneumococcal “pneumonia” vaccine protects against the bacterium Streptococcus pneumoniae. Following the current guidelines for vaccination during childhood and adulthood decreases pneumococcal infections. According to the CDC, this vaccine has reduced pneumococcal infections by more than 90% in children. In addition, antibiotic-resistant pneumococcal infections have decreased in the United States since the pneumococcal vaccine was introduced.
The shingles vaccine also minimizes antibiotic use. The shingles vaccine “Shingrix”, is currently approved for individuals 50 years old (and older) as a two-dose series. Not only does it effectively prevent the occurrence of shingles, a painful, debilitating re-emergence of the chickenpox virus, but also reduces the risk of a potential secondary bacterial skin superinfection. Vaccine prevention of viral illness may subsequently eliminate antibiotic use.
Educating patients and prescribers will lead to the proper use of antibiotics to curb antibiotic resistance.
Guest Author: Dr. Gretchen Welby, PharmD, MHA
Dr. Welby received degrees from Keystone College and Philadelphia College of Pharmacy and Science. She received a Master of Health Administration Degree from the University of Scranton and a Doctor of Pharmacy degree from Temple University. She is currently the Academic Director of the Physician Assistant Program at Marywood University where she teaches Anatomy, Physiology, Pathophysiology, and Pharmacology.
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This article is not intended as a substitute for medical treatment. If you have questions related to your medical condition, please contact your family physician. For further inquires related to this topic email: firstname.lastname@example.org
Paul J. Mackarey PT, DHSc, OCS is a Doctor in Health Sciences specializing in orthopaedic and sports physical therapy in Scranton and Clarks Summit. Dr. Mackarey is in private practice and is an associate professor of clinical medicine at Geisinger Commonwealth School of Medicine. For all of Dr. Mackarey's articles, visit our exercise forum!