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: drpmackarey@msn.com
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!
Ankle swelling is a common symptom that occurs when your body retains fluid in the lower legs, ankles and feet. Most people have experienced it at some point in their lives and it often resolves on its own with elevation and muscle movement. While it is usually benign and occurs on both sides of the body, in some instances immediate medical attention is required. The most common causes of ankle swelling are:
Prolonged Positions – you have probably noticed swelling in your ankles and feet after a long trip by plane or car. Some may also experience symptoms after a long day at work sitting or standing in one position for an extended period of time. It may be the most common cause of lower leg swelling and easiest to resolve.
Diet- excessive salt in your diet is associated with swelling in the lower legs, especially when associated with other risk factors for swelling such as organ function or obesity.
Varicose Veins – when the valves in the blood vessels which carry blood from the legs back to the heart are damaged, blood and fluid can collect in the lower legs. Prolonged standing or sitting without intermittent movement with worsen the condition.
Pregnancy – during pregnancy, the body retains more fluids than usual and most women experience some form of swelling in the lower legs, ankles and feet.
Medications – certain drugs can cause fluid retention in the lower legs such as: anti-inflammatory medications, steroids, diabetes medications, antidepressants and cardiac medications.
Blood Clots – blockages in the blood vessels of the lower leg can limit the movement of fluid from the legs back to the heart. It is often present in only one leg and associated with warmth, pain, and cramping. It is a serious condition and requires immediate medical attention.
Trauma/Infection – after a trauma or injury such as an ankle sprain, bruise or fracture, the damaged tissue leaks fluid surrounding the affected area. Also, when specific area of the lower leg can becomes infected, as in the case of a cut or splinter in the ankle or foot that has not healed properly, swelling occurs in the surrounding tissues. These situations are often associated with warmth, pain and limited to the side of the injury. Treatment to injured tissues and the infection is required.
Lymphedema – swelling in the lower leg can occur when there is a blockage in the lymphatic system is blocked or when lymph nodes are removed in surgery for cancer. Medications, massage, compression garments, and elevation, can address the symptoms.
Obesity – due to the excessive weight placed on the tissues of the legs, ankle and feet and adipose tissue in the abdomen compressing blood vessels, obesity is one of the most common causes of lower leg swelling. It also complicates all of the above conditions associated with swelling in the legs.
Diseases – such as those of the kidney, heart, and liver are associated with swelling in the lower legs.
Change Positions – on a long plane ride or sitting all day at school or work – get up and walk around every 30-45 minutes. Set a timer on your phone to remind you.
Exercise – regular exercises keeps the muscles and blood vessels in you lower extremities healthier. Also, intermittent movement of the leg muscles throughout the day, even when sitting, serve to prevent swelling. Try ankle pumps and toe curls.
Elevation – when sitting or lying down, try elevating your ankles and feet on a pillow to allow gravity to assist fluid movement in your legs.
Low-Sodium Diet – read the labels on your food and you will be shocked by how much sodium is in most foods, especially canned soups and vegetables. But, there are low-sodium options and don’t add more salt to your food.
Weight Loss – maintaining a healthy BMI is the single best thing you can do, not only for lower leg swelling, but for your overall health and wellness.
Compression Socks – for most people, over-the-counter compression socks will adequately prevent fluid retention in the lower legs. For comfort, begin with the lightest compression possible. 12-15 or 15-20 mm of mercury is a good start and put them on as soon as you get up in the morning, before swelling begins.
Visit your doctor regularly and listen to your body.
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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: drpmackarey@msn.com
Paul J. Mackarey PT, DHSc, OCS is a Doctor in Health Sciences specializing in orthopaedic and sports physical therapy. Dr. Mackarey is in private practice and is an associate professor of clinical medicine at Geisinger Commonwealth School of Medicine. For all of Dr. Paul's articles, check out our exercise forum!
Most people know that some medicines don’t work well together. However, many may not be aware that what you eat and drink can have an effect on some drugs, too. Natural herbal supplements and other over the counter drugs can also have serious interactions with your prescribed medications. So, it might be wise to talk with your physician or pharmacist to see if there’s anything you should stay away from before you take a medication for the first time.
This otherwise benign citrus fruit changes the way certain cells in your gut break down and metabolize medication through your body -- it can affect more than 50 drugs. It can make some, like fexofenadine (Allegra) for allergies, less effective and make others too strong, including ones that lower your cholesterol like atorvastatin (Lipitor).
Some dairy products, like milk, can make it harder for your body to process certain antibiotics. Minerals in milk like calcium and magnesium are part of the reason, along with the protein casein. If you’re taking antibiotics, ask your physician or pharmacist about the foods or beverages you should stay away from.
Licorice is a popular herbal remedy for digestion and to flavor foods. But glycyrrhizin, a chemical in licorice, can weaken the effect of some drugs, including cyclosporine, used to keep people who’ve had transplants from rejecting their new organs.
According to sources at WebMD, dark chocolate can weaken the effects of drugs meant to calm you down or make you sleep, like zolpidem tartrate (Ambien). It also can boost the power of some stimulant drugs, like methylphenidate (Ritalin). And if you take an MAO inhibitor, used to treat depression, it can make your blood pressure dangerously high.
Alcohol can make certain drugs less effective or even useless, including some blood pressure and heart medicines. It also can make others stronger than they should be or cause dangerous side effects.
Coffee, while typically enjoyable and harmless, contains caffeine which can affect the levels of antipsychotic drugs like lithium and clozapine. It can also but boost the effects (and side effects) of other drugs such as: aspirin, epinephrine (used to treat serious allergic reactions), and albuterol (taken by inhaler for breathing problems). Additionally, it can make it harder for your body to take in and use iron.
Iron supplements can lower the effects of levothyroxine (Synthroid), a medicine that gives you thyroid hormone when your body doesn’t make enough (a condition called hypothyroidism). If you take this medication and a multivitamin, check to see if the vitamin has iron in it. If you need an iron supplement, ask your physician or pharmacist if you can take your medication at different times.
These drugs help with the sneezing and runny nose caused by allergies and are in most cases safe to use. However, when they are combined with other medications it can make blood pressure medications less effective and raise your heart rate. Talk to your physician or pharmacist about other ways to manage your allergies if you take blood pressure medicine safely and effectively.
Vitamin K is the antidote to reverse anticoagulation. So, if you take the drug warfarin, (Coumadin) which is used to treat and prevent blood clots, be aware of how much vitamin K you take in. It can make the blood thinning drug less effective and put you at higher risk of a dangerous blood clot. Broccoli, Brussels sprouts, kale, parsley, and spinach are some of the most common foods high in vitamin K. Try to eat the same amount of these foods every day so the level of warfarin in your blood stays the same.
Ginseng, can also lower the effects of warfarin (Coumadin), putting you at risk for blood clots. And it can make you more likely to have internal bleeding, especially if you take antiplatelet medications (blood thinners) such as heparin or aspirin, as well as nonsteroidal anti-inflammatory drugs like ibuprofen or naproxen. For those who take MAO inhibitors, ginseng can cause headaches, sleep problems, hyperactivity, and nervousness.
While taken by many people with depression, this herbal remedy has not been a proven treatment for that, or any other health condition and it is not benign It increases the action of specific liver enzymes (things that boost certain chemical reactions in your body) that can weaken some medications. Those include cholesterol drugs (Lovastatin and Mevacor), the erectile dysfunction drug sildenafil (Viagra), and digoxin (Lanoxin), used to treat certain heart conditions. These are just a few of the many medications St. John’s Wort can affect.
As with St. John’s Wort, while used by many to help with or prevent high blood pressure, dementia, ringing in the ears (tinnitus), and other conditions, there is no research that supports its value. It can weaken the effect of drugs used to control seizures, including carbamazepine (Tegretol), and valproic acid (Depakote). Ginkgo biloba also has natural blood thinning properties that can increase your risk of bleeding, especially if taken with other blood thinning medications such as aspirin, ibuprofen, warfarin (Coumadin) and clopidogrel (Plavix).
According to WebMD, only about 50% of medication is taken as it’s prescribed. People often take less than they need, take it at random times, or leave big gaps between doses -- all of which can weaken the effects. Make sure you understand your treatment plan and follow your physicians instructions. Moreover, the use of some supplements, as well as what you eat and drink, may have a serious impact on the safety and efficacy of your medications…when in doubt; ask your physician or pharmacist!
Sources: WebMD; National Institutes of Health
Guest Contributor: Dr. Carina Mackarey Pharm.D. is a doctor of pharmacy and clinical pharmacist at Wilkes-Barre VA and Primecare Pharmacy Services in Scranton.
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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: drpmackarey@msn.com
For all of Dr. Mackarey's articles visit mackareyphysicaltherapy.com/forum/
Paul J. Mackarey PT, DHSc, OCS is a Doctor in Health Sciences specializing in orthopaedic and sports physical therapy. Dr. Mackarey is in private practice and is an associate professor of clinical medicine at Geisinger Commonwealth School of Medicine.
