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Do you really need that antibiotic?

Question  Do you need an antibiotic for every illness?

Answer No.

Its hard to believe that penicillin was only discovered in 1928 by Sir Alexander Fleming.  It became widely available in 1945.  In that three-quarters of a century we are now looking at the beginnings of antibiotic resistance due to overuse.  TV shows like "The Knick" tell stories of turn-of-the-century medicine where patients routinely died from curable infections like appendicitis, meningitis and sepsis.   Now, in 2023, antibiotic resistance is a top global health threat and America reports an estimated 2.8 million antimicrobial-resistant infections, leading to more than 35,000 deaths.

Now, we have a disconnect between physicians and patients regarding necessity and usage of antibiotics.  Antibiotics are used as anti-bacterial agents which by definition mean they are helpful in bacterial infections. The truth is, many infections are viral.  Did you know that 70% of pharyngitis (throat infections) are viral in children aged 5-16? This number increases to 85-95% in adults.  Many patients come in thinking they have "strep throat" and leave with a diagnosis of pharyngitis.  Strep throat suggests the pharyngitis is caused by streptococcus, a common bacteria that lives on our skin.

As physicians, our experience in symptom pattern recognition helps us to determine if infections are viral or bacterial in nature.  Many upper respiratory infectious start out as viral infectious most commonly from adenovirus, rhinovirus, influenza and SARS.  If a patient's immune system is working hard to fight a virus, we can see secondary bacterial infectious develop.  This is why your physician asks questions about time-course and which symptoms happened at what time.  Evidenced by the recent COVID19 pandemic, antibiotics were only helpful if patients developed a bacterial infection while they were fighting COVID19.

Unfortunately, our health care system has poor access to experienced physicians.  Patients are often unable to get into see their physicians.  Many patients fear if they don't get antibiotics at their visit, they won't be able to get another appointment and therefore, pressure physicians to give antibiotics.  This poor access lead to the development of urgent care centers which seem to give Z-packs and prednisone for every ailment.  In urgent care centers, and hospitals, physician's can have their salaries decreased with poor satisfaction scores.  This leads to over-prescribing of antibiotics and medications to ward off bad reviews.

Direct primary care improves access.  Patients are able to discuss symptoms and receive guidance.  They know they have a trained physician that knows when antibiotics are needed immediately and when we can treat symptoms without needing antibiotics.  Patients know their physician will be available if their symptoms worsen and they can access antibiotics, if needed.  

"Swallowing an antibiotic is like carpet-bombing the trillions of microorganisms that live in the gut, killing not just the bad but the good too," said Dr. Martin Blaser, author of the book “Missing Microbes” and director of the Center for Advanced Biotechnology and Medicine at Rutgers University.  If you take a lot of antibiotics, you are at risk for an antibiotic-resistant infection with a "superbug." Moreover, excess antibiotics leads to disruption in the gut microbiome which could increase risk for metabolic disease such as diabetes and autoimmune disease.

This New York times article suggests the need for increased awareness by physicians but also patients.  If a clinician offers a therapy option, such as antibiotics, you should consider their training and ask how and why they are suggesting their plan.  You should feel empowered to ask what the diagnosis is and what options exist so you can make an appropriate choice for your health.

Antibiotics were an amazing discovery and critical in the practice of medicine.  We must honor their ability to heal as well as harm if not used appropriately.  All therapeutic interventions have a risk and benefit; it is important to consider both when making a decision about your care. 


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