Patient Handout: Antibiotics

Common myths about infections and antibiotics

Much attention has been given to the fact that antibiotics are given too often. The reason for this concern is that the overuse of antibiotics can create resistance in the bacteria a person carries, making it much harder to treat serious infections in the future.

For that reason, the physicians in our practice are trying to avoid using antibiotics unless they are necessary. The problem is that many patients come to the office already convinced that their infection requires an antibiotic and so will not be satisfied unless they get one. This puts our staff in a difficult position, as we want to practice good medicine, but also strive keep our patients happy.

To help with this problem, here is a list of common misconceptions about when antibiotics are appropriate.

  • If mucous is green, it is time for antibiotics. Almost all respiratory infections go through a stage where the mucous turns green (or darker). This is due to a large number of white blood cells, and may actually mean that your body is winning the battle against the infection.
  • When a fever starts, it is time for antibiotics. Fever is part of the body’s defense against infection. Even fevers as high as 104 can be caused by viruses (which are not killed by antibiotics).
  • Sinus pain means you need antibiotics. Sinus pain is caused by a difference in pressure between the inside of the sinuses and the outside world. This is usually caused by thick mucous, and not necessarily infection. Decongestants can help with this (although they may not be appropriate with certain heart conditions and hypertension), as can salt water spray in the nose. The pain is best treated with acetaminophen (Tylenol, etc), or ibuprofen (Advil, etc.).
  • “The last time I had this I needed antibiotics, so I wanted to catch it early this time.” Most infections that do require antibiotics start with a virus infection and then turn into bacterial infection for which antibiotics are appropriate. To treat an infection “early” means that you would treat it when it does not yet need antibiotics. This is exactly what can cause resistant bacteria. If your symptoms are that of a virus, then antibiotics are a bad choice.
  • Bronchitis requires antibiotics. While there are some cases of bacterial bronchitis, the majority of cases of bronchitis are caused by viruses. Bronchitis happens when a person has a coarse cough (loose phlegm), and does not have pneumonia (as heard by the physician on exam). Overall, bronchitis probably accounts for the biggest number of inappropriate antibiotic prescriptions.
  • “I am immune to amoxicillin.” Amoxicillin is not the strongest antibiotic. This is exactly the reason we like to use it first. The goal of antibiotic therapy is to knock the bacterial infection down to the point that a patient’s body can do the rest. Most of the time, the “weaker” antibiotics do the job just fine. Stronger antibiotics are used when:
    • A person is has just finished a course of “weaker” antibiotics. In this instance, the bacteria are more likely to be resistant. This resistance only lasts for a few months.
    • A person who is physically frail.
    • An infection that appears especially serious.
  • “Can I have antibiotics to be on the safe side?” Antibiotic resistance is much less safe than waiting to see if an antibiotic will be needed.
  • “Can you call in an antibiotic?” We usually don’t call in antibiotics. The one sure exception for this is if a family member has a documented case of strep throat. The contagiousness of this is enough that it is reasonable to call it in. Sinus infections, bronchitis, and ear infections are not something we will call in antibiotics for. Please don’t ask.
  • “When I got an antibiotic last time, I got better. That means the antibiotic made me better.” Thankfully, most illnesses get better over time. It is very possible that it would have gotten better just as fast without the antibiotic. Just because the rooster crows every morning, doesn’t mean it causes the sun to rise.

In the past, physicians were quick to offer antibiotics in many situations we now know they are not needed. This changed, not only with the emergence of resistance, but also with studies that show that they may not really help. Here are some examples:

  • In one study, parents of children with obvious ear infections and fever were given ear drops to treat the pain and a prescription of an antibiotic to use if the child did not get better. 90% of the parents did not fill the antibiotic prescription.
  • A recent study of patients with sinusitis and fever showed that antibiotics and prednisone were no better than placebo at treating the infection.

Much of the problem is our mindset. Even many doctors and nurses find it hard to un-learn the long-held beliefs in antibiotics (so past and even recent experiences with physicians may not reflect this new mindset). Still, the need to change is clear.

We really want to practice the best medicine on our patients. I hope that reading this will help you realize that when we are reluctant to offer antibiotics, it is really in your best interest. If we use them unnecessarily, then when you really need them, they might not work. Please help us accomplish the goal of doing what is best for you and for all of our patients.

33 thoughts on “Patient Handout: Antibiotics”

  1. Clear and convincing. I’m a little disappointed that there wasn’t at least one zinger. Like “some studies suggest to lower the risk of drug resistance, pills might be inserted directly into the nose.” On the other hand…

  2. Clear and convincing. I’m a little disappointed that there wasn’t at least one zinger. Like “some studies suggest to lower the risk of drug resistance, pills might be inserted directly into the nose.” On the other hand…

  3. I think these handouts are a great idea! From the patient’s perspective it would be nice to get one of these. You would have it to refer to should you wonder if your at a point you need to call or take a wait and see approach.

  4. I think these handouts are a great idea! From the patient’s perspective it would be nice to get one of these. You would have it to refer to should you wonder if your at a point you need to call or take a wait and see approach.

  5. Great list. I did such a thing once. Handed it to the patient. They glanced at it and said,” So, you’re not going to call it in?”They went home and called my partner who called it in for them….
    Changing the course of a herd takes communication and cooperation. I found this sort of thing a real “Opportunity” for selection…by both patients and physicians…

  6. Great list. I did such a thing once. Handed it to the patient. They glanced at it and said,” So, you’re not going to call it in?”They went home and called my partner who called it in for them….
    Changing the course of a herd takes communication and cooperation. I found this sort of thing a real “Opportunity” for selection…by both patients and physicians…

  7. Great list. One thing that I might suggest (from a patient perspective) is a paragraph explaining that all antibiotics have side effects and that some of these side effects while rare could be serious. For many people a very small but immediate risk of something bad (kidney failure, hearing loss, take your pick) may be scarier than discussion of antibiotic resistance. You can have a several most often prescribed antibiotics with the list of most serious potential side effects for each. Look at how much discussion and outcry there is when some news story about some rare side effect of some new drug breaks out. Yet, the risk of a particular side effect is usually rare.
    This is from personal experience: I grew up in the 70s in a communist country plagued by shortages of everything, including antibiotics. Partially because of the shortages, but the antibiotics were reserved for really serious infections like pneumonia. At the same time, doctors did a really good job convincing everyone that all antibiotics have potentially serious side effects and should be avoided unless absolutely necessary. As a result, rather than ask for antibiotics, we were weary of them. The only time I had antibiotics before coming to the US was at 15 when I had a two-sided pneumonia. It was actually quite surprising to see how quickly antibiotics were prescribed in the US in the 80s.

  8. Great list. One thing that I might suggest (from a patient perspective) is a paragraph explaining that all antibiotics have side effects and that some of these side effects while rare could be serious. For many people a very small but immediate risk of something bad (kidney failure, hearing loss, take your pick) may be scarier than discussion of antibiotic resistance. You can have a several most often prescribed antibiotics with the list of most serious potential side effects for each. Look at how much discussion and outcry there is when some news story about some rare side effect of some new drug breaks out. Yet, the risk of a particular side effect is usually rare.
    This is from personal experience: I grew up in the 70s in a communist country plagued by shortages of everything, including antibiotics. Partially because of the shortages, but the antibiotics were reserved for really serious infections like pneumonia. At the same time, doctors did a really good job convincing everyone that all antibiotics have potentially serious side effects and should be avoided unless absolutely necessary. As a result, rather than ask for antibiotics, we were weary of them. The only time I had antibiotics before coming to the US was at 15 when I had a two-sided pneumonia. It was actually quite surprising to see how quickly antibiotics were prescribed in the US in the 80s.

  9. This was interesting Rob. I remember when docs would say if it’s green then you need antibiotics.
    I didn’t know that the green was indicative of our bodies fighting and winning over the infection.

    I had an awful uRI back in nov/dec and after 2 weeks of NO improvement caved and went to the doctor secretly hoping he’d give me antibiotics because i was sure I needed them but stated that I didn’t want antibiotics if not necessary because I know it isn’t good to do that. i didn’t get antibiotics. The week before, he told me to drink honey, tea and lemon and at the office he said to sit in a hot steamy bathroom twice a day for 10-15 minutes. and to stop taking the theraflu.

    I lived on the honey/tea and lemon and it is the ONLY think that stopped me from coughing but I was taking it constantly. I had to use crest whitener for a couple of weeks to get my teeth white again! The steamy bathroom did wonders!

    So…now here I am…with an URI…again..but not quite as bad. So, i am not using theraflu and using the hot steamy bathroom. Also, I am only drinking the honey, lemon and hot water because i don’t want to stain my teeth.

    Rob…or anyone…is there any reason that one is supposed to drink tea with the honey, lemon and hot water? It tastes good, but is it medicinal?

    I also just started using MonaVie although I didn’t take it yesterday because of the energy boost and I wanted to sleep as much as I could. Took it again today though because i am hoping all the antioxidants in it also give my immune system a boost.

    I probably did get antibiotics a lot in the past for bad URIs and believed they worked because I got better. There was a lot of emotional comfort in thinking you could just get an antibiotic and get better. And even though I knew better…I still couldn’t help wondering if my doc made a mistake last time…but he was right and I got better.

    WhiteCoat had just written a post about the over use of antibiotics prior to my getting sick and so armed with that info is why I bit the bullet and said what I said. This doc had given them to me in the past for same symptoms although perhaps he thought the bronchitis was bacterial.

    WhiteCoat also mentioned nasal washes which I did get and have used although not consistently stuffy.

    You docs are helping to get the word out to us patients. I may not have believed him otherwise. Not that I don’t trust him but because it was all I have ever known.

    Thanks for the informative post! 🙂

  10. This was interesting Rob. I remember when docs would say if it’s green then you need antibiotics.
    I didn’t know that the green was indicative of our bodies fighting and winning over the infection.

    I had an awful uRI back in nov/dec and after 2 weeks of NO improvement caved and went to the doctor secretly hoping he’d give me antibiotics because i was sure I needed them but stated that I didn’t want antibiotics if not necessary because I know it isn’t good to do that. i didn’t get antibiotics. The week before, he told me to drink honey, tea and lemon and at the office he said to sit in a hot steamy bathroom twice a day for 10-15 minutes. and to stop taking the theraflu.

    I lived on the honey/tea and lemon and it is the ONLY think that stopped me from coughing but I was taking it constantly. I had to use crest whitener for a couple of weeks to get my teeth white again! The steamy bathroom did wonders!

    So…now here I am…with an URI…again..but not quite as bad. So, i am not using theraflu and using the hot steamy bathroom. Also, I am only drinking the honey, lemon and hot water because i don’t want to stain my teeth.

    Rob…or anyone…is there any reason that one is supposed to drink tea with the honey, lemon and hot water? It tastes good, but is it medicinal?

    I also just started using MonaVie although I didn’t take it yesterday because of the energy boost and I wanted to sleep as much as I could. Took it again today though because i am hoping all the antioxidants in it also give my immune system a boost.

    I probably did get antibiotics a lot in the past for bad URIs and believed they worked because I got better. There was a lot of emotional comfort in thinking you could just get an antibiotic and get better. And even though I knew better…I still couldn’t help wondering if my doc made a mistake last time…but he was right and I got better.

    WhiteCoat had just written a post about the over use of antibiotics prior to my getting sick and so armed with that info is why I bit the bullet and said what I said. This doc had given them to me in the past for same symptoms although perhaps he thought the bronchitis was bacterial.

    WhiteCoat also mentioned nasal washes which I did get and have used although not consistently stuffy.

    You docs are helping to get the word out to us patients. I may not have believed him otherwise. Not that I don’t trust him but because it was all I have ever known.

    Thanks for the informative post! 🙂

  11. rob,here lies the problem. I practice in a rural farming community. 80% of all antibiotics which are made go to agriculture in the form of feed for cattle, pigs, horses and fowl (not humans). In fact Tamiflu (our national response in the event of a bird flu pandemic) is now routinely being fed to ducks in China. The best way to obtain plasmid formation and the establishment of resistance is to provide low dose, long duration, enteric antibiotics. In fact, there is no DNA evidence that the use of high dose, short duration (as is used in humans) antibiotics actually produces resistance. Vancomycin resistant staph have however been DNA traced to Danish cattle.
    Until the agriculture department gets on board, how do you answer the mom who states “Let me get this straight, you are not going to give little Johnny amoxicillin for his ear infection when I am feeding Cipro to the horses? All in the name of the greater good?”

  12. rob,here lies the problem. I practice in a rural farming community. 80% of all antibiotics which are made go to agriculture in the form of feed for cattle, pigs, horses and fowl (not humans). In fact Tamiflu (our national response in the event of a bird flu pandemic) is now routinely being fed to ducks in China. The best way to obtain plasmid formation and the establishment of resistance is to provide low dose, long duration, enteric antibiotics. In fact, there is no DNA evidence that the use of high dose, short duration (as is used in humans) antibiotics actually produces resistance. Vancomycin resistant staph have however been DNA traced to Danish cattle.
    Until the agriculture department gets on board, how do you answer the mom who states “Let me get this straight, you are not going to give little Johnny amoxicillin for his ear infection when I am feeding Cipro to the horses? All in the name of the greater good?”

  13. Sid: You can put them in your nose if you want. I won’t stop you.DDx: Education takes a long time. Part of the purpose of this is to keep myself in line as much as anything. As a people-pleaser, I sometimes do what is good for business and bad for medicine.
    Graham and Diora: Agreed – there are many tacts to take. I am thinking if I will add to it. Obviously it has hit a nerve (big bump in traffic).
    JK: Hmm….I don’t quite know how to deal with it except perhaps pointing out that we do many things for animals we would never do for people (don’t tend to send kids to slaughter house or neuter them). I agree, however, that this double standard is hard to deal with. That is why I wrote the post. Perhaps a few would be dissuaded from begging.

    Thanks to the rest of you for the positive feedback!

  14. Sid: You can put them in your nose if you want. I won’t stop you.DDx: Education takes a long time. Part of the purpose of this is to keep myself in line as much as anything. As a people-pleaser, I sometimes do what is good for business and bad for medicine.
    Graham and Diora: Agreed – there are many tacts to take. I am thinking if I will add to it. Obviously it has hit a nerve (big bump in traffic).
    JK: Hmm….I don’t quite know how to deal with it except perhaps pointing out that we do many things for animals we would never do for people (don’t tend to send kids to slaughter house or neuter them). I agree, however, that this double standard is hard to deal with. That is why I wrote the post. Perhaps a few would be dissuaded from begging.

    Thanks to the rest of you for the positive feedback!

  15. This is very informative and likewise a refreshing outlook on the proper use of antibiotics. I definitely recommend this material to people who often self-medicate with antibiotic treatments. I am an herbal enthusiast but I do not dismiss the fact that medications do play an important role in the context of health and would recommend the integration of mainstream medicine with alternative treatments such as herbal supplemenst in the practice of health care. Thus, it would be to our benefit to use antibiotics only when severe bacterial infection has been determined and would threaten life itself. And for recurrent bacterial infections that could only promote bacterial resistance and the depletion of good bacterial flora, the patient might as well try alternative remedies that won’t trigger the same side effects.

  16. This is very informative and likewise a refreshing outlook on the proper use of antibiotics. I definitely recommend this material to people who often self-medicate with antibiotic treatments. I am an herbal enthusiast but I do not dismiss the fact that medications do play an important role in the context of health and would recommend the integration of mainstream medicine with alternative treatments such as herbal supplemenst in the practice of health care. Thus, it would be to our benefit to use antibiotics only when severe bacterial infection has been determined and would threaten life itself. And for recurrent bacterial infections that could only promote bacterial resistance and the depletion of good bacterial flora, the patient might as well try alternative remedies that won’t trigger the same side effects.

  17. Gary,
    They “might as well” take a placebo, as it would probably have the same effect as herbal supplements..

  18. Gary,
    They “might as well” take a placebo, as it would probably have the same effect as herbal supplements..

  19. EEJ,
    Herbal remedies or supplements may work differently with antibiotics and other prescription drug but the kind of healing alternative medicine provides is definitely not due to a placebo effect. Herbal extracts and homeopathic ingredients do contain active substances that provide therapeutic benefits–particularly in the case of “recurrent” bacterial infections.

  20. EEJ,
    Herbal remedies or supplements may work differently with antibiotics and other prescription drug but the kind of healing alternative medicine provides is definitely not due to a placebo effect. Herbal extracts and homeopathic ingredients do contain active substances that provide therapeutic benefits–particularly in the case of “recurrent” bacterial infections.

  21. You know,I try to be good and stay off the pills, but with asthma triggered by illness, by the time I’ve been convinced I need prednisone (ugh) and I’m smoking the ol’ nebulizer because my lungs feel like they have roadrash, I want me some good antibiotics. Because the asthma will not resolve if there’s an underlying infection feeding it.
    Still, I think there are times when maybe it’s viral. It’s a tough call.

    But I’d like to stay out of the ER and the hospital too. And I can count on one hand the number of times I’ve managed to improve on my own without antibiotics (it’s exciting when that happens, I fell, like healthy or something).

    I do wait as long as possible, but as soon as the peak flow nosedives at the same time my symptoms aren’t abating, I go for the pills.

    Actually, I’d like a list of when antibiotics are a good idea. Maybe my criteria is no good. Maybe I could learn something.

    M

  22. You know,I try to be good and stay off the pills, but with asthma triggered by illness, by the time I’ve been convinced I need prednisone (ugh) and I’m smoking the ol’ nebulizer because my lungs feel like they have roadrash, I want me some good antibiotics. Because the asthma will not resolve if there’s an underlying infection feeding it.
    Still, I think there are times when maybe it’s viral. It’s a tough call.

    But I’d like to stay out of the ER and the hospital too. And I can count on one hand the number of times I’ve managed to improve on my own without antibiotics (it’s exciting when that happens, I fell, like healthy or something).

    I do wait as long as possible, but as soon as the peak flow nosedives at the same time my symptoms aren’t abating, I go for the pills.

    Actually, I’d like a list of when antibiotics are a good idea. Maybe my criteria is no good. Maybe I could learn something.

    M

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