Catching Some Z\’s

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“I’ve got bronchitis and my doctor gave me a Z-Pak.”

I hear this from friends, from family members, and from my patient who went to the urgent care over the weekend.  I smile and don’t say what I am really thinking:

Bronchitis:  noun  –  inflammation of the mucous membrane in the bronchial tubes. It typically causes bronchospasm and coughing
Translation: a loose cough.

This is one of the most common tricks we use as doctors: stating the obvious using a Latin or Greek word to describe the symptoms and call it the diagnosis.  The suffix –itis refers to inflammation. Dermatitis is one I frequently use: someone comes with a rash (skin inflammation) and I tell them it’s dermatitis, which simply means…drum roll please… it’s a rash.  If you have sore throat, we call it pharyngitis, which means inflammation of the back of the throat. The suffix –algia, which which means “painful” is also quite useful.  Headaches can be called cephalgia, joint pain, arthralgia, and proctalgia is a pain…where the sun don’t shine.

In all of these circumstances, of course, the person is quite aware of their cough, rash, sore throat, headache, joint pains, and pain in the butt.  Why call it by it’s fancy name?  Two reasons: 1.  it sounds better when we tell the patient, and 2. we can bill for it.  It does not, however, say anything about prognosis, treatment, or expected course; it simply states what is obvious.

Which brings me back to the Z-Pak.  Zithromax (Azithromycin) is truly a great drug, and the friend of many doctors.  It treats strep throat, skin infections, sexually transmitted disease, whooping cough, and certain kinds of, yes, bronchitis.  It is very easy to take, requiring a total of 5 doses over 5 days, and it comes in a handy-dandy pack with a catchy name.  When a patient tells their friends and family, \”I got a Z-Pak,\” they are much more impressed than if they say, \”I got an antibiotic.\”

The problem with Zithromax, however, is that it spends very little time in the blood stream, going directly inside the cells of the body and spending a very long time there, often away from the infection itself.  This is OK for certain types of infections, but not so good for ones that involve infected extra-cellular fluid, such as infected mucous (AKA sputum, green snappers, loogies, whatever you want to call them).  This means that it’s a fairly weak drug for middle-ear infections or sinusitis, and only marginally good against many forms of bacterial bronchitis.  These, of course, are the main things for which the drug is prescribed.

Why?  Why do people get a medication for conditions that are not well-treated by that medication?  For most of these conditions, bronchitis included, the real cure for them is simple: breathing.  You just have to keep breathing long enough while your body fights off the infection like it was designed to do and the infection will go away.  Skeptics out there who want to try not breathing will soon find out that this approach is not successful.  Trust me.

So what difference does it make to take a Z-Pak while you breathe?  In many, if not most cases, it has no benefit.  It does, however, makes the patient feel like the doctor is doing something for the patient, who paid the co-pay and waited 2 hours in the office.  There are still a good number of people who are dissatisfied when they spend their tie and money only to be told to breathe. Plus, modern medicine has indoctrinated doctors and patients with the belief that doing something is always better than just breathing for a little longer.  This untrue, but highly profitable belief is hard to dispel.  The patient got a Z-Pak and they got better!  Both doctor and patient make this causal connection, and both are happier for it, but breathing gets the shaft because the Z-Pak gets all the credit for what it did.

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I once cynically said that Zithromax is the antibiotic you prescribe when you don’t think the person needs an antibiotic.  While that’s not completely true (I think it’s a good choice for strep, and for a chronic cough), I do think it’s the reality seen in primary care offices, urgent cares, and emergency rooms across this great land.  In fact, my PA told me on the week leading up to Christmas that she had joked with a colleague that they call this week “Zithromax Week,” as many prescriptions are written “just in case,” or “to make sure they are healthy for the holiday.”  I’m sometimes guilty for that one.  I do run a business, you know.

\"\"Of course, there is definite risk in taking an antibiotic when it’s not needed.  I’ve read (but am to lazy to find the citation) that overuse of macrolide antibiotics (of which Zithromax is the dominant drug) is one of the main sources of antibiotic resistance.  People can have side effects from the medication as well.  But as is the case with donuts, not exercising, spending time reading blogs when you should be otherwise productive, or watching reality TV, the inertia of the bad choice in the moment totally overwhelms any desire to do the right thing.  \”Come on,\” the doctor says to himself, \”The world won\’t fall apart if I give a Z-Pak to this one patient!\”  Krispy Kreme donuts is depending on you to make a similar argument.

So, when you have a cough and go to the doctor, get the diagnosis of bronchitis, and get a Z-Pak think of me.  You may want to ask if you really need the antibiotic, or if you can wait to see if it will go away without it.  In many, if not most cases, you might just as well meditate with the word “Zithromax” as your mantra, or burn the pills in a sacrifice to the Greek god Z-pacchus.

God bless America, land of the Z.

*Obligatory disclaimer: This is not meant to convince people to not take prescribed medications.  I don’t know about your own personal medical conditions.  It is just meant to make you appropriately skeptical, and perhaps ask your doctor, “can I wait to take this?” or “do I really need this?”  If they say “yes, you do need it,” take the dang Z-Pak!

33 thoughts on “Catching Some Z\’s”

  1. Antibiotics are nasty things I fail to understand why one would want it when they don’t need it. (I hate the taste in my mouth after taking one, the smell in my noise .. not to mention GI upset and well .. other issues I’ll leave off of this family friendly site)I’m always relieved when the doc says “no need for antibiotic” …

  2. I have multiple antibiotic allergies (penicillins, sulfas) and intolerances (tetracycline, erythromycin), and yet still had to talk a doctor OUT of giving me a prescription for antibiotics for a recent sore throat. My throat was horribly sore, and because it wasn’t resolving, I went to the doctor to check things out. Low-grade fever (under 100F), bad sore throat, NO other symptoms; told him straight up I didn’t think I had strep because I wasn’t sick enough, but wanted to make sure. He did a strep test, it was negative, then he started writing a prescription (for a Z-Pak, of course!). I told him I didn’t need it if the strep test was negative. I wasn’t surprised by the negative strep test, figured it was viral but just wanted to check it out. He said, “well, you don’t have to fill it, just take the prescription and if you still feel yucky in a few days, take it.” I refused and thanked him for his time and the assurance that I didn’t have strep.
    This was admittedly not my regular doctor, but he had full access to my full medical record, with the big orange notes about drug allergies and intolerances. His last thought for someone not terribly sick, with a sore but strep-negative throat, who has difficulty taking antibiotics, should have been antibiotics.

    Don’t even get this ID epidemiologist started on giving antibiotics used in humans to animals just to “keep them healthy”…

  3. Nice post.
    I *never* use the term “bronchitis” with patients. Now that we give patients visit summaries, I don’t even use it in charts anymore. If you tell the patient they have “bronchitis,” but don’t give them antibiotics it creates a lot of friction, because to patients, bronchitis = antibiotics. (Just like green mucus = antibiotics!) “Everybody knows that,” they will say. I gave up educating patients that nearly all forms of “bronchitis” are viral and don’t respond to antibiotics, as when I am done patiently explaining this, they end up staring at me blankly and then ask what antibiotic I am sending to their pharmacy.

  4. Yes to this whole post. At my office we joke about the Zpak- “It’s the antibiotic patients ask for by name”. And how elated people are when they say “my doctor gave me a zpak!”. It is so hard to convince people they don’t need an antibiotic- especially if you call what they have “bronchitis” and the zpak is like pure magic- you get a Rx and you are better within 48 hours (so the symptom improvement is less likely to be from the med anyway, given it’s long half life). I’d be interested to hear what Maryland MD tells his or her patients what they have when they come in for a loose cough.Anyway, glad you are back Dr. Rob- you’ve been missed!

  5. “…spending time reading blogs when you should be otherwise productive…”
    Laughed aloud at this, and stopped reading right there to go bake the cookies my children were hoping for. 🙂 Came back to finish the post after tucking everyone into bed. Thanks for a good article on bronchitis and antibiotics – and a reminder about priorities.

  6. Karen Beleal-Ehrhardt

    Thanks Rob, I’ve been an internal medicine use for 20 (OMG are we that old!) years now and my favorite patient response has always been “But I always get better when I take a Z-Pack” They never want to hear the “you would have gotten better anyway” part. Oh well. I guess it’s just another part of the job.

  7. I use the terms “viral cough,” “viral infection,” “viral cold,” and sometimes “viral lower respiratory infection” (the last one I don’t use often, as it is more technical, but it comes in handy with the patients who are nerdy, like me).

  8. How about, “you have a chest cold”? That’s what our family doc called it when I was a kid, unless my dad or I (both asthmatic) had really bad bronchitis, in which case he called it what it was and prescribed steroids to make the inflammation go away.

  9. Janna,
    See my response above. I guess you could call it “VIRAL bronchitis” if you really want to call it a bronchitis, but I swear I get *much* less pushback from patients who don’t get antibiotics since I completely stopped using the term “bronchitis” a few years ago.

    –MdMD

  10. yeah… a Z-pack might (or might not) fix your cough, but it’s also likely to give you a yeast infection, GI issues, and, if you take it more than about once a year, IBS and/or Crohn’s disease. So that’s awesome. I mean, who doesn’t want Crohn’s??
    ABX are a fantastic medical tool, and we’re all lucky to live in an era when they are available. But they are NOT harmless. Doctors that give them out to shut people up are violating the most basic ethics of their field.

  11. I actually have bronchitis as we speak and my patients are asking why I am not taking an antibiotic to fix myself. I tell them that I have been watching the trends and realized that it’s not responding to antibiotics, ie: some patients have called back to report that the first round didn’t work. When I say that, they are more inclined to try to tough it out like the others.

  12. Good post and so true (of course 😉 ) It seems doctors are so much likely to offer an antibiotic than pain killers. I understand the abuse issues but those who have a legitimate need for them are often jumping through hoops to get them. Ah in a perfect world….

  13. I mis-read Z-Pack as ZAP pack (azithromycin 1g, amoxycillin 3g, probenecid 1g) we use for treating Gonorrhoea and Chlamydia out here in remote Indigenous Australia.
    With our government run Pharmaceutical Benefits Scheme, GP prescribing of azithromycin is restricted to uncomplicated urethritis and cervicitis due to Chlamydia trachomatis and for treating Trachoma.

    And yes there is no amoxycillin resistant Neisseria gonorrhoea in remote central Australia.

    Nice to have you back writing

  14. Welcome back to one of my favorite medbloggers! I was hoping that hiatus was temporary…and I have many days this time of year when this post would be great to have as a sort of handout for many of the patients whose records I code. It makes me cringe a little every time I see a pt. with a URI or bronchitis get antibiotics, mostly because that’s part of the reason we now have nasty critters like MRSA and VRE (the former of which got me a week plus inpatient a few years back). I don’t blame the docs for this, though, as I know a lot of it comes from patient insistence that “something” be done beyond stating the simple truth that antibiotics aren’t indicated for what’s likely a viral infection. I could write an entire post on that if I still had a blog.

  15. I was on tetracycline for around 5 years for acne as a late teen-early 20something and then I’ve been given an antibiotic (not always Z-pack…the newest is Levaquin) every time I have the diagnosis of bronchitis or a UTI as well as with a few surgeries. I am extremely prone to treatment resistant yeast infections and/or thrush when I take any antibiotic (even a single dose with surgery) and I have IBS and Ulcerative Colitis. Doctors are always SO quick to prescribe an antibiotic for bronchitis and UTIs, which then result in yeast infections that take at least a month to get rid of as well as irritating my IBS/UC. More recently I’ve been questioning the doctor to make sure I really need the antibiotic. With Bronchitis/Upper-respiratory whatever-you-want-to-call-it, it’s always a tough call with me, though, because I have a neurological condition and cannot take oral steroids or steroidal inhalers unless it’s an absolute emergency. It really makes it a tough decision…

  16. So, am I the only one in the US who hasn’t been prescribed a Z-pak?
    Actually, I don’t get near as many colds since I started using auto CPAP for my upper airway resistance syndrome — that’s like sleep apnea except vaguer.  That’s a huge help, especially since it’s harder to use CPAP when you do have a cold.

    So glad you’re blogging again!

  17. […] with symptoms that make them feel they need an antibiotic, many of whom have gotten Zithromax.  I wrote an early post on the subject of the temptation to give a Z-Pak in the gift basket we give our patients for walking into our […]

  18. I don’t understand what you mean by “just breathing” don’t we breathe anyways? What you are saying makes entirely no sense.

  19. Breathing means you do nothing.  It’s a way of telling people what to do when I’m actually telling them to do nothing.

  20. Juliana Jaynes

    I am having hip repacment srgery tomorrow at 1p.m.– I had brochitis on Monday and took the famous z-pack for the last three days– have 2 moe pills- on surgery day and one next day post -op– i am still a little “wheezy” and some cough ing but not very bad or ugly colors mucus–YUK– mostly clear from nose , and rumble-cough that is sometimesproductive but again ,not real “ugly color— Do you think they will still go ahead with the surgery ? I pray to God that they will, can anyone tell me what they think ???/ Please Help- it’s almost gone…

  21. So how long should we expect this breathing technique to take until the cough subsides? I have been coughing and had rattling lungs for 3 weeks. (chest xray was clear) . (I like the breathing technique by the way…i just coughed myself through my yoga class 🙂 Want to get my hands on that Zpack!

  22. Rule of thumb is cough going on for more than a week is reasonable to treat, although waiting is not necessarily dangerous. Sounds like you’ve done your due diligence.

  23. I have bronchitis and I finished my Z pack a week in a half ago and I still have bronchitis!! dont take the Z pack it’s useless!

  24. I get inner ear fluid. I have a eustachian tube that doesnt drain properly, The fluid makes me almost incapable of functioning. Right now I cant even swallow because it hurts so bad…..I am dizzy and feel nauseous..However, because a visit to the doctor’s office doesnt shown infection, I am always told to just drink water and chew gum!That does nothing….It will just get worse and worse until I am finally prescribed Z pak….within 2 days I am fine…But getting the antibiotics is like pulling teeth! I had a family doctor for years that understood the problem and it was always maintained. He has since retired though and I am now back to square one, chewing gum, drinking water, and getting sicker!
    Why is it only certain doctors know what to do with patients with this issue….The fluid doesnt dry up on its own,You need antibiotics…….but you would think I was asking for narcotics ever time I try to get help.
    Spent 5 hours today….got nowhere again, I sit chewing my gum…….feeling worse! I think more tests and training need to be done with these issues…It is awful. I will soon lose my voice, and once again try to find
    a doctor that will actually prescribe me my antibiotics! I am not addicted to antibiotics truly! It is the only thing
    that helps me function….Tomorrow, I will try again….uuugh……….this is awful

  25. I, too, was diagnosed with bronchitis and given a Z-pak. It was usless. Went back to the doctor and was given ciprofloxacn. Today is the 10 day taking it and I am going back to the doctor AGAIN! STILL coughing up hockers and blowing my nose for the first 1/2 of the day. The only thing gone is the terrible cough that I am sure would be gone even if I didn’t take antibiotics. Won’t take yet another antibiotic! I am convinced that this article is right is saying “bronchitis” does NOT respond to antibiotics. Maybe an inhailer to open up sinuses. I went to the store this a.m. and going to take garlic capsules 4 times a day. Antibiotics are too overused in this country.

  26. I had confirmed strep 4-6 times a year as a child. No insurance = no tonsillectomy. As a result, I have an immunity to Amoxicillin and Keflex. So, I NEVER go to the doctor when sick as I don’t want to be unable to take Penicillin or a Z pack when needed. However, I’ve had a respiratory/sinus infection for NINE WEEKS now and it’s just not resolving on its own. Started taking the Z pack and poof! Instant reduction in congestion and cough. So, please don’t assume that all respiratory infections are viral or that antibiotics are not effective to treat these infections. Should have gone to get an antibiotic five weeks ago…

  27. RN4littlebits

    I had a fever w severe congestion and hacking cough turning into bronchitis almost 2a weeks..mucous was thick greenish yellow. Was waiting it out as it got worse but then a friend of mine prescribed a Zpak and it cleared it up in 48 hrs. Still have a clear residual cough but nowhere near the thick nasty secretions that were there before. I can breathe now… Fever gone in 24 hrs. So, although 90 percent of bronchitis is caused by virus…you can still get mycoplasma pneumonae and h influenza and other bacteria growing too. Those are very hard to culture. Do you need antibiotics every time you sniffle…no….but in some cases you need them before you end up in the hospital getting q 2 hour nebulizers.

  28. I know this is an old post but just a question, if you happen to read this at all. I had a fever up to 101.8 for 2 days, sore throat, achiness, malaise, etc. with no upper respiratory symptoms. I had my tonsils out several years ago, because I was getting frequent episodes of pharyngitis/tonsillitis. This is the first time I had these symptoms since that surgery. I went to the doctor complaining of these symptoms. They did a rapid strep and it was negative and told me it was viral. They sent it for culture because I insisted. The next day I still felt the same, if not worse. So, I went to a different doctor who also did a rapid strep that came back negative but decided to treat me with antibiotics anyway due to my history. Within less than 24 hours (more like 12-18) my fever was gone and my throat started to feel better. If it truly was viral, why would my fever and sore throat improve so quickly after starting antibiotics? This had been the same scenario as every time I had gotten a pharyngitis/tonsillitis before I got my tonsils out. Is it just coincidence that every time I was sick it was viral but my doctor gave me antibiotics anyway and I got better so quickly? I would think maybe once or twice but not every time, which was quite frequent. By the way, the first doctors office called today to say the culture was negative. Any thoughts?

  29. I have allergic asthma I think. I don’t normally take medication for asthma but I do take allergy shots.normally I’m okay but when I get sick with a cold I know it’s going to get progressively worse because it’s been happening since I wad a kid and I’m 31 now. I usually end up with bronchitis and I can’t eat or drink because it all comes up. I end up in the er because my doctor doesn’t do anything when I go in at the beginning of the cold. I really want to stop the symptoms and not be sick for a month but the doctor always says just breath. I try and rest and have soup,vitamins, hot tea, mucinex, etc.My body doesn’t seem to do this fighting back on its own. What do you suggest about that isn’t there anyway to not be sick for a month? Do I have to fail before the doctor will help me? It’s miserable….please advise

  30. I have allergic asthma I think. I don’t normally take medication for asthma but I do take allergy shots.normally I’m okay but when I get sick with a cold I know it’s going to get progressively worse because it’s been happening since I wad a kid and I’m 31 now. I usually end up with bronchitis and I can’t eat or drink because it all comes up. I end up in the er because my doctor doesn’t do anything when I go in at the beginning of the cold. I really want to stop the symptoms and not be sick for a month but the doctor always says just breath. I try and rest and have soup,vitamins, hot tea, mucinex, etc.My body doesn’t seem to do this fighting back on its own. What do you suggest about that isn’t there anyway to not be sick for a month? Do I have to fail before the doctor will help me? It’s miserable….please advise

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