By Laurence Degelsmith, MD
December 14, 2007
‘Tis the season of cold and flu once again.
We haven’t seen any flu yet in the emergency department but we have seen plenty of colds which we tend to call “upper respiratory infections.” Viruses run rampant from the late fall through early spring and seem to spread from one member of the household to another quite easily. Viruses may be the only things that siblings share without squabbling. We all average about two to three viral infections over this wintry period, though some parents can attest that their children seemed to be sick the entire winter. Indeed, it is common to recover from one cold and develop another one soon after. I can remember having a horrible sinus cold that lasted for ten days. Just when I started to feel better my daughter came home from school with a new runny nose and within two days I was sick again.
Recently, scientists discovered why these viruses are so contagious during the cold months of the year. The temperature and humidity during the colder months are ideal for the transmission of viruses. This is partly because water droplets that carry the viruses from person to person by way of sneezing or coughing are best formed with a temperature near 40 degrees Fahrenheit. Humidity, in combination with the colder temperatures, also aids in the dispersal of the virus through the air. Viruses also cause that dreaded “stomach flu” which isn’t the flu but just another virus. We have seen a lot of people with stomach viruses in the emergency department, but for some reason this virus seems to be common throughout the year and not just in the winter.
Antibiotic does not mean antiviral or anti-cold
Sometimes I think that antibiotics should be renamed “antibacterials.” Antibiotics only work against bacteria; they do not work on viruses. The medical establishment sometimes refers to antibiotics as antibacterial agents but when I hear that term I think of Lysol and not a pill. Antibiotic literally means anti-life, but it actually means anti-bacterial life. Viruses laugh in the face of antibiotics.
I think that the medical establishment has done a fairly good job over the past few years in convincing the public that antibiotics are not indicated for most illnesses that are seen in the doctor’s office or even in the emergency department. I still have to explain once or twice a day to patients why I am not prescribing antibiotics for their bronchitis. Bronchitis is a viral respiratory infection that often causes coughing, fever and sometimes wheezing, but it is not pneumonia. The drug companies have spent a lot of money promoting their antibiotics and many doctors like to appease their patients who ask for antibiotics because they think that they will get better quicker with them. Historically, antibiotics have been greatly over prescribed when not indicated, which is one of the causes of drug resistant bacteria such as MRSA.
Often, I used to see patients who had come to the emergency department because of persistent cold symptoms. They had already seen their doctor, who had put them on amoxicillin for their cold. I would ask them why their doctor prescribed the antibiotic and they would usually say, “My doctor said I had a cold.” So we doctors are as guilty for over prescribing antibiotics as the public is for requesting them. The good news is that this practice has dramatically changed over the last several years, in my opinion, and I think that the medical profession is now much better in restricting antibiotics to those ailments that can truly be helped by them.
“I always get better with antibiotics”
I’ve had many a patient who told me that their doctor always prescribes an antibiotic for their bronchitis and they always get better. My standard response is that you would have gotten better anyway but you just associate the antibiotic with improvement of your symptoms. Most colds last about a week and most people see their doctor two to three days after their cold starts. Therefore, with or without antibiotics, people’s symptoms will usually improve in three or four more days anyway.
So what about those antiviral drugs you might ask. Tamiflu and Relenza are the only antiviral medications that are prescribed to people who have viral infections, but these medications are only effective against viral infections caused by the influenza virus. They are not effective against the viruses that cause the common cold, such as the rhinovirus and adenovirus. Your sore throat, congestion, runny nose, cough, fever, headache, vomiting and diarrhea are invariably attributed to a simple common virus which must run its course and will not be deterred by an antibiotic.
That’s not to say that there aren’t effective treatments for the symptoms of viral infections. Personally, I’m a big fan of Nyquil and Mucinex DM for bad head and chest colds and no, I don’t receive any endorsements from the companies that make either. Mucinex has the same ingredient (guaifenesin) that is in Robitussin but Mucinex has a dose of guaifenesin that actually works. The amount of guaifenesin in a typical adult dose of most over the counter cough medicines is 100 mg which is too little to do anything, but Mucinex has 600 mg per dose. It is no miracle drug but it does help loosen the phlegm that causes sore throats and coughing. Stronger prescription medications with codeine or hydrocodone are also very effective for bad chest colds. I usually prescribe this type of medication to people who have that continuous dry hacking cough, often causing chest pain, and preventing them from sleeping. I find that the over the counter cough medications are ineffective in these cases.
Maybe you do need an antibiotic
There are many instances when antibiotics are indicated for children and adults. Strep throat, which is often diagnosed within twenty minutes using the rapid strep test, is uniformly treated with antibiotics. This doesn’t promote any significant improvement in symptoms but it will cause the symptoms to dissipate maybe a day or two earlier than if antibiotics were not given.
I will often give a dose of steroids plus Motrin to an adult or child with a bad sore throat because I have found that this combination provides significant relief from the pain. The Motrin works within an hour and the steroids take effect in about six hours. Antibiotics do not work immediately and provide no direct pain relief. They provide relief as the infection begins to resolve which typically takes a few days. Antibiotics when given early (within 48 hours) shorten the duration of the infection, decrease the period that the infection is contagious, decrease the incidence of other complications, such as mastoiditis (an infection of the bone behind the ear); otitis (ear infection); and peritonsillar abscess formation (an abscess in the throat near the tonsils).
They also prevent the long term complications of rheumatic fever, which is associated with strep infections. Rheumatic fever is a very rare complication that can occur from non-treated or undertreated cases of strep throat. It should be stressed that its incidence is very rare even if the strep infection goes untreated.
Ear infections in children were always treated with antibiotics in the past. Now we mostly treat those children who are less than six months; children older than six months with severe symptoms such as high fever or severe pain; children who might not have adequate follow up care; and, children with ear infections that don’t resolve in a few days. The reason is that most ear infections are viral and not bacterial.
Children vaccinated against two most common bacterial infections
Children are now being vaccinated against Haemophilus influenzae and Strep pneumonia, the two most common bacteria that cause bacterial infections in children. It is now even more likely that most infections in children are caused by viruses. In the emergency department we often see parents bringing in a child at 3 a.m. because their child woke up with ear pain and they believe that antibiotics are needed immediately. Very often all that we do is give the child a dose of Motrin and send them home. Antibiotics may or may not be needed, but they are rarely needed in the middle of the night since they won’t start working for up to 24 hours anyway and they do very little for pain.
Children and adults with pneumonia are always treated with antibiotics, although many cases of pneumonia are also viral. We don’t take chances when it comes to the lungs. Many patients with chronic conditions such as asthma, emphysema and diabetes get treated with antibiotics more often than not just to prevent them from developing a bacterial infection while they’re sick with a viral infection. Smokers who develop acute bronchitis often get antibiotics for the same reason. Patients with clear cut sinus infections will usually get antibiotics but those with sinusitis don’t. The difference between the two is not always obvious but it usually depends on the duration of the symptoms, presence of fever and what’s coming out of the nose.
Antibiotics are clearly a good thing. They save and prolong lives. They often make us feel better when we get sick and sometimes even prevent us from getting sick when we are at risk. However, just because we have them doesn’t mean we should use them indiscriminately. Millions of dollars are spent annually researching which illnesses benefit from which antibiotics. Unfortunately, we don’t always listen to the research.
We must have faith that our bodies will fight these infections. Exposure to viral infections throughout our history has made us stronger. Our immune systems are built to fight these infections and although antibiotics have significantly improved our survival from more serious bacterial infections, we must resist the urge to reach for the latest and greatest antibiotic for these common colds and viral infections that affect each and every one of us throughout the year and especially during the winter months.
Author’s note: This article encompasses general guidelines taken from several published sources as well as my ten years of personal experience as an emergency physician. There will often be exceptions to the above guidelines because the risk vs. benefit ratio of using any medication will be different for each patient.
Laurence Degelsmith graduated from Horace Greeley High School in 1985, has an undergraduate degree from Washington University in Saint Louis, attended New York Medical College and did his residency in emergency medicine at the University of Michigan. He is an emergency department physician at Northern Westchester Hospital in Mt. Kisco.
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