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Say no to unnecessary antibiotic use

By Ephraim L. Tsalik, MD November 14, 2014

Ephraim Tsalik, MD, an infectious disease expert at Duke, explains why life-saving antibiotics aren’t a magic pill when you’re plagued by common aches and pains, fever and coughing. Instead, their overuse could make you sicker, and even have global health consequences.

After years of advanced education and specialty training in infectious disease, people expect me to know exactly what’s wrong when they complain of a cough, fever, or sore throat, and that I know how to make them feel better. The truth is that far too often, the best I can do is flip a coin.

Given that uncertainty, why not prescribe an antibiotic just in case? Because it’s becoming very clear that while antibiotics can be life-saving, they are far from harmless. They can cause serious drug reactions.  They can change the balance of your healthy bacteria. They can cause a potentially fatal antibiotic-triggered infection.  Millions of Americans are hospitalized every year because of antibiotic resistant infections.

I often don’t know how to treat you because your symptoms may not be specific to a particular condition. For example, that thick, green phlegm you’ve been coughing up could be pneumonia.  Or it could be a cold you picked up when your three-year-old gave you a big kiss. Or it could be that thick haze of pollen you strolled through which set off your allergies.  As a doctor, sometimes it’s easy to tell the difference.  But most of the time it’s not.  That’s when doctors resort to testing. Unfortunately, the tests are terrible.

There’s now a recognition that unnecessary antibiotic use is far from harmless.

Is it a bacterial infection?

While there’s no great solution, we are getting close.  The most widely available tool is culture, which has been in use for about a century.  That’s when a sample of your blood or that green phlegm is tested to see if any bacteria grow.  Finding bacteria is important because that is the type of infection for which antibiotics may be helpful.  However, cultures take days and too often provide false results. 

Newer, more accurate tests provide results within hours.  They look for common viruses such as influenza or rhinovirus (a cause of the common cold).  A positive result is helpful but can’t tell whether that virus is the reason you’re sick.  A lot of people, especially children, will carry these viruses but have no symptoms.  Another caveat, something I learned from one of my mentors, is that “the absence of evidence is not the evidence of absence.” So if you don’t find bacteria in that green phlegm (because the test didn’t look for it), that doesn’t mean it’s not there. Since a possibly un-identified bacterial infection might benefit from antibiotics, many doctors prescribe an antibiotic “just in case.”

Measuring your body’s reaction to infection

A new and promising approach to build a better test is to focus on you and not what infected you. Research that I and many others have done reveals how we react, at the most basic level, to either a viral or bacterial infection.  Genes are turned on and off in a very specific and measurable way.  However, the idea of measuring your body’s genetic reaction to an infection is so new that the technology to do it quickly, easily, and cheaply is still catching up.

Global consequences of antibiotic overuse

There’s now a recognition that unnecessary antibiotic use is far from harmless. It can lead to negative consequences for you, as well as global consequences in the form of antibiotic resistance.  The problem has gotten so bad that antibiotic resistance was designated a national security and public health priority by President Obama in September 2014.  Part of how we got into this mess is that your highly educated doctors simply lacked the tools to make a fully informed decision, and used antibiotics  “just in case.” 

Next time you see your doctor for that cough, recognize that antibiotics may not be the answer.  Recognize that in most cases, you’ll get better in spite of the antibiotics.  And don’t hesitate to ask your doctor if the antibiotics are really necessary.  The good news is that a convergence of knowledge and technology has made it possible for powerful new diagnostic tools to stack the odds in your favor.  In the near future, the decisions I make about how to get you feeling better will involve more than a coin flip.

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