During my urgent care shifts, I see 20 to 30 people with viral upper respiratory infections. They are all feeling miserable, and they just want to feel better. They want an impressive-sounding diagnosis to justify their suffering to themselves, their spouses, and their bosses. They want a prescription medication which will immediately cure their illness, so they can get back to their lives. Their faces fall when they receive their diagnosis and recommendation for over-the-counter cold medications. “Just a virus?” they cry! “Then why do I feel so terrible?”
There seems to be a public perception that bacterial infections are serious and viral infections are not, but this could not be further from the truth. Nobody would refer to HIV, Hepatitis, or Ebola as “just a virus.” HPV causes over 40,000 cases of cancer in the U.S. annually. Tens of thousands in the U.S. and hundreds of thousands worldwide die from the influenza virus every year. Over one million die from the malaria virus every year. The measles virus caused 2.6 million deaths annually prior to the invention of the measles vaccine in 1963. Vaccination has eliminated the crippling effects of the polio virus and has significantly decreased rates of death, disability and birth defects due to varicella, mumps and rubella.
Doctors hate viruses as much as patients do. We love to help people feel better, and we feel pretty helpless when our patients or our family members are suffering from viral illness. We especially hate it when we have a viral infection because we are notoriously bad patients and do not give ourselves time to rest and recover. My colds always last at least 2 to 3 weeks. I’m on the tail end of one now and have been coughing for over a month! A post-viral cough can last for up to three weeks after the infection has resolved. We believe that you are suffering; we have all experienced it, too.
Viruses cause over 98 percent of sinusitis and over 90 percent of bronchitis. Antibiotics only treat bacterial infections; they do nothing to treat viral infections and can cause potentially severe side effects. If it’s not effective or safe to prescribe antibiotics for viral infections, why do so many doctors do it? Simply, it’s the path of least resistance. With a click of the mouse, you can give a patient what they came for, make them happy, and move on to the next patient without any argument. Most of the time, the antibiotic seems to work because the patient is seen mid-way through their illness, and the viral infection resolves before the antibiotic course is finished. Also, the placebo effect is real, so patients who believe that an antibiotic will make them well, will start feeling better after they take it. However, patients who come in on the first day of their cold to “nip it in the bud” or “get ahead of it” will inevitably get worse on antibiotics and then call back to get “a stronger antibiotic.”
The problem, in addition to the risks for individual patients, is that bacteria are becoming resistant to antibiotics, and we could face a future in which we are unable to treat serious bacterial infections. The most popular “placebo” given for colds is a Z-Pak (azithromycin). Bacteria in the upper respiratory tract are resistant to this antibiotic, so it does not work for bacterial sinusitis. In the U.S., azithromycin is used to treat Chlamydia, but in Europe, Chlamydia is now resistant to azithromycin due to inappropriate overprescribing for viral illnesses. Azithromycin is a potentially dangerous medication and can cause a fatal heart arrhythmia, so using it as a placebo is not just bad medicine, it’s malpractice. So next time you’re sick, and your doctor does not offer you an antibiotic, thank him or her for caring more about your health than about patient satisfaction scores.
Emily O’Rourke is a family physician.
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