Author Topic: Antibiotics...when not to swallow  (Read 4452 times)


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Antibiotics...when not to swallow
« on: May 26, 2009, 12:40:42 AM »
I often talk with my associates (medical professionals, family, friends, etc.) about when not to take antibiotic medications.  Antibiotics are one of the greatest therapeutic agents of modern medicine, but also one of the most highly requested “cure-alls” of our modern culture. 

My diatribe today is about the common misuse of antibiotics that is leading us all down a very slippery slope.  Each time you take an antibiotic, truly needed or not, they kill or slow the reproduction of bacteria, but often not all are killed.  Each time these bacteria are exposed to the antibiotic agent, they have an opportunity to adapt in several ways resulting in antibacterial resistance.  This adaptation may occur quickly within several exposures, or it may take generations of exposures to finally adapt.  Here is a good review about this problem:

For those of you who squirrel away antibiotics acquired from your local provider, Internet pharmacy, another country, or even a veterinarian supply source, please educate yourself on their proper use.  It is very tempting to begin popping antibiotic pills during the first miserable week of an illness.  If you feel you require medical treatment (taking an antibiotic is medical treatment), go seek consultation from a good provider if you can.  I have seen many many patients where they were taking the wrong stockpiled pills for the type of illness they thought they had, only to cause themselves a whole new set of medical problems.  If you plan to journey to very remote/austere locations and plan on taking antibiotics with you, educate yourself to the level necessary to make wise medical decisions.

Here are some simple tips that your Pharmacist probably told you, or should have:
1.Take the correct medication for the illness, as directed, ALL of it, even if you begin to feel better
2.Contact your pharmacist or health care provider (if possible) if you experience significant side-effects  (If you can't because of austere conditions, then discontinue the medication and evacuate.  I say “evacuate” because you should only take antibiotics for serious illness, and serious illness may kill you if you don't get proper care.)
3.Don't save partial courses of medication for another time, if you have a legitimate reason to store antibiotics, ask your provider for a full course of medication.
4.Don't stake your life on expired drug.  You shouldn't take antibiotics for non-serious illnesses, and if it is serious enough to warrant treatment, it is serious enough to get a fresh supply. Certainly in austere conditions, expired drug may be the only option, but it should be the last option.
5.Don't give pills to other people unless you are trained to do so.  Your buddy with a kidney infection says he has an allergy to Avelox, would you feed him some Cipro you have left over from your wife's urinary infection treatment 2 years ago?  No, that could be deadly silly (same drug class), but I have seen it done.

Finally, if you store antibiotics for SHTF, or remote/austere vacations, or self-treatment, use your meds very wisely in a frugal manner.  Why waste a precious medicine on a case of sinusitis when a nasty wound infection is much much more likely to kill you?  Below is but a small list of credible research on this topic, I edited out the details, but if you are interested just Google the name of the study for a more in-depth reading.

I apologize for the length of this post, but if you are serious about wanting to take antibiotics without medical consultation (which I do not advise), then you should try to understand the seriousness of your endeavors.  If you don't like the details, just read the bold print.

Pediatr Infect Dis. 1984 May-Jun;3(3):226-32.
Bacteriology and treatment of purulent nasopharyngitis: a double blind, placebo-controlled evaluation.
One hundred forty-two children with purulent nasopharyngitis were randomized to four treatment groups with an antibiotic (cephalexin) alone or combined with a decongestant/antihistamine (pseudoephedrine/triprolidine) or their corresponding placebo equivalents. There were no significant differences between active drug and placebo treatment groups for change in nasal discharge, complications or apparent drug benefit. Cephalexin therapy did not result in a decrease in cultivation of pathogenic organisms from the nasopharynx.
PMID: 6377256

Cochrane Database Syst Rev. 2004;(1):CD000219.
 Antibiotics for acute otitis media in children.
University of Oxford, Department of Primary Health Care, Institute of Health Sciences
BACKGROUND: Acute otitis media is one of the most common diseases in early infancy and childhood. Antibiotic use for acute otitis media varies from 31% in the Netherlands to 98% in the USA and Australia. MAIN RESULTS: Ten trials were eligible based on design, only eight of the trials, with a total of 2,287 children, included patient-relevant outcomes. The methodological quality of the included trials was generally high. The trials showed no reduction in pain at 24 hours, but a 30% relative reduction in pain at two to seven days. Since approximately 80% of patients will have settled spontaneously in this time, this means an absolute reduction of 7% or that about 15 children must be treated with antibiotics to prevent one child having some pain after two days. Nor did antibiotics influence other complications or recurrence. REVIEWER'S CONCLUSIONS: Antibiotics provide a small benefit for acute otitis media in children. As most cases will resolve spontaneously, this benefit must be weighed against the possible adverse reactions. Antibiotic treatment may play an important role in reducing the risk of mastoiditis in populations where it is more common.
PMID: 14973951

Annals of Internal Medicine
Principles of Appropriate Antibiotic Use for Treatment of Acute Respiratory Tract Infections in Adults: Background, Specific Aims, and Methods
20 March 2001 | Volume 134 Issue 6 | Pages 479-486
The need to decrease excess antibiotic use in ambulatory practice has been fueled by the epidemic increase in antibiotic-resistant Streptococcus pneumoniae. The majority of antibiotics prescribed to adults in ambulatory practice in the United States are for acute sinusitis, acute pharyngitis, acute bronchitis, and nonspecific upper respiratory tract infections (including the common cold). For each of these conditions—especially colds, nonspecific upper respiratory tract infections, and acute bronchitis (for which routine antibiotic treatment is not recommended)—a large proportion of the antibiotics prescribed are unlikely to provide clinical benefit to patients.

Principles of Appropriate Antibiotic Use for Acute Rhinosinusitis in Adults: Background
20 March 2001 | Volume 134 Issue 6 | Pages 498-505
The following principles of appropriate antibiotic use for adults with acute rhinosinusitis apply to the diagnosis and treatment of acute maxillary and ethmoid rhinosinusitis in adults who are not immunocompromised.
1. Most cases of acute rhinosinusitis diagnosed in ambulatory care are caused by uncomplicated viral upper respiratory tract infections.
2. Bacterial and viral rhinosinusitis are difficult to differentiate on clinical grounds. The clinical diagnosis of acute bacterial rhinosinusitis should be reserved for patients with rhinosinusitis symptoms lasting 7 days or more who have maxillary pain or tenderness in the face or teeth (especially when unilateral) and purulent nasal secretions. Patients with rhinosinusitis symptoms that last less than 7 days are unlikely to have bacterial infection, although rarely some patients with acute bacterial rhinosinusitis present with dramatic symptoms of severe unilateral maxillary pain, swelling, and fever.
4. Acute rhinosinusitis resolves without antibiotic treatment in most cases. Symptomatic treatment and reassurance is the preferred initial management strategy for patients with mild symptoms. Antibiotic therapy should be reserved for patients with moderately severe symptoms who meet the criteria for the clinical diagnosis of acute bacterial rhinosinusitis and for those with severe rhinosinusitis symptoms—especially those with unilateral facial pain—regardless of duration of illness.

Principles of Appropriate Antibiotic Use for Acute Pharyngitis in Adults: Background
 20 March 2001 | Volume 134 Issue 6 | Pages 509-517
The following principles of appropriate antibiotic use for adults with acute pharyngitis apply to immunocompetent adults without complicated comorbid conditions, such as chronic lung or heart disease, and history of rheumatic fever. They do not apply during known outbreaks of group A streptococcus.
1. Group A ß-hemolytic streptococcus (GABHS) is the causal agent in approximately 10% of adult cases of pharyngitis. The large majority of adults with acute pharyngitis have a self-limited illness, for which supportive care only is needed.
2. Antibiotic treatment of adult pharyngitis benefits only those patients with GABHS infection. All patients with pharyngitis should be offered appropriate doses of analgesics and antipyretics, as well as other supportive care.
3. Limit antibiotic prescriptions to patients who are most likely to have GABHS infection. Clinically screen all adult patients with pharyngitis for the presence of the four Centor criteria: history of fever, tonsillar exudates, no cough, and tender anterior cervical lymphadenopathy [lymphadenitis]. Do not test or treat patients with none or only one of these criteria, since these patients are unlikely to have GABHS infection. For patients with two or more criteria the following strategies are appropriate: a) Test patients with two, three, or four criteria by using a rapid antigen test, and limit antibiotic therapy to patients with positive test results; b] test patients with two or three criteria by using a rapid antigen test, and limit antibiotic therapy to patients with positive test results or patients with four criteria; or c) do not use any diagnostic tests, and limit antibiotic therapy to patients with three or four criteria.

Principles of Appropriate Antibiotic Use for Treatment of Uncomplicated Acute Bronchitis: Background
20 March 2001 | Volume 134 Issue 6 | Pages 521-529
The following principles of appropriate antibiotic use for adults with acute bronchitis apply to immunocompetent adults without complicating comorbid conditions, such as chronic lung or heart disease.
1. The evaluation of adults with an acute cough illness or a presumptive diagnosis of uncomplicated acute bronchitis should focus on ruling out serious illness, particularly pneumonia. In healthy, nonelderly adults, pneumonia is uncommon in the absence of vital sign abnormalities or asymmetrical lung sounds, and chest radiography is usually not indicated. In patients with cough lasting 3 weeks or longer, chest radiography may be warranted in the absence of other known causes.
2. Routine antibiotic treatment of uncomplicated acute bronchitis is not recommended, regardless of duration of cough. If pertussis infection is suspected (an unusual circumstance), a diagnostic test should be performed and antimicrobial therapy initiated.

Principles of Appropriate Antibiotic Use for Treatment of Nonspecific Upper Respiratory Tract Infections in Adults: Background
20 March 2001 | Volume 134 Issue 6 | Pages 490-494
The following principles of appropriate antibiotic use for adults with nonspecific upper respiratory tract infections apply to immunocompetent adults without complicating comorbid conditions, such as chronic lung or heart disease.
1. The diagnosis of nonspecific upper respiratory tract infection or acute rhinopharyngitis should be used to denote an acute infection that is typically viral in origin and in which sinus, pharyngeal, and lower airway symptoms, although frequently present, are not prominent.
2. Antibiotic treatment of adults with nonspecific upper respiratory tract infection does not enhance illness resolution and is not recommended. Studies specifically testing the impact of antibiotic treatment on complications of nonspecific upper respiratory tract infections have not been performed in adults. Life-threatening complications of upper respiratory tract infection are rare.
3. Purulent secretions from the nares or throat (commonly observed in patients with uncomplicated upper respiratory tract infection) predict neither bacterial infection nor benefit from antibiotic treatment.

CHEST January 2006
Chronic Cough Due to Acute Bronchitis
ACCP Evidence-Based Clinical Practice Guidelines
1.Sidney S. Braman, MD, FCCP
Background: The purpose of this review is to present the evidence for the diagnosis and treatment of cough due to acute bronchitis and make recommendations that will be useful for clinical practice. Acute bronchitis is one of the most common diagnoses made by primary care clinicians and emergency department physicians. It is an acute respiratory infection with a normal chest radiograph that is manifested by cough with or without phlegm production that lasts for up to 3 weeks. Respiratory viruses appear to be the most common cause of acute bronchitis; however, the organism responsible is rarely identified in clinical practice because viral cultures and serologic assays are not routinely performed. Acute bronchitis is a self-limited respiratory disorder, and when the cough persists for > 3 weeks, other diagnoses must be considered.
Conclusion: Acute bronchitis is an acute respiratory infection that is manifested by cough and, at times, sputum production that lasts for no more than 3 weeks. This syndrome should be distinguished from the common cold, an acute exacerbation of chronic bronchitis, and acute asthma as the cause of acute cough. The widespread use of antibiotics for the treatment of acute bronchitis is not justified, and vigorous efforts to curtail their use should be encouraged.

Arch Intern Med. 2003 Aug 11-25;163(15):1793-8.
Effect of amoxicillin-clavulanate in clinically diagnosed acute rhinosinusitis: a placebo-controlled, double-blind, randomized trial in general practice.
Basel Institute for Clinical Epidemiology, Medizinische Universitäts-Poliklinik, and Universitätsklinik für Hals-, Nasen- und Ohrenkrankheiten, Kantonsspital Basel, Basel, Switzerland.
BACKGROUND: Acute rhinosinusitis is one of the most common reasons for prescribing antibiotics in primary care. However, it is not clear whether antibiotics improve the outcome for patients with clinically diagnosed acute rhinosinusitis. We evaluated the effect of a combination product of amoxicillin-potassium clavulanate on adults with acute rhinosinusitis that was clinically diagnosed in a general practice setting. METHODS: We conducted a randomized, placebo-controlled, double-blind trial with 252 adults recruited at 24 general practices and 2 outpatient clinics. Each patient had a history of purulent nasal discharge and maxillary or frontal pain for at least 48 hours. Patients were given amoxicillin, 875 mg, and clavulanic acid, 125 mg, or placebo twice daily for 6 days. CONCLUSIONS: Adult patients in general practice with clinically diagnosed acute rhinosinusitis experience no advantage with antibiotic treatment with amoxicillin-clavulanate and are more likely to experience adverse effects.
PMID: 12912714

Lancet. 2008 Mar 15;371(9616):908-14.
 Antibiotics for adults with clinically diagnosed acute rhinosinusitis: a meta-analysis of individual patient data.
Basel Institute for Clinical Epidemiology, University Hospital Basel, Basel, Switzerland.
BACKGROUND: Primary-care physicians continue to overprescribe antibiotics for acute rhinosinusitis because distinction between viral and bacterial sinus infection is difficult. METHODS: We identified suitable trials--in which adult patients with rhinosinusitis-like complaints were randomly assigned to treatment with an antibiotic or a placebo--by searching the Cochrane Central Register of Controlled Trials, Medline, and Embase, and reference lists of reports describing such trials. Individual patients' data from 2547 adults in nine trials were checked and re-analysed. FINDINGS: 15 patients with rhinosinusitis-like complaints would have to be given antibiotics before an additional patient was cured. Patients with purulent discharge in the pharynx took longer to cure than those without this sign; the NNT was 8 patients with this sign before one additional patient was cured. Patients who were older, reported symptoms for longer, or reported more severe symptoms also took longer to cure but were no more likely to benefit from antibiotics than other patients. INTERPRETATION: Common clinical signs and symptoms cannot identify patients with rhinosinusitis for whom treatment is clearly justified. Antibiotics are not justified even if a patient reports symptoms for longer than 7-10 days.
PMID: 18342685
« Last Edit: May 01, 2013, 12:05:51 AM by Archer »

Offline RonH2K

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Re: Antibiotics...when not to swallow
« Reply #1 on: May 26, 2009, 04:13:07 PM »
"Hey, Doc!  Me, I'm doing well.  Thanks for asking.  Oh, by the way... ...can I get a 30-day supply of antibiotics?  Huh?  Oh... see, I think the end of the world as we know it is near and just want to have some onhand so I can be better prepared."

Maybe it's my straight-shooting nature, but I'm just not sure of how to ask for something like medications to put in a BOB.  I really don't want to lie, but as you can see above, I could definitely use a little help with a better "story" for the Doc!

Seriously, what is a legitimate way to go about asking for "contingency medications"?

Offline fritz_monroe

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Re: Antibiotics...when not to swallow
« Reply #2 on: May 26, 2009, 06:29:33 PM »
Good information.  Thanks for posting it.

RonH2K,  good question.  Do you take any extended vacations?  You could tell your doctor that you will be camping in the backwoods and will be gone for some time without being in contact with another human being.

Other than that, I have no idea how to ask for it.  I've also read that the veterinarian drugs are identical to the ones intended for human use.  Some people pick up fish antibiotics to keep on hand.


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Re: Antibiotics...when not to swallow
« Reply #3 on: May 26, 2009, 07:13:58 PM »
Awesome post!

Offline RonH2K

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Re: Antibiotics...when not to swallow
« Reply #4 on: May 26, 2009, 07:16:16 PM »
Thanks for the reply.  I've been looking at the fishtank antibiotics as an option.  Might just buck-up and ask the ole Doc next time I'm in his presence.  LOL.


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Re: Antibiotics...when not to swallow
« Reply #5 on: May 27, 2009, 12:11:21 AM »
Seriously, what is a legitimate way to go about asking for "contingency medications"?

Well, if you are serious, I think you need to do a little preparation before just asking such a question to your Doc.  (Maybe you already have, but bear with me.)  Which antibiotics do you want?  What are you preparing to treat in SHTF/remote medical care?  How many "standard courses of therapy" do you want to store?  If your medical provider asks you some basic questions, are you prepared to answer them in an educated manner?

Let me put it another way.  A local 18YO kid you know somewhat (and care about) comes to your house and says "Can I borrow one of your guns and some ammo?"  Are you going to toss him a .375 H&H and some ammo and tell him to go have fun?  No, a responsible gun owner would ask some questions.  "What are your plans to use this gun?"  He answers "I am going camping and I want to do some hunting."  You ask "What do you plan to hunt?"  He answers "Animals and stuff."  You ask "Sounds like fun, which animals?"  He says "I dunno, maybe some deer, turkey, or rabbits, maybe a chupracabra if one comes into camp."  You say "It is the middle of summer, you can't get a hunting license for deer and turkey in July around here, and chupracabras are a myth buddy."  He says "Yea, well I just want to shoot some rabbits."  You ask "Do you know how to safely handle a firearm?"  He says "Um, yea."  You ask "What are the four rules of safely handling a firearm?"  He says "Like make sure you put the bullet in the shotgun the right way?"  You say "Uh, no, and you load shells in a shotgun.  You shouldn't be handling a firearm without proper training."  From here, some gun owners like myself might take interest in this young lad and try to become a positive influence by teaching him some things.  (Many others are going to tell this kid to go pound sand.)  I might take him out to the range a few times to get a feel for his level of responsibility, take him on a rabbit hunt to see if he has learned what I have taught.  Only then, I might (after careful consideration) hand him my Model 60 and a box of .22LR.

What responsible licensed medical provider is going to hand over a potentially deadly, or often misused, drug to someone who has no idea about what he/she is getting into?  (I am not saying you RonH2K have no knowledge, just that the average person has little or no knowledge.) 

Would I provide some "contingency meds" to someone I had full faith and trust in?  Well yes, I have and continue to do so.  No different than I have provided medications to someone traveling overseas, or to take remote journeys here in the States, or to my buddy who is leaving for Iraq.  If I had the feeling they were irresponsible nut jobs, no way no how, not on my license, nor my ethics.

In short, my answer to your question RonH2K, is to build a healthy rapport with your provider.  Go get an annual physical, and during the exam ask some basic questions like "I want to ensure I am physically prepared for a month long backpacking trip, what would you suggest I change about my health or bring with me to protect my health?"  "Do you ever take some remote travel journeys Doc?"  (If not, then ask him/her who they would suggest to seek for advice on the medical aspects of remote/wilderness travel.)  If yes, begin the conversation about what they would take with them, and why.  End the conversation with "I would certainly want to go prepared.  What can I do to educate myself to the point where you might be willing to provide me with some basic contingency meds?"

Don't say "I want 30 days of antibiotics for my Bug Out Bag in case SHTF, if you won't I can just go get some fish antibiotics!"  ???

I will warn you not to lie about some fabled journey that you plan to hike the Appalachian trail, lies beget lies and often ultimately fail.  Most medical professionals have a pretty good B.S. meter, folks try to talk us out of meds (painkillers, antibiotics, and steroids) on a regular basis.  If you burn their trust, they will never forget.

Before anyone asks, there is no way in hell I am sending someone I have met via the Internet a prescription for meds, even if I find you interesting because you believe in zombies or chupracabras.   :P 

One last thought.  Do you pack questionable ammo in your concealed carry weapon, or recently manufactured quality defensive ammo?  I want mine to go bang and do some damage with very high reliability if I should need to pull the trigger.  I feel the same way about antibiotics, no "fishy fishy bite my hook" prayers for me! 
« Last Edit: May 01, 2013, 12:06:12 AM by Archer »