Saturday, January 28, 2017

#11: The Cold War: You're Not Getting Antibiotics!

This one goes to eleven!

Dear Dr. Tumorific, why do you refuse to give me an antibiotic when I have a bad cold?


Dear Nina,

I hesitate to answer this, because to do so would break a solemn vow of secrecy that all doctors must make. Furthermore, if I do so, I may be targeted by Big Pharma's squad of flying monkeys, because it is an issue of serious liability to them. But I will tell you, because I believe in the truth even at great personal cost:
Every time a doctor gives a patient with a cold a prescription for antibiotics, there is a real chance that the patient will spontaneously combust. There have been a few famous cases of this, like the talented drummer, Peter James Bond, but there are many less famous ones. As Bond's bandmate, David St. Hubbins said, "Dozens of people spontaneously combust every year. It's just not that widely reported." *

Of course, there are other reasons. . .

[Before I go any further, I have to make a few qualifications. If you have asthma, COPD, a long history of heavy smoking, cystic fibrosis, hereditary or acquired immunosuppression (like from chemotherapy), or have a giant piece of dead skull behind your face, this may not apply to you.] 

Newsflash: There are some medical issues I cannot fix. The common cold is one. Let me illustrate with a fictional scenario:

It's January in Massachusetts. The sky darkens at 4 pm, and the waiting room is packed with patients coughing and sneezing on each other. I walk to the door of exam room 1, and on it is a paper with the name of my patient, the 24-year-old Nigel Tufnel. ** 

I vaguely remember Nigel from his last visit 2 years ago, when he came in to get a health clearance for a bungee-jumping stunt for his heavy metal band. Lower down on the paper, I see written, "complaint: cold." My blood runs cold in anticipation of the battle ahead. I knock and slowly open the door. ***

Nigel looks over at me from the exam table. He appears generally healthy, but his eyes are a little bloodshot, and his upper lip is chapped from wiping. He coughs a loud, juicy cough and greets me in hoarse, broken voice. I avoid his extended hand and make a polite elbow bump.

He has been feeling lousy for three days. He has had a little fatigue and a headache. He has  been coughing all night. He can't stop blowing his nose, and his throat hurts. He has had no sweats or chills, is not short of breath, and he is not wheezing. He has no muscle aches. He might be feeling a little better than yesterday, but he's not sure. 

Nigel has tried three different brands of cough syrup. None of them have worked. I smile sadly. Nigel is doomed. He is doomed for maybe the next few days to cough and sniffle and talk like Tom Waits sings, and there is little or nothing I can do about it. Nigel has a cold. 

I tell him to take a day off and rest. I give him some advice about over the counter medications to make it less unpleasant and maybe prescribe codeine cough syrup. That won't make him cough any less, and it certainly won't fix his cold any sooner, but it will help him sleep. (More about symptomatic remedies another time.)

"But wait, " says Nigel. "Why aren't you giving me an antibiotic? My roommate Derek Smalls had the same thing last week. He went to Dr. Strangelove at the McHealth Stop next to DeMoulas, and Dr. Strangelove cured him with an antibiotic. I think it was called Bubbamycin." This is where the visit gets difficult.  

A cold is a viral upper respiratory infection. Unlike bacteria, viruses do not respond to antibiotics. There are antiviral drugs, but they are not useful against cold viruses. A cold is transmitted when a patient touches something touched by a cold sufferer and then touches their own face. **** One to three days later, the patient gets a cough and/or runny nose and/or sore throat, and/or a bunch of other unpleasant stuff we all know. 

Generally, a cold should start to dissipate after a week or ten days. This can cause a lot of confusion. 

Dr. Strangelove cured Derek of nothing at all. Derek would have gotten better all by himself. But since Derek got better after taking the Bubbamycin, Derek and Nigel logically think the Bubbamycin was responsible. *****

Also, Derek has not told my patient about the very irritating jock itch that happened after Bubbamycin killed off Derek's normal skin bacteria, allowing a nasty fungus to grow. Furthermore, Derek does not know it yet, but the Bubbamycin has also killed off many of his normal gut bacteria. Because of that, in a couple of weeks, Derek will come down with a life-threatening case of Clostridium difficil diarrhea. 

More frightening, every time anyone takes an antibiotic for good or bad reasons, bystander bacteria, or incompletely-eradicated disease bacteria, become a little more resistant to antibiotics. As a society, we are creating bacteria that cannot be cured by antibiotics. There have already been some cases, and we may soon face a post-antibiotic world.

I explain all of this to Nigel. He asks me how I know about Derek's jock itch. I prepare myself for a HIPAA lawsuit. He then says, "But I think I have sinusitis! My sinuses hurt!" 

Nigel isn't wrong. Nigel does have sinusitis. It's probably a viral sinusitis. That's what a cold is. There is a small chance that he has bacterial sinusitis, which also usually resolves on its own within 10 days. Statistically speaking, though, the benefits of antibiotics only start to outweigh the risks after about 10 days. I explain all this to Nigel, watching the clock as it ticks further past the time I was supposed to start seeing the next patient.

Finally, Nigel grudgingly relents. He takes a copy of my custom-made handout for over-the-counter upper respiratory infection treatments (See below! ******) and checks out. I spend the next half hour documenting and billing the visit in the electronic medical record.

This is a common scenario. Doctors find it very difficult. If we give the patient antibiotics, the patient leaves happy and gets well (with the help of their own immune system) and thanks us. Saying 'no' tactfully takes precious time, and the patient may still be annoyed with us. It may also detract from our scores on patient satisfaction surveys, which can lower our pay.

But being a good doctor may mean disappointing the patient. So, sorry Nina. No antibiotics for your cold.

Be well,

Dr. Tumoriffic

PS: By the way, Nina, the same basically goes for the flu. Technically, there is medicine for it, but it's not very effective, it's expensive, and has lots of side effects. I would only use it for very sick patients since it does slightly decrease their risk of dying from the flu.

PPS: Don't buy combo cold products. They're overpriced combinations of medications that you can buy more cheaply individually. If you must get one of these combis, look closely at the identity and dosage of each component before you take a different medication, such as acetaminophen (aka Tylenol), that may actually be the same as one those included. Otherwise, you may overdose. (Also, by the way, never take more of a medication that is recommended on the bottle unless your doctor says so. Just because it's over-the-counter does not mean that it's safe to take it like candy. I've seen that, and it can be ugly.)

** I have no patient with the name Nigel Tufnel. In fact, I have never met such a person.

*** Never tell your doctor you are coming in for a 'cold.' It's like announcing that you're going to waste their time. That can be a dangerous distraction when what you thought was a cold turns out to be a pneumonia. That has happened in my experience.

**** So wash your hands, all of you! The flu, on the other hand, is transmitted through the air, so you should try not to breath when you are around other people during the winter.

***** This is why we need statistical analysis in medicine. Without being able to compare at many different cases of patients who have gotten better from a given condition, we have no way of knowing whether the remedy they used had anything to do with their getting better. Eons of worthless remedies have flowered, not because people in the past were stupid, but because there was no way to distinguish between a cause and a coincidence.

Advice for Allergies, Colds, Coughs, and Sinusitis

Nearly all short-term upper respiratory illnesses are viral or allergic, and not bacterial.  Viruses cause infections, but we have no treatment for them. Therefore, antibiotics are usually more likely to give you diarrhea or put you at risk for a more dangerous infection than make you better. The following nonprescription treatments may make your illness less unpleasant:

1. REST!  Take a day or two off if you can.

2. Neti-Pot or Sinus Rinse:  Use as often as you want and at least twice daily when you are sick. This is very important. Salt water in a teapot-like container or a bottle flows in one nostril and out the other or the mouth, clearing out nasal discharge and preventing serious bacterial infection. (Best to use boiled tap water or distilled. Most places are probably safe, but you never know.) This is not the same as saline nasal sprays, which can help, but not nearly as much.

3. Honey: Spoonfuls of any kind of honey sooth the throat and may help with coughing. You can also gargle with warm water and honey mixed with salt and baking soda. Go easy on the honey if you have diabetes.

4. Cough drops or hard candy: These, especially the ones with lidocaine, may sooth a sore throat and suppress a cough.

5. Humidifier: Useful for all respiratory conditions during cold weather. Clean frequently to avoid fungus, or use a hot water humidifier.

6. Steam: either buy a sinus steamer from the pharmacy or boil pot of water, put on the table and lean over it with a towel over your head and the pot and breath until the water stops steaming. This will moisten your airways and help clear dried mucus.

7. Over-the-counter nasal steroids: Fluticasone (Flonase) and triamcinolone nasal spray (Nasacort) are very helpful for allergies and sinusitis. They are much safer than oral or intravenous steroids. Do not let the spray get into your eyes. Do not use without a doctor's advice if you have glaucoma.

8. Oxymetazoline nasal spray (such as Afrin): This works immediately to stop congestion and open the sinuses. 2 puffs every 12 hours FOR 3 DAYS ONLY.  Longer use can make stuffiness worse! You may use this at the same time as other nasal sprays if your doctor prescribes them. Do not use this if you have glaucoma

9. Pseudoephedrine (You have to ask the pharmacist for this directly): This helps dry up mucus, and open sinuses. It may cause insomnia, anxiety, or cardiac arrhythmias. Do not use if you have severe hypertension.  Elderly men or men with benign prostatic hypertrophy (BPH) should avoid pseudoephedrine as it may worsen urinary symptoms.

10. Antihistamines: These are mostly for allergies. They help dry up nasal secretions and decrease congestion.  Older antihistamines such as diphenhydramine (aka Benadryl) are stronger, but may make you drowsy. Avoid them if you are over 75 as they may cause confusion. The newer antihistamine, fexofenadine (Allegra), is less likely to cause this.  Elderly men or men with BPH should avoid antihistamines as they may worsen urinary symptoms.

Upper respiratory infections usually improve by 10 days or so whether or not you take medicine for them. If you are sick for more than 10 days and are not improving, if have a fever >101 for more than 3 days, if you have difficulty breathing, if you cannot keep down fluids, or if you suddenly become much sicker after mostly recovering, give us a call or visit.

This sneezing marine iguana is not getting antibiotics!

The iguana is actually sneezing. For marine iguanas, sneezing is the equivalent of urinating. They sneeze out extra salty fluid to maintain a proper salt balance in their bodies. So this is also a picture of an iguana taking pee.

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