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The Nuance

When Should You Take an Antibiotic?

How to assess whether you really need that prescription

Illustration: Kieran Blakey

AAntibiotics save lives by slaying infectious bacteria, but they’re indiscriminate killers. While some are more precise than others, all of them wipe out good bacteria along with the bad.

The loss of good bacteria can leave a person vulnerable to developing post-antibiotic health issues. For example, people who are on antibiotics or have recently been on them are up to 10 times more likely to contract a Clostridium difficile (C. diff) infection than those who have not been on antibiotics. C. diff usually causes symptoms like diarrhea and stomach pain, and it can return again and again. Antibiotics can also trigger allergic reactions, and they may disrupt the gut microbiome in ways that cause or contribute to inflammatory bowel disease and other health issues.

The rise of antibiotic-resistant bacteria is another, broader concern. “We’re creating superbugs,” says Dr. Ateev Mehrotra, an associate professor of health care policy and medicine at Harvard Medical School.

The more a species of bacteria is exposed to an antibiotic, the more likely that species is to adapt and develop defenses against that antibiotic. Over time, those defenses can render an antibiotic ineffective. “Already, on a day-to-day level, we’re seeing patients who we start on an antibiotic that typically works, but now we have to switch them after we learn the bacteria is resistant,” Mehrotra says. In some cases, an individual may have to undergo days of antibiotic treatment before doctors can determine which “cocktail” of drugs will get the job done.

Antibiotic-resistant “bugs” already kill roughly 23,000 people a year, and experts warn that, eventually, a shortage of effective antibiotics may return the human species to a time when even minor infections are fatal. “On both a personal and a societal level, antibiotic overuse is a huge issue,” Mehrotra says.

When to take antibiotics

Experts say there are two overarching problems when it comes to the way doctors administer antibiotics to their patients.

The first has to do with the specific types of antibiotics doctors employ to treat bacterial infections. “A lot of doctors prescribe azithromycin or ciprofloxacin, which are extremely broad-spectrum antibiotics, meaning they target a lot of different bacteria,” says Dr. Michael Barnett, an associate professor of health policy at Harvard T.H. Chan School of Public Health. These two antibiotics are often referred to as a “Z-pack” or “Cipro,” respectively, and Barnett says prescribing them for run-of-the-mill infections is like firing a shotgun when all that’s needed is “the tap of a hammer.”

“Doctors use these indiscriminately because they’ve got all their bases covered with that drug,” he says. “But the bacteria that develop resistance to those antibiotics become some of the most difficult for us to treat.” These powerful drugs are also riskier for the patient. “C. diff is much more common with these broad-spectrum antibiotics because they really wipe out the microbiome, and harmful bacteria can grow back,” he says. Unnecessarily long courses of antibiotic treatment are yet another issue, he adds.

While over-aggressive treatment is a problem, employing antibiotics when they’re neither indicated nor likely to help is the bigger issue. Between 80% and 90% of all antibiotics are prescribed by doctors in outpatient settings. And according to the CDC, one out of three of these prescriptions is unnecessary — meaning antibiotics will do no good whatsoever.

“About 75% of inappropriate antibiotic prescriptions are written for acute upper respiratory infections, including the common cold, which are caused by viruses.”

Why do doctors prescribe drugs that aren’t needed? “The answer is complicated, but I think a lot of it boils down to the fact that in America, we have a real bias toward wanting to do something when there’s a problem,” Barnett says. Sick people want a pill to make their illness go away, and many doctors feel pressure to oblige them, he says.

He says antibiotics are appropriate for bacterial infections — such as the ones that cause bacterial pneumonia, Lyme disease, and some sexually transmitted infections (like chlamydia, gonorrhea, and syphilis).

But antibiotics do nothing to resolve a viral infection. And Mehrotra says that about 75% of inappropriate antibiotic prescriptions are written for acute upper respiratory infections, including the common cold, which are caused by viruses.

Bronchitis, viral pneumonia, and the flu are other illnesses for which antibiotics are useless. And many GI maladies — the types that cause mild stomach upset and diarrhea — are viral, and therefore won’t benefit from antibiotics. In kids, earaches are also “a big one,” Barnett says. “The overwhelming majority of ear infections are viral, not bacterial.”

Challenge your doctor about unnecessary antibiotics

Urgent care clinics account for nearly half of all unnecessary antibiotic prescriptions, according to the CDC. If a doctor or clinician at one of these walk-in facilities prescribes an antibiotic, some follow-up research — or getting a second opinion — may be worthwhile.

Whatever the setting, asking your doctor a few questions can help you avoid taking an antibiotic you don’t need.

“You could say, ‘I hear antibiotics don’t work against viral infections. Do I have a bacterial infection?’” Barnett suggests. If the doctor or clinician “hems and haws” or says something like, “We’re just playing it safe,” consider asking if you could wait a day or two before filling that prescription, he advises. Take that time to figure out if your diagnosed condition really requires an antibiotic. If it doesn’t, don’t take it.

Another suggestion: At some point before your doctor makes a diagnosis, tell them you would rather not take an antibiotic unless it’s really critical. “Doctors tend to overestimate the number of patients who want an antibiotic,” Mehrotra says. “If more patients introduced the idea that they don’t want an antibiotic, fewer will be prescribed.”

Finally, Barnett says “overuse” of doctor or clinic services is a major driver of unnecessary antibiotic scrips. “A lot of people go to the doctor every time they get a common cold,” he says. It’s unfair to blame a person who feels rotten for seeking a doctor’s help. But if a person has a mild illness — a head cold, for example, or a case of diarrhea — they’re better off waiting a few days to see if symptoms improve, rather than rushing to a doc’s office.

“As soon as someone goes in, their risk of an unnecessary antibiotic prescription rises dramatically,” he says.

I write about health and science. I live in Detroit with my wife and kids. I’m trying to learn German, but my progress so far is nicht gut.

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