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From: "Steve Harris" <>
Subject: Re: do I have antibiotic resistant infection?
Date: Thu, 14 Mar 2002 20:51:44 -0700
Message-ID: <a6rr9b$i8n$>

"CBI" <> wrote in message
> "PF Riley" <> wrote in message
> >
> >  recently, data has
> > come out showing that our "soft-call" cases of sinusitis, namely "the
> > cold that won't go away" but with no specific signs, all go away at
> > the same rate, antibiotics or no. (I think there was a similar study
> > in the medicine literature regarding bronchitis in adults, antibiotics
> > vs. bronchodilators, Dr. Harris?)
> There is similar information on adults with sinusitis. In adults with
> "bronchitis" albuterol inhalers work better than antibiotics.
> --


Yes, so long as we're talking about your average reasonably healthy
non-geriatric patient. The toughest of these is bronchitis, where you're
always wondering if you're looking at an early pneumonia. Everybody else can
wait a week or two to see if whatever virus they probably have goes away.
I've often been guilty of giving antibiotics to younger people who were
coughing up purulent-looking sputum, who I didn't think had pneumonia
clinically. Even in whom I *knew* didn't, from a clear chest X-ray. Perhaps
this isn't usually necessary. Often people satisfied with a mere script for
Zithromax, which they know they fill if things get worse over the weekend,
but are told they probably won't have to.

But then comes the question of what to do with elderly patient with the
chest infection, who more often go on to develop pneumonia (though this is
by no means the usual case), but in whom it's always more serious when they
do develop it (they usually require hospitalization for at least a couple of
days of IV antibiotics and careful monitoring, since they have a much high
probability of going to respiratory failure and even death; by contrast
young vigorous patients with pneumonia can sometimes be treated as
outpatients if they're seen every day).

So what to do. I'd be perfectly happy to keep the 85 yo lady with the
clinical acute bronchitis off antibiotics so long as her O2 sats stay
normal. If I only had somebody to check it 3 times a day and who I could
trust to call me when it started to go down.  That's hardly ever possible (I
won't say never, because I actually recently treated a 91 year-old lady at
home with a home O2 monitor and an intelligent family; it saved many days of
hospitalization). In the real world it's usually a elderly lady who is
widowed and lives alone, who is bought in the by the daughter on a Friday
with two days of severe cough and green sputum, temp 98.0, pretty clear
lungs, sat of 90% (which even at sea level is about what you expect from a
nonsmoker this old) and you know there's no easy way to recheck her finger
oxymetry without sending her to an ER, until Monday. So there you are. She's
feeling lousy. Treat with reassurance only?  You're gutsier than me if you


Arch Intern Med 2002 Feb 11;162(3):256-64

Antibiotics for common respiratory tract infections in adults.

Hirschmann JV.

Medical Service (111), Puget Sound Veterans Affairs Medical Center,
University of Washington School of Medicine, 1660 S Columbian Way, Seattle,
WA 98108, USA.

A thorough review of the published information indicates that antibiotics
rarely benefit acute bronchitis, exacerbations of asthma and chronic
bronchitis, acute pharyngitis, and acute sinusitis, although they are
commonly prescribed for these illnesses. Rather than prescribing them for
these conditions, practitioners should explain to their patients that
antibiotics, which have numerous adverse effects, will not hasten resolution
of their symptoms, which will often respond to other medications. Most
patients will accept this approach if the clinician addresses their
concerns, shows a personal interest in them, discusses the expected course
of the ailment, and explains the treatment.

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