Because antibiotics only work against bacteria, a person with a viral infection who takes antibiotics is no better off than a person who takes no medication at all. And taking antibiotics in that situation may even make matters worse.

It’s a scenario that plays out numerous times in doctors’ offices every day. A patient comes in with a sore throat and a runny nose and leaves with a prescription for an antibiotic.

What’s the matter with that? Plenty, according to infectious disease specialists and public health organizations. To begin with, using antibiotics for anything other than a bacterial infection is ineffective and unnecessarily exposes the body to a powerful drug. Antibiotics are medications that either kill or stop the growth of harmful bacteria, microscopic, one-celled structures that can cause illness.

An antibiotic can act against a specific bacterium or many different bacteria; the latter is often referred to as a broad-spectrum antibiotic. Viruses are also microscopic and can produce illness, but are very different organisms than bacteria. They can’t grow outside the host cell and, unlike many helpful bacteria, are never good for the body. Because antibiotics only work against bacteria, a person with a viral infection who takes antibiotics is no better off than a person who takes no medication at all. And taking antibiotics in that situation may even make matters worse. Antibiotics can destroy the body’s friendly bacteria, too, causing such problems as diarrhea or yeast infections.

Then there’s the “big picture.” “The overuse of antibiotics is a major problem that potentially can cause significant harm,” says Dr. Robert Wallis, an associate professor of medicine at New Jersey Medical School and an infectious disease specialist at University Hospital. “Bacteria can ‘outsmart’ the drug and change, or mutate, so that it takes more of an antibiotic to destroy the bacteria than it had before. Bacteria can also exchange DNA with each other, another way for antibiotic-resistant bacteria to proliferate.”

Dr. Robert Wallis

Every time bacteria are exposed to an antibiotic, their innate quest to survive comes into play. Taking an antibiotic for a cold offers bacteria additional and unnecessary opportunities to become more drug resistant.

“Over time, an antibiotic can totally lose its effectiveness. Difficult-to-treat, drug-resistant bacteria then require stronger and often more expensive antibiotics,” says Dr. Wallis. He cites the example of pneumoccocus, a bacterium associated with middle ear infections. Until the mid-1980s, pneumoccocus was highly sensitive to penicillin. But as the bacterium’s resistance against penicillin grew, doctors found they had to prescribe slightly higher doses of penicillin. Since about the late 1990s, pneumoccocus has been increasingly difficult to treat with penicillin, causing doctors to turn to a new class of antibiotics, fluoroquinolone, to do the job. It comes at a financial cost and a risk to public health. “Now other organisms are developing resistance to fluoroquinolone,” says Dr. Wallis.

Unfortunately, antibiotic overuse is quite common. According to a 2001 study published in Pediatrics, about 110 million courses of antibiotics are prescribed each year in America, many to children. The U.S. government estimates that about half of all antibiotic prescriptions are unnecessary. Drug-resistant bacteria can affect the individual, such as the patient who needs multiple courses of antibiotics before the infection is resolved. They can be costly: when pharmaceutical companies develop new, stronger antibiotics because old ones are no longer effective, the high cost of research and development gets passed on to the consumer.

Breaking the cycle of antibiotic overuse/bacterial resistance is not an easy matter. A major hurdle is the patient’s expectation to be “treated.” “People wait to see the doctor and pay for a visit, and they want to leave with something they think will help them get better,” says Dr. Wallis.

	© 2003 Eric MacDicken
	A typical bacterium has a rigid cell wall and a thin cell membrane surrounding the fluid inside the cell. Its genetic information is stored as DNA. Bacteria also contain all the machinery needed for replication, including ribosomes, which are special tools necessary for copying DNA. Each antibiotic has a specific way to kill certain kinds of bacteria by attacking one of these special structures. Penicillin, for example, disrupts the cell wall.
	© 2003 Eric MacDicken
	A virus may or may not have an outermost spiky layer called the envelope. All viruses have a protein coat and a core of genetic material, either DNA or RNA, but that all. Viruses don't have the targets (ribosomes, cell walls, and so on) that most antibiotics use to kill bacteria, so they are unaffected by these antibiotics.

And yet, even doctors have divergent ideas about when to prescribe antibiotics. It is sometimes difficult to determine whether an infection is bacterial or viral from physical exam alone. Even if it is unlikely but possible that the person’s problem is bacterial, some doctors will prescribe an antibiotic just to be on the safe side. Additionally, the desire to satisfy the patient’s expectations can influence a doctor’s decision. “When I was completing my fellowship in infectious disease, I worked evenings at an urgent care center. Some of the patients had true emergencies, but many of them had colds. Once, I was called on the carpet for not prescribing antibiotics to patients who had viral infections. I was told by another doctor, ‘People are coming to you and expecting treatment. They’ll stop coming if they don’t feel they are receiving care.’”

Hospitals and other healthcare facilities can become a staging ground for antibacterial-resistant organisms. Many hospitals, like University Hospital, have protocols and guidelines in place to help protect patients and staff. When Dr. Wallis came to University Hospital in 2001, one of his first responsibilities was to develop prescribing guidelines for certain antibiotics. “In the past, residents and attending physicians would order costly, broad-spectrum antibiotics to treat very simple problems,” he says. “Now, for about 12 antibiotics and antifungal medications, we have criteria that patients must meet before they can be prescribed. We studied the effect of this program last year, and found that it had reduced antibiotic costs and decreased the number of resistant bacteria in the hospital at the same time. ”

Health organizations worldwide have been working on solutions for many years, some of which are beginning to show results. In Europe, most children presenting with symptoms of an ear infection now are not given an antibiotic at the first visit, only pain medications. This is because recent research shows that most middle ear infections are caused by viruses, not bacteria. Children now only get antibiotics if things haven’t improved on their own after four days.

Some doctors are prescribing fewer antibiotics. One research study, published in the June 19, 2002, issue of the Journal of the American Medical Association, found that doctors wrote 838 antibiotic prescriptions per 1,000 children in 1989-1990 and only 503 antibiotic prescriptions per 1,000 children a decade later.

Education of the public and physicians alike is an important part of the answer. In September 2003, the Centers for Disease Control launched an educational campaign, “Get Smart: Know When Antibiotics Work,” to help patients understand when antibiotics are helpful and when they are not, as well as the potential dangers of antibiotic overuse. The campaign includes information and support materials for physicians, as well. (see the CDC website for more information: http://www.cdc.gov/GetSmart/ )

A Time for Everything

Although Dr. Wallis contends that antibiotics are over-prescribed, he also believes that they are valuable medications when used as intended: to treat bacterial infection. “Most of the people who come to a doctor with head colds, sore throats, and bronchitis have viral infections,” he says. “However, when the patient has fever, a productive cough, and green or yellow nasal discharge, those symptoms are more indicative of a bacterial infection, and it sometimes may be appropriate for the doctor to prescribe an antibiotic.”

In the future, says Dr. Wallis, there could be an antiviral drug developed that’s effective against colds; there are already antivirals that are useful against viruses such as herpes and influenza. But until that day arrives, there are ways that patients can alleviate the miseries of the common cold: plenty of liquids, throat lozenges or ice chips to soothe a sore throat, a vaporizer to relieve a stuffy nose, and lots of rest.

To arrange for a consultation with Dr. Robert Wallis, call (973) 972-2500.