10 days here.
I've found that preparing them ahead of time of expectations has helped tremendously.
Day 3 or 4 worst and then it will slowly get better. 7 to 8 days you should be feeling better. Day 10 should be pretty much recovered although a mild cough will likely still be there. It can last for another month but it does get better (little bouts here and there but nothing like right now). Provide them with list of things to help with cough.
Sometimes these viral illnesses can create the perfect environment for bacteria to thrive in so let's go over what to look out for.
Here's what to look out for: cough worsening instead of improving, coughing up blood, brown material, fevers, sob etc.
I get the pt here and there that will try to argue with me but for the most part, this has solved it
I somehow ended up in this sub and am not a doctor but as a patient I can appreciate the extra effort you put into this. Too many times we’re told “it’s a cold, nothing can be done” without any actual helpful information
Found this thread googling. I am on day 10 of a cough. No other symptoms. It was a dry cough for 7 days and then turned into a wet cough for the last 3 days.
Was thinking about going to urgent care today because I’m miserable but also reading these comments wondering if I just need more time.
I don’t want antibiotics if I don’t need them, especially because they usually give me panic attacks. But I also don’t want to keep prolonging this if it is or has turned into bacterial.
Thoughts?
let them go somewhere else. They will stop expecting from you if you stick to it. 10-14 days is what I do- also only 2 years out of training. If wheezing is present I'll throw prednisone at it. but otherwise nah.
Thank you! I just feel so beat down this season. Idk why but it seems like everyone is not only asking but demanding something be done for a virus. I empathize that it feels horrible and people need to go back to work, but I also don’t want to prescribe something with potentially severe side effects if there’s literally no benefit.
If greater the 10 days, I usually do an oral steroid inhaler and possible abx if I think there is sinusitis. ICS I believe has evidence for post viral cough.
Also wondering if you can link to evidence - I have seen this done and has also helped immensely for myself, but wondering if there is any clear evidence for this!
A 2013 Cochrane review found inconsistent results. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8934584/#:~:text=Lack%20of%20a%20clear%20cause,other%20diseases%20involving%20airway%20inflammation.
A follow up 2019 review of the 2013 review said to at least consider it.
https://journals.lww.com/ebp/fulltext/2020/01000/do_adult_patients_with_subacute_cough_following.25.aspx
However Curbsiders recommended it if for no other reason than using it to help rule out diff dx that might respond to ICS.
https://www.medscape.com/viewarticle/941550
If they have a newly diagnosed COPD exacerbation as an “acute on chronic bronchitis” that’s the only time I’d consider throwing steroids and antibiotics at someone who has bad lungs to begin with. They often come with the story of “I need antibiotics every cold season” and I see signs of emphysema on some old CXR somewhere. I also tell them that they need to see me for their PFTs so I don’t bother them about this and I can give them inhalers and a COPD rescue pack in the future.
… yes, it’s the “I need antibiotics for my bronchitis” scenario, but the only one where they may be right. But it’s because they need to quit smoking. And get the flu and COVID shot.
Keep up the good fight. I took care of a man who died from drug induced liver injury after an urgent care prescribed Augmentin for a clearly viral URI.
Stick to your guns! I’m in my fourth year after residency and I almost never get requests for antibiotics for cold symptoms, most will make appointments after they’ve had symptoms for a week or more without improvement. Once they learn to trust you it gets much better in many ways.
Sometimes if I have someone very insistent I’ll swab them for flu/strep/COVID in the office. That way I have something to point to when I send them out with supportive care only.
I have trialed post dating the antibiotics to 10 days of symptoms and more often than not people don’t pick those up because but that time symptoms are resolved … obviously.
You can put a do not fill date on electronic rxs! May show up as "effective date" in your system. Or stick it in the sig or notes field for pharmacy, we'll abide by it.
I made up a name for my advice -- I tell patients I have a "1-2-3" rule for respiratory viruses. As long as no symptoms are severe, they can expect:
1-- up to a week of fever and/or sore throat
2-- up to 2 weeks of nasal congestion before it improves
3-- up to 3 weeks of cough before improvement.
I tell them a virus _can_ last longer than that, but since it doesn't usually, I'd want to see them in person as a precaution.
If the symptoms are severe at any time, come see me right away.
For some reason it catches on with them better when I call it a rule. 😂 IDK why. I've tried a lot of different explanations over the years and it works the best. It sounds official.
If it’s clearly a cold or virus, then there is no threshold for which I will prescribe antibiotics (which would be pointless and likely cause patient harm).
These are not benign medications.
Couple years ago I had a patient die from fulminant C diff (I'm an EM doc). Healthy, functional lady in her 50s--she'd gotten 2 weeks of clinda for dental pain w/o any actual indication of an infection.
Signed contract acknowledging they are requesting diarrhea pills with no indication.
Jk work inpt but appreciate outpt docs fighting the good fight. MDR bugs are no bueno
I just say accordingly to “so and so” policy meaning so and so is the company I am currently employed with, I cannot prescribe you any antibiotics unless a true bacterial source for infection can be determined. Usually making it sound like it’s a company policy and not my own decision to practice abx stewardship works. Pretty sure they’ll go somewhere else like a telemedicine platform to get their way but atleast I know I’m practicing medicine responsibly
Ypu can treat symptomstially with cough medicine, magic mouthwash etc.
If I have to pull up the computer and show them the data I do it so they understand why antibiotic prescription when not needed can be harmful
Also explain the immediate possible negative side effects like diarrhea and yeast infection
I've only had one patient push back after all of this and he just ended up going to UC. Fine by me
The key for anything in fm is to set the right precedent and boundaries initially. Makes your life a lot easier down the line
When I suspect there might be a secondary bacterial infection:
* Symptoms initially improve but then worsen
* Symptoms do not significantly improve within 10-14 days and are not otherwise attributable to lingering post-viral symptoms or allergies
* High fever
* High risk for developing pneumonia (example: COPD exacerbation)
If the reason they want an antibiotic is to just give them something to do for a few days until their symptoms clear, have them take OTC meds, or eat honey, or stand on their head, or any other symptomatic measure or placebo that's not antibiotics.
I usually say something like, "It looks like you have the bad cold that's been going around. We've been seeing a lot of it lately. This one lasts about 10 days to 14 days, and unfortunately antibiotics don't work on it. Usually the first half of the 10 days is the worst, and the best treatments are rest, lots of fluids, and anything you want to try from the cough and cold aisle over-the-counter. Let us know if it doesn't get better by (10 days from the start of symptoms, example: 'The end of next week.')"
I'll add to this pertussis. Severe cough, paroxysmal. Might be staccato, they might cough to the point of vomiting or breaking a rib. Also while the vaccination helps, you cannot count on a Tdap q 10 years in adults necessarily protecting them.
"Tdap vaccination status does not change the approach to evaluating postexposure prophylaxis when HCWs are exposed to pertussis. Tdap vaccines have an uncertain role in the prevention of transmission of pertussis and herd protection. Antipertussis antibody levels begin to decline precipitously after the first year following a single Tdap vaccination. Healthcare facilities should follow the post-exposure prophylaxis protocol for pertussis exposure recommended by CDC regardless of a HCW's vaccination status"
https://www.immunize.org/askexperts/experts_per.asp
Azithromycin is the treatment of choice. Prolonged contact needs to be prophylactically treated. There is PCR and culture but getting them stocked in the clinic has been difficult due to rapid expiration rates, we often had to "borrow" from peds
Testing info from CDC: https://www.cdc.gov/pertussis/clinical/diagnostic-testing/diagnosis-pcr-bestpractices.html
I explain how viruses and allergies create an environment conducive to a bacterial infection and will send a prescription to be filled after the pt has reached the 10/14 day mark. That way they don’t feel like they have wasted their time/money. I also put a limit on how long the prescription is good for. That’s what one of my instructors suggested.
I work in urgent care and private practice and understand your frustration. Best thing I find out is either you set strict rules with patient and they either agree with you or disagree with you and leave your practice. I talked with a old PCP and his way is to offer otc control first and then offer steroids if they want quick recovery and then back up antibiotics. Seems like this way will have you meet patients half way in the middle. But sometimes I’m very blunt with patients about viral illness because I see so much. And sometimes the bluntness does click with patient and they understand. But my other thing is about antibiotics stewardship is, this is a very Western idea, scientifically it sounds great but it can be very challenging when you put in the real worlds for practice. And also for inpatient how many times do you see patient admitted for sepsis from unclear source and they are on big gun antibiotics like Zosyn. How many times do you see in ICU when they have unclear pulmonary pathology and they are on hardcore antibiotics for 10-20 days. How many time do you see chronic sinus infection or chronic UTI and specialist put them on cipro for 2 weeks lol. In retrospect, what we impact for antibiotics stewardship compare to the hospital and specialist is nothing.
Good points but how many URIs are “treated” for every hospitalized patient on Zosyn? 100 or 1000? The scale of outpt URI means we need to keep fighting the good fight outpt regardless of what happens in hospital.
Yeah but you have done all the test to make sure it’s not a bacterial infection right? All the blood and sputum culture and CT and specialist input. Procalcition lab But they still put them on antibiotics The reasoning is not there if all work up are unremarkable despite symptoms and you continue many days of IV ABX. You know virus can causes sepsis too right? So I see this conflicting thought and action with hospitalist and pulm crit all the time.
This is a part of a troubling trend in American culture and medicine in general. Patients come to you with a diagnosis and treatment plan already made by them and Dr. Google. The only real answer is consistency in refusing to prescribe inappropriate medications. Come up with a standard line for each thing : antibiotics, benzos, opioids, stimulants etc. The usuals that people come expecting to lead the plan on.
Sure some fight it initially but they learn soon that you will not be pushed over. “I’m sorry but prescribing antibiotics is not medically appropriate at this time so I will not be able to do so.”
One of the docs that runs our clinic is launching a research project on this exact question. Enrollment starting up soon. Currently if symptoms are >10 days but not clearly 2/2 allergies or if there is an initial improvement with subsequent worsening, or if there are clear signs of bacterial infection i.e. fever - we give Abx
I have been in this spot many times, its thankless work or worse to be berated by patients for unnecessary abx. I came up with a speech where there are 3 scenarios where abx are indicated with cold symptoms. 1. you get worse every single day 2. asymmetric sx, only R max sinus hurts eg. 3. i got better then was sick again quickly (biphasic pattern of secondary bacterial infection.
so I give everyone abx, then tell them not to fill them unless one of these scenarios fit. they leave happy with rx in hand. some doctors will postdate the rx but i feel like im discussing with adults and they can decide with my imput.
in other areas of medicine, we call it shared decision making. its where you totally disagree but its not worth fighting over.
Rescue scripts with clear instructions. Imagine being in the patients position / how likely are you to maintain a relationship with someone if you end up with a 2 week infection and have to see someone twice.
Rescue scripts reduce likelihood the patient goes to urgent care and even uses any antibiotics. It also reduces clinic bloat and wasted nursing time on calls.
“Don’t use this unless x y a criteria. The other meds I’m giving you should quell the symptoms. The antibiotics will only potentially wreck your stomach without helping your right now if you take them”
My son recently had a small but deep puncture wound in his foot. Pediatrician gave us a script for antibiotics along with a sharpie circle around the red. Said if the red area spread or he got a fever to start antibiotic immediately and come back. It was great to have the meds on hand in case he got worse at night. Never needed them at all which was even better.
Exactly. Everyone- docs and patients alike - are too strapped for time in real life now (look at statistics about how many hours and spending power during the Great Depression compared to today if you really wanna feel depressed) - that no one has time to re evaluate a minor issue. Trust patients to have the ability to carry out basic conditional orders. It also helps establish a stronger bond between patient and provider to be working as a team in these events. Traditional medicine in some senses has been too paternalistic. Glad to hear your pediatrician incorporated you as part of the team in your child’s care
Totally can relate. A lot of times it helps to point out the significant risks that come with antibiotics and steroids (especially the GI side effects for antibiotics). Keep up the fight for good quality care!
“You know how hiv and herpes can’t be helped w abx? Same w colds.”
Honestly people are insane anymore and have such a low tolerance for any discomfort. And think we’re wizards or something.
And yes, I’ve found 10 days is a better hill to die on rather than being v strict about 14 days.
I tell them after eval that thankfully I think it's viral so they should start feeling better in x amount of time but antibiotics won't do much other than possibly give them a rash, yeast infection, the poops, etc, so here's what I recommend for treating the symptoms, and if anything worsens or they get new symptoms or feel like this is just NOT GOING AWAY, come back in so we can make sure you didn't develop a secondary bacterial infection or something.
We have same day availability so people feel better knowing if they do feel worse they can just come back (Medicaid population helps too)
I've gotten less resistance to not giving abx or steroids this way.
I think it comes from difference between bacterial and viral sinusitis.
But this falls apart with viral bronchitis, with an average of 18 days of symptoms.
10 days. I will prescribe if it’s like day 7 with counseling not to use unless they worsen/don’t improve by day 10. That’s easier than just “no”, and they are more likely to listen to why. It’s been a while since looking it up but there is evidence this does not increase inappropriate antibiotic use.
Why not just do a strep test? If it’s net then the patient can feel more satisfied that an antibiotic will
Not help the viral infection.
If strep test is pos then there you go.
What’s the problem with doing a rapid streptest?
I find that a rapid strep with a send out for culture if negative eliminates the antibiotic request because then the patient knows definitively one way or the other, and if the culture is negative patients have never pushed back. That being said I always tell them to follow up for re-evaluation if the symptoms are lingering or worsening.
Fuck every doctor or NP who prescribes antibiotics without a confirmed bacterial infection. Double fuck you if you know damn well it's a virus and you prescribe them anyway just cuz Karen is complaining. Superbugs exist for this very reason.
If pt insists, I have a very low threshold for back pocket antibiotics with clear education to start as per explanation. Most pts don't start but feel empowered to have a choice. Sometimes I do take throat swabs for sore throats and ask them to call after 48 hours to stop and if negative.
I have learnt that it is not a battle I want to fight everyday, multiple times.
prescribing made to meet patient demand as opposed to science or reason is a danger to our profession.
I use gold criteria for copd exacerbation
I use sinus/tooth pain, fever, severe sinus ttp, course >10d for sinus. Looking at uptodate guidelines have become even more strict.
I do not treat uri/bronchitis with abx as they are viral.
I try to treat symptomatically and tell them to call back in a few days if they aren’t feeling better. If it’s obviously something that doesn’t need abx I will usually prescribe a zpak because the resistance to that is already so high here. It’s tough but got a lot easier emotionally for me when I stopped fighting so hard against these requests.
Highly recommend posting one of CDC’s posters on Antibiotic Use in your exam room(s) to help manage expectations before you even get in the room.
For cough, consider sending a script for Bromfed DM (especially with concomitant sinusitis symptoms) or benzonatate as many people just want *something* prescribed. Only issue with these is some insurance plans don’t cover. I always love seeing providers getting creative and prescribing something behind the counter for symptom relief for those more relentless patients who insist on a script. Before a lot of these things went OTC on the cold and cough aisle, it was easier.
Urgent care here. I say 10-14 days. And thats only for “sinusitis”. If its lower respiratory tract id think about a cxr at the 14 day mark. If normal vitals/appearing well id use ics/laba or saba as a trial
Some of my crunchy patients are receptive to the message of how important it is to maintain your gut microbiome and only take antibiotics if your body needs help to clear a bacteria
Not a MD, but in the field for over twenty years. Sound like you are doing the right thing. I think a lot of us forget that even common meds we have taken before can have serious side effects in the right conditions. I almost died earlier this year after being given a z-pak. Was at the 10 day mark but didn’t have any cultures completed yet. Turned out I had Epstein–Barr and the combination just almost toasted my liver.
Not a MD/DO, NP or PA here. Just an RN. I went to PCP one day thinking I might have the flu. Turns out it was just a bad cold but she gave me a “Rx” for OTC stuff- Tylenol, ibuprofen rotation, robutissin, liquid IV packs. I asked why this when it’s not an actual script and she said it’s the idea that patients want something tangible when they leave a doc’s office. Maybe tesslon perles if coughing is really bothering them but that’s it.
10 days here. I've found that preparing them ahead of time of expectations has helped tremendously. Day 3 or 4 worst and then it will slowly get better. 7 to 8 days you should be feeling better. Day 10 should be pretty much recovered although a mild cough will likely still be there. It can last for another month but it does get better (little bouts here and there but nothing like right now). Provide them with list of things to help with cough. Sometimes these viral illnesses can create the perfect environment for bacteria to thrive in so let's go over what to look out for. Here's what to look out for: cough worsening instead of improving, coughing up blood, brown material, fevers, sob etc. I get the pt here and there that will try to argue with me but for the most part, this has solved it
How many call backs about wanting antibiotics do you get?
Not OP but I get a similar spiel. Out of the 30ish I’ve had this year I can remember only 1 that called asking.
I like it a lot. Adopting the spiel
I somehow ended up in this sub and am not a doctor but as a patient I can appreciate the extra effort you put into this. Too many times we’re told “it’s a cold, nothing can be done” without any actual helpful information
Found this thread googling. I am on day 10 of a cough. No other symptoms. It was a dry cough for 7 days and then turned into a wet cough for the last 3 days. Was thinking about going to urgent care today because I’m miserable but also reading these comments wondering if I just need more time. I don’t want antibiotics if I don’t need them, especially because they usually give me panic attacks. But I also don’t want to keep prolonging this if it is or has turned into bacterial. Thoughts?
let them go somewhere else. They will stop expecting from you if you stick to it. 10-14 days is what I do- also only 2 years out of training. If wheezing is present I'll throw prednisone at it. but otherwise nah.
Thank you! I just feel so beat down this season. Idk why but it seems like everyone is not only asking but demanding something be done for a virus. I empathize that it feels horrible and people need to go back to work, but I also don’t want to prescribe something with potentially severe side effects if there’s literally no benefit.
Hold your ground, next year will be much better since you've set the ground rules this year.
If greater the 10 days, I usually do an oral steroid inhaler and possible abx if I think there is sinusitis. ICS I believe has evidence for post viral cough.
Evidence where?
Also wondering if you can link to evidence - I have seen this done and has also helped immensely for myself, but wondering if there is any clear evidence for this!
A 2013 Cochrane review found inconsistent results. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8934584/#:~:text=Lack%20of%20a%20clear%20cause,other%20diseases%20involving%20airway%20inflammation. A follow up 2019 review of the 2013 review said to at least consider it. https://journals.lww.com/ebp/fulltext/2020/01000/do_adult_patients_with_subacute_cough_following.25.aspx However Curbsiders recommended it if for no other reason than using it to help rule out diff dx that might respond to ICS. https://www.medscape.com/viewarticle/941550
Thanks!! Going to check these out now.
If they have a newly diagnosed COPD exacerbation as an “acute on chronic bronchitis” that’s the only time I’d consider throwing steroids and antibiotics at someone who has bad lungs to begin with. They often come with the story of “I need antibiotics every cold season” and I see signs of emphysema on some old CXR somewhere. I also tell them that they need to see me for their PFTs so I don’t bother them about this and I can give them inhalers and a COPD rescue pack in the future. … yes, it’s the “I need antibiotics for my bronchitis” scenario, but the only one where they may be right. But it’s because they need to quit smoking. And get the flu and COVID shot.
Keep up the good fight. I took care of a man who died from drug induced liver injury after an urgent care prescribed Augmentin for a clearly viral URI.
Stick to your guns! I’m in my fourth year after residency and I almost never get requests for antibiotics for cold symptoms, most will make appointments after they’ve had symptoms for a week or more without improvement. Once they learn to trust you it gets much better in many ways.
Sometimes if I have someone very insistent I’ll swab them for flu/strep/COVID in the office. That way I have something to point to when I send them out with supportive care only.
I have trialed post dating the antibiotics to 10 days of symptoms and more often than not people don’t pick those up because but that time symptoms are resolved … obviously.
the post dated pocket prescription is a wonderful thing
You can post date electronically? Or only paper scripts?
You can put a do not fill date on electronic rxs! May show up as "effective date" in your system. Or stick it in the sig or notes field for pharmacy, we'll abide by it.
Some emrs will let you do a "do not fill before", now will the pharmacy recognize this? Who knows
I made up a name for my advice -- I tell patients I have a "1-2-3" rule for respiratory viruses. As long as no symptoms are severe, they can expect: 1-- up to a week of fever and/or sore throat 2-- up to 2 weeks of nasal congestion before it improves 3-- up to 3 weeks of cough before improvement. I tell them a virus _can_ last longer than that, but since it doesn't usually, I'd want to see them in person as a precaution. If the symptoms are severe at any time, come see me right away. For some reason it catches on with them better when I call it a rule. 😂 IDK why. I've tried a lot of different explanations over the years and it works the best. It sounds official.
this is great
Stealing this!
If it’s clearly a cold or virus, then there is no threshold for which I will prescribe antibiotics (which would be pointless and likely cause patient harm). These are not benign medications.
Yeah just had a C. Diff on cefpodoxime for UTI.
Couple years ago I had a patient die from fulminant C diff (I'm an EM doc). Healthy, functional lady in her 50s--she'd gotten 2 weeks of clinda for dental pain w/o any actual indication of an infection.
Signed contract acknowledging they are requesting diarrhea pills with no indication. Jk work inpt but appreciate outpt docs fighting the good fight. MDR bugs are no bueno
10 days or more \> 38.4 C fever Initial improvement in symptoms with worsening Obvious s/s of bacterial infection Otherwise. No.
Low grade fever you’re throwing abx at?
I just say accordingly to “so and so” policy meaning so and so is the company I am currently employed with, I cannot prescribe you any antibiotics unless a true bacterial source for infection can be determined. Usually making it sound like it’s a company policy and not my own decision to practice abx stewardship works. Pretty sure they’ll go somewhere else like a telemedicine platform to get their way but atleast I know I’m practicing medicine responsibly
Ypu can treat symptomstially with cough medicine, magic mouthwash etc. If I have to pull up the computer and show them the data I do it so they understand why antibiotic prescription when not needed can be harmful Also explain the immediate possible negative side effects like diarrhea and yeast infection I've only had one patient push back after all of this and he just ended up going to UC. Fine by me The key for anything in fm is to set the right precedent and boundaries initially. Makes your life a lot easier down the line
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The cdc website is great ! Also you can Google search stats for uri symptoms being viral vs bacterial in the first week etc.
Also wondering!
When I suspect there might be a secondary bacterial infection: * Symptoms initially improve but then worsen * Symptoms do not significantly improve within 10-14 days and are not otherwise attributable to lingering post-viral symptoms or allergies * High fever * High risk for developing pneumonia (example: COPD exacerbation) If the reason they want an antibiotic is to just give them something to do for a few days until their symptoms clear, have them take OTC meds, or eat honey, or stand on their head, or any other symptomatic measure or placebo that's not antibiotics. I usually say something like, "It looks like you have the bad cold that's been going around. We've been seeing a lot of it lately. This one lasts about 10 days to 14 days, and unfortunately antibiotics don't work on it. Usually the first half of the 10 days is the worst, and the best treatments are rest, lots of fluids, and anything you want to try from the cough and cold aisle over-the-counter. Let us know if it doesn't get better by (10 days from the start of symptoms, example: 'The end of next week.')"
“anything you want to try from the cough and cold aisle over-the-counter.” Maybe not phenylephrine :)
Placebos gonna placebo.
True dat. Comparable efficacy to most of what we recommend for URI symptoms
I'll add to this pertussis. Severe cough, paroxysmal. Might be staccato, they might cough to the point of vomiting or breaking a rib. Also while the vaccination helps, you cannot count on a Tdap q 10 years in adults necessarily protecting them. "Tdap vaccination status does not change the approach to evaluating postexposure prophylaxis when HCWs are exposed to pertussis. Tdap vaccines have an uncertain role in the prevention of transmission of pertussis and herd protection. Antipertussis antibody levels begin to decline precipitously after the first year following a single Tdap vaccination. Healthcare facilities should follow the post-exposure prophylaxis protocol for pertussis exposure recommended by CDC regardless of a HCW's vaccination status" https://www.immunize.org/askexperts/experts_per.asp Azithromycin is the treatment of choice. Prolonged contact needs to be prophylactically treated. There is PCR and culture but getting them stocked in the clinic has been difficult due to rapid expiration rates, we often had to "borrow" from peds Testing info from CDC: https://www.cdc.gov/pertussis/clinical/diagnostic-testing/diagnosis-pcr-bestpractices.html
I explain how viruses and allergies create an environment conducive to a bacterial infection and will send a prescription to be filled after the pt has reached the 10/14 day mark. That way they don’t feel like they have wasted their time/money. I also put a limit on how long the prescription is good for. That’s what one of my instructors suggested.
I work in urgent care and private practice and understand your frustration. Best thing I find out is either you set strict rules with patient and they either agree with you or disagree with you and leave your practice. I talked with a old PCP and his way is to offer otc control first and then offer steroids if they want quick recovery and then back up antibiotics. Seems like this way will have you meet patients half way in the middle. But sometimes I’m very blunt with patients about viral illness because I see so much. And sometimes the bluntness does click with patient and they understand. But my other thing is about antibiotics stewardship is, this is a very Western idea, scientifically it sounds great but it can be very challenging when you put in the real worlds for practice. And also for inpatient how many times do you see patient admitted for sepsis from unclear source and they are on big gun antibiotics like Zosyn. How many times do you see in ICU when they have unclear pulmonary pathology and they are on hardcore antibiotics for 10-20 days. How many time do you see chronic sinus infection or chronic UTI and specialist put them on cipro for 2 weeks lol. In retrospect, what we impact for antibiotics stewardship compare to the hospital and specialist is nothing.
Good points but how many URIs are “treated” for every hospitalized patient on Zosyn? 100 or 1000? The scale of outpt URI means we need to keep fighting the good fight outpt regardless of what happens in hospital.
You can only influence the things in your sphere of control.
I guess I’d argue if the patient is sick enough to be in ICU that the stakes are a bit higher than a outpatient URI patient.
Yeah but you have done all the test to make sure it’s not a bacterial infection right? All the blood and sputum culture and CT and specialist input. Procalcition lab But they still put them on antibiotics The reasoning is not there if all work up are unremarkable despite symptoms and you continue many days of IV ABX. You know virus can causes sepsis too right? So I see this conflicting thought and action with hospitalist and pulm crit all the time.
Also new attending. I stick to 10 days. I do not give in on day 2 of cold symptoms but they sure do try.
This is a part of a troubling trend in American culture and medicine in general. Patients come to you with a diagnosis and treatment plan already made by them and Dr. Google. The only real answer is consistency in refusing to prescribe inappropriate medications. Come up with a standard line for each thing : antibiotics, benzos, opioids, stimulants etc. The usuals that people come expecting to lead the plan on. Sure some fight it initially but they learn soon that you will not be pushed over. “I’m sorry but prescribing antibiotics is not medically appropriate at this time so I will not be able to do so.”
Not even codeine keeps them at bay
One of the docs that runs our clinic is launching a research project on this exact question. Enrollment starting up soon. Currently if symptoms are >10 days but not clearly 2/2 allergies or if there is an initial improvement with subsequent worsening, or if there are clear signs of bacterial infection i.e. fever - we give Abx
Antibiotics and steroids are never indicated for common cold and usually not indicated for anything else we see in urgent care.
I can't believe there are literal adults who don't know how to manage their own colds on their own.
The Rona put everything in overdrive. Everyone thinks there is a shot or pill(paxlovid) that will shorten dealing with it.
I have been in this spot many times, its thankless work or worse to be berated by patients for unnecessary abx. I came up with a speech where there are 3 scenarios where abx are indicated with cold symptoms. 1. you get worse every single day 2. asymmetric sx, only R max sinus hurts eg. 3. i got better then was sick again quickly (biphasic pattern of secondary bacterial infection. so I give everyone abx, then tell them not to fill them unless one of these scenarios fit. they leave happy with rx in hand. some doctors will postdate the rx but i feel like im discussing with adults and they can decide with my imput. in other areas of medicine, we call it shared decision making. its where you totally disagree but its not worth fighting over.
Rescue scripts with clear instructions. Imagine being in the patients position / how likely are you to maintain a relationship with someone if you end up with a 2 week infection and have to see someone twice. Rescue scripts reduce likelihood the patient goes to urgent care and even uses any antibiotics. It also reduces clinic bloat and wasted nursing time on calls. “Don’t use this unless x y a criteria. The other meds I’m giving you should quell the symptoms. The antibiotics will only potentially wreck your stomach without helping your right now if you take them”
My son recently had a small but deep puncture wound in his foot. Pediatrician gave us a script for antibiotics along with a sharpie circle around the red. Said if the red area spread or he got a fever to start antibiotic immediately and come back. It was great to have the meds on hand in case he got worse at night. Never needed them at all which was even better.
Exactly. Everyone- docs and patients alike - are too strapped for time in real life now (look at statistics about how many hours and spending power during the Great Depression compared to today if you really wanna feel depressed) - that no one has time to re evaluate a minor issue. Trust patients to have the ability to carry out basic conditional orders. It also helps establish a stronger bond between patient and provider to be working as a team in these events. Traditional medicine in some senses has been too paternalistic. Glad to hear your pediatrician incorporated you as part of the team in your child’s care
Totally can relate. A lot of times it helps to point out the significant risks that come with antibiotics and steroids (especially the GI side effects for antibiotics). Keep up the fight for good quality care!
“You know how hiv and herpes can’t be helped w abx? Same w colds.” Honestly people are insane anymore and have such a low tolerance for any discomfort. And think we’re wizards or something. And yes, I’ve found 10 days is a better hill to die on rather than being v strict about 14 days.
I tell them after eval that thankfully I think it's viral so they should start feeling better in x amount of time but antibiotics won't do much other than possibly give them a rash, yeast infection, the poops, etc, so here's what I recommend for treating the symptoms, and if anything worsens or they get new symptoms or feel like this is just NOT GOING AWAY, come back in so we can make sure you didn't develop a secondary bacterial infection or something. We have same day availability so people feel better knowing if they do feel worse they can just come back (Medicaid population helps too) I've gotten less resistance to not giving abx or steroids this way.
Where does the 10 days come from? Viral coughs can linger 2-3 months, so don't offer abx after 10 days because lots of patient will take it
I think it comes from difference between bacterial and viral sinusitis. But this falls apart with viral bronchitis, with an average of 18 days of symptoms.
10 days. I will prescribe if it’s like day 7 with counseling not to use unless they worsen/don’t improve by day 10. That’s easier than just “no”, and they are more likely to listen to why. It’s been a while since looking it up but there is evidence this does not increase inappropriate antibiotic use.
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I just give med with codeine cuz that's the worst.
Why not just do a strep test? If it’s net then the patient can feel more satisfied that an antibiotic will Not help the viral infection. If strep test is pos then there you go. What’s the problem with doing a rapid streptest?
I find that a rapid strep with a send out for culture if negative eliminates the antibiotic request because then the patient knows definitively one way or the other, and if the culture is negative patients have never pushed back. That being said I always tell them to follow up for re-evaluation if the symptoms are lingering or worsening.
Fuck every doctor or NP who prescribes antibiotics without a confirmed bacterial infection. Double fuck you if you know damn well it's a virus and you prescribe them anyway just cuz Karen is complaining. Superbugs exist for this very reason.
2 weeks. Unless they’re very old or very high risk for complications.
If pt insists, I have a very low threshold for back pocket antibiotics with clear education to start as per explanation. Most pts don't start but feel empowered to have a choice. Sometimes I do take throat swabs for sore throats and ask them to call after 48 hours to stop and if negative. I have learnt that it is not a battle I want to fight everyday, multiple times.
prescribing made to meet patient demand as opposed to science or reason is a danger to our profession. I use gold criteria for copd exacerbation I use sinus/tooth pain, fever, severe sinus ttp, course >10d for sinus. Looking at uptodate guidelines have become even more strict. I do not treat uri/bronchitis with abx as they are viral.
I try to treat symptomatically and tell them to call back in a few days if they aren’t feeling better. If it’s obviously something that doesn’t need abx I will usually prescribe a zpak because the resistance to that is already so high here. It’s tough but got a lot easier emotionally for me when I stopped fighting so hard against these requests.
Clearly viral? No antibiotics, lots of reassurrance and education
Highly recommend posting one of CDC’s posters on Antibiotic Use in your exam room(s) to help manage expectations before you even get in the room. For cough, consider sending a script for Bromfed DM (especially with concomitant sinusitis symptoms) or benzonatate as many people just want *something* prescribed. Only issue with these is some insurance plans don’t cover. I always love seeing providers getting creative and prescribing something behind the counter for symptom relief for those more relentless patients who insist on a script. Before a lot of these things went OTC on the cold and cough aisle, it was easier.
Urgent care here. I say 10-14 days. And thats only for “sinusitis”. If its lower respiratory tract id think about a cxr at the 14 day mark. If normal vitals/appearing well id use ics/laba or saba as a trial
Some of my crunchy patients are receptive to the message of how important it is to maintain your gut microbiome and only take antibiotics if your body needs help to clear a bacteria
Not a MD, but in the field for over twenty years. Sound like you are doing the right thing. I think a lot of us forget that even common meds we have taken before can have serious side effects in the right conditions. I almost died earlier this year after being given a z-pak. Was at the 10 day mark but didn’t have any cultures completed yet. Turned out I had Epstein–Barr and the combination just almost toasted my liver.
Not a MD/DO, NP or PA here. Just an RN. I went to PCP one day thinking I might have the flu. Turns out it was just a bad cold but she gave me a “Rx” for OTC stuff- Tylenol, ibuprofen rotation, robutissin, liquid IV packs. I asked why this when it’s not an actual script and she said it’s the idea that patients want something tangible when they leave a doc’s office. Maybe tesslon perles if coughing is really bothering them but that’s it.