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Antibiotics for Coughs and Colds
The cough you brought to the clinic is almost certainly viral, and antibiotics do nothing to a virus. Across the Cochrane reviews of colds, bronchitis, sinusitis, and sore throat, they buy no meaningful relief while side effects run two-and-a-half times higher Kenealy 2013. What they reliably hit is your gut and your year-long odds of carrying a resistant strain Costelloe 2010. Decline the script you don't need and you lose nothing but the diarrhea.
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A cold is a virus, and antibiotics have no mechanism against viruses. Antibiotics kill bacteria: amoxicillin dissolves the bacterial cell wall, which viruses don't have. A drug aimed at an organism that isn't there can't help, however miserable you feel.

Four Cochrane reviews, one answer four ways. The common cold: no difference in how long symptoms last, side effects two-and-a-half times more common on the drug 1. Acute bronchitis: about half a day less cough 2. Adult sinusitis: eighteen people treated for one extra cure, against eight for one extra harm 3. Sore throat: sixteen hours less pain by day three, and only in the minority with confirmed strep 4.

Guidelines already say this: the ACP and CDC recommend against antibiotics for the cold, uncomplicated bronchitis, and early sinusitis 5. Yet about a third of US outpatient prescriptions are unnecessary, and respiratory infections drive most of it 6.

Green snot is not the signal you think it is. The colour is myeloperoxidase from your own white cells, and viruses turn snot green as readily as bacteria do. What separates them is the pattern over time, not the colour 5. At scale the resistance those needless courses feed was tied to 1.27 million deaths in 2019 7.

The move that keeps a backstop without the risk: ask for a delayed prescription. You take the script home and fill it only if named things happen by day five. About half are never filled, and complication rates don't rise 5.

Decline the course and here's the arc.

  • This week: no diarrhea, rash, thrush, or yeast infection that the drug would have caused in roughly one patient in five 3.
  • This year: no year spent as a resistant carrier, and C. difficile risk stays at baseline instead of three to four times higher 9.
  • Long run: the front-line drug is likelier to work the first time you have a real bacterial infection.
The fine print — when to skip it, and what people get wrong

Antibiotics are right for confirmed strep 10, sinusitis past ten days or worsening after improving 11, suspected pneumonia, pertussis, or immunocompromise. Already on a course for a real infection? Finish it.

"I felt better right after starting it" is the cold ending on schedule: colds turn the corner by day three to five regardless of the pill 1. And they don't prevent pneumonia in healthy adults 2.

Hinting you want a script roughly quadruples the odds you get an unneeded one 12. If one is prescribed anyway, avoid azithromycin: broader gut and resistance damage, plus a cardiac-death signal during treatment 13.

References
  1. 1Kenealy T, Arroll B (2013). Antibiotics for the common cold and acute purulent rhinitis. Cochrane Database of Systematic Reviews. link
  2. 2Smith SM, Fahey T, Smucny J, Becker LA (2017). Antibiotics for acute bronchitis. Cochrane Database of Systematic Reviews. link
  3. 3Lemiengre MB, van Driel ML, Merenstein D, Liira H, Mäkelä M, De Sutter AI (2018). Antibiotics for acute rhinosinusitis in adults. Cochrane Database of Systematic Reviews. link
  4. 4Spinks A, Glasziou PP, Del Mar CB (2021). Antibiotics for treatment of sore throat in children and adults. Cochrane Database of Systematic Reviews. link
  5. 5Harris AM, Hicks LA, Qaseem A (2016). Appropriate Antibiotic Use for Acute Respiratory Tract Infection in Adults: Advice for High-Value Care From the American College of Physicians and the Centers for Disease Control and Prevention. Annals of Internal Medicine. link
  6. 6Fleming-Dutra KE, Hersh AL, Shapiro DJ, Bartoces M, Enns EA, File TM, et al. (2016). Prevalence of Inappropriate Antibiotic Prescriptions Among US Ambulatory Care Visits, 2010-2011. JAMA. link
  7. 7Murray CJL, Ikuta KS, Sharara F, Swetschinski L, et al. (2022). Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. The Lancet. link
  8. 8Linder JA, Doctor JN, Friedberg MW, Reyes Nieva H, Birks C, Meeker D, Fox CR (2014). Time of day and the decision to prescribe antibiotics. JAMA Internal Medicine. link
  9. 9Deshpande A, Pasupuleti V, Thota P, Pant C, Rolston DD, Sferra TJ, et al. (2013). Community-associated Clostridium difficile infection and antibiotics: a meta-analysis. Journal of Antimicrobial Chemotherapy. link
  10. 10Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G, et al. (2012). Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America. Clinical Infectious Diseases. link
  11. 11Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, Brook I, Ashok Kumar K, Kramper M, et al. (2015). Clinical practice guideline (update): Adult Sinusitis. Otolaryngology–Head and Neck Surgery. link
  12. 12Mangione-Smith R, Zhou C, Robinson JD, Taylor JA, Elliott MN, Heritage J (2015). Communication practices and antibiotic use for acute respiratory tract infections in children. Annals of Family Medicine. link
  13. 13Ray WA, Murray KT, Hall K, Arbogast PG, Stein CM (2012). Azithromycin and the risk of cardiovascular death. New England Journal of Medicine. link
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