Do You Need Antibiotics?

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One hundred fifty million prescriptions for antibiotics are written each year in the United States. By some estimates, one third of them are unnecessary. One of the most common diagnoses for which antibiotics are inappropriately prescribed is upper respiratory tract infections (URIs). The overwhelming majority of these infections are viral—infections for which we have no treatment that speeds resolution of symptoms (with one possible non-antibiotic exception, discussed below).

Why are antibiotics so commonly overused? First, because patients so often want and expect them. Bacterial infections seem to be something almost everyone considers himself to be able to diagnose accurately. Second, people don’t realize that distinguishing between bacterial and viral infections is important, not realizing that antibiotics don’t work against the latter. Third, patients (and doctors) think antibiotics are harmless. This is, unfortunately, sometimes not true (as with all medical interventions). As one of my infectious disease specialist colleagues often says, “The dirty little secret of infectious diseases is that antibiotics often make you feel lousy.” Fourth, unless your doctor happens to be a direct primary care doctor, doctors often don’t have enough time to explain why antibiotics aren’t necessary. Occasionally, antibiotics even cause disease (sometimes serious disease like clostridium difficile colitis, a malady I myself once had the displeasure of contracting). Antibiotic use also breeds antibiotic resistance. And though any one course of antibiotics isn’t itself likely to breed a bacterial superorganism, repeated exposure ratchets up the risk. Finally, we’re just beginning to understand the complex biomass of bacteria, the microbiome, that inhabit our large intestines (the number of such bacteria exceeds the number of cells in our bodies) and the beneficial functions they may perform for us. Some have theorized that changes in the microbiome may give rise, or at least contribute to, a number of diseases (perturbations in the microbiome may even contribute to obesity). Though it’s far too early to draw any conclusions about this, it’s not too early to remain disinclined to disturb the microbiome unless we expect a great benefit from doing so (i.e., the speedy resolution of a bacterial infection that would otherwise not resolve).

What clues do clinicians use to figure out when antibiotics are necessary in URIs? A number of things help us sort out the probability that a URI is bacterial rather than viral:

    1. The infection involves only one body cavity. Viruses love to leap around, often beginning in the sinuses only then to leap into the throat and ear and then down into the chest. Bacterial infections, with rare exceptions, start in one place and stay there.
    2. Both viruses and bacteria can cause fevers. In viral infections, the fever tends to be lower (100-101ºF), however, and last only the first few days of the infection (one exception is influenza where the fevers are higher, 101-104ºF, and last 3-5 days). Bacterial infections, in contrast, cause slightly higher fevers that persist.
    3. Both viral and bacterial URIs can produce colored mucus, which only represents white blood cells that have fought valiantly on your behalf and died. The color of mucus does nothing to differentiate between the two types of infections.
    4. In general, bacterial infections are more severe than viral infections. Though you may feel terrible when you have a viral infection, you rarely feel so bad you can’t get out of bed after the first few days. People with bacterial infections just look sicker than people with viral infections (one notable exception is strep throat, which can present as mildly as viral pharyngitis).
    5. Viruses improve on their own. Many patients get an idea in their minds about how long their infection should last, and when it lasts longer, decide they need to be seen by a doctor because “something might be seriously wrong,” as numerous patients have explained to me over the years. But the average length of time viral symptoms last is three weeks. The take home point, however, is that if you start to improve on your own, you almost certainly have a virus.

Sometimes, however, even with the help of these guidelines, it’s difficult to tell if a URI is bacterial or viral. Some viruses can mimic bacterial infections and some bacterial infections can mimic viral ones. An example of the former would be influenza. An example of the latter would be mycoplasma. Mycoplasma is the smallest living bacteria that infects humans and like viruses can infect more than one body cavity at a time (sinuses and throat and ears and chest). But it has a stereotypical set of symptoms and clinical course as well as a long incubation period (meaning that unlike most viruses that cause us to become symptomatic generally within 3-5 days of exposure, we develop symptoms from mycoplasma 1-2 weeks after coming in contact with someone who has it). But as testing for it is better at identifying past infections than current ones, the diagnosis is usually made on clinical grounds. So if someone complains of a sore throat that’s every bit as painful on day 7 as it was on day 1, I often treat presumptively for mycoplasma with antibiotics (it will get better without them, but if they aren’t given, it tends to recur).

Finally, though in the 21st century we still don’t have a cure for the common cold (a viral URI), some studies do show that adults who begin taking zinc gluconate lozenges within the first 24 hours of developing viral symptoms will often shorten the duration and intensity of those symptoms. So I tell people to keep a bag of them around the house and to start taking one every two to three hours while awake at the first sign of symptoms and to continue like that for 5 days. It causes mild nausea in some people, and makes just about everything—including water—taste terrible. But it seems to work. And prevents patients from asking for antibiotics when they really don’t need them.

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  • Every article I have ever seen on this topic blames the patient for wanting antibiotics. In my experience it is often the doctors that want it. I have never had surgery without an antibiotic. I always say I don’t want an antibiotic because I end up with a yeast infection as a result but I was told to just take something for the yeast infection as a preventative before the surgery.

    My son had meningitis when he was 6 weeks old. It was viral meningitis but he was treated with at least 2 kinds of antibiotics. I was told that by the time it was determined if it was viral or bacterial, it might be too late to prevent serious damage so the safest course of action was to give him antibiotics. I agree with that but as you see the doctors definitely play a role here.

    Helen: Doctors do, but that’s mostly because in many circumstances giving antibiotics is indeed the right choice. I was writing about one specific circumstance in the post.


  • It IS very Buddhist to be patient . . . to wait and watch for the variations that you describe in points 1-5.

    Rainer Marie Rilke said to be patient towards all that is unresolved within (the next line was about learning to live the questions . . . but that is a different point).

    While you are waiting for your malaise to declare itself (points 1-5), you can listen to your body which is craving for a) rest; b) hydration; c) chicken soup; d) respite from being driven. Our bodies, when our immune response is robust, mount a defense. It takes more than hours. It takes a day, 2 days, perhaps 3 days.

    I was sick for 3 weeks-plus in February. I DID rest and drink and sleep for a few days, but it wasn’t enough. I relapsed 3 times. The lesson? Let go. Be patient. Be MORE patient. Don’t rush to judgment, in any nuance of the phrase.

    I am semi-retired now, so it is easy for me to say this, but it is true nonetheless for all of us—and it is a dirty little secret that we all fear to face: that we don’t feel we can be absent from work, that we cannot call in sick. We are too indispensable. Our bosses would have serious doubts about our seriousness, etc.

    Can you imagine calling in (sick) and saying, “I am trying to mount a defense against an illness”? Or, “I am trying to beat this respiratory infection WITHOUT getting antibiotics”? So, we are in a bind because we know that that type of excuse won’t fly. Or maybe we cannot put on the brakes—we are so driven from within that we cannot stop-to-heal.

  • Some days I get very tired of the patient blame. Do you realize how difficult it is to tell a provider that their suggested course of treatment is incorrect for your situation. It never ends well and only adds to the “bad” or “non-compliant” patient blame.

    As a patient with seasonal allergic rhinitis that causes impressively painful inflammation and sinus infection like symptoms I commonly find myself arguing with docs about antibiotics. As in turning them down. I didn’t undergo surgery to remodel the inside of my face to help reduce infections only to have inflammation misdiagnosed and still be feed unnecessary antibiotics.

    Frustrating to go in needing a spring booster of IM steroids and extra allergy meds and have to argue with a strange provider (because my normal doc is overbooked and unavailable) that a Z-pak/medrol dose pack combo isn’t relevant to my illness. Especially when symptom onset is less than seven days, doesn’t have temp over 99.5 and drainage is still mostly clear. Grrr. Maybe I should start demanding CT scans to confirm their “sinus infection” dx.

    And if it really is a sinus infection I doubt a 5 day hit of an overused antibiotic is going to do anything. Not when my staph colonized nose has already been hit with bigger gun antibiotics for far longer periods of time but overzealous docs in the past (I didn’t know better then).

    If I accept but don’t fill a script it is still documented in my chart that one was given so the next doc wants to know why or assumes I’ve taken them and then makes bad choices off bad data.

    Doctors easily and frequently turn down patient requests for pain medication when they are concerned it is not the best course of treatment for the patient. Patients demanding pain meds are far more distressed and insistent and if docs can stand against and not appease them then why is it so difficult for them to stand up to the guy with a cold?

  • I’ve been in that ugly place with the late parent where NO antibiotic worked, because of antibiotic overuse in my country and consequent resistance. For my colds I take hot water and turmeric in milk. For GI infections, Norflox tini is almost OTC here, I’m afraid.

  • Thanks for this article, Dr. Lickerman. The worry that overuse of antibiotics in the human population is causing large scale resistance is causing physician prescribing to change in our practice of pharmacy. Some people do have to go back to their MD for treatment with an antibiotic.

    What about the wide scale use of antibiotics in farm animals which the FDA is trying to curtail? They are putting a voluntary plan in place which I do not think will do much. To me this is a huge problem.

  • Is there a risk in NOT taking antibiotics if you do, indeed, have a bacterial infection? Can’t bacterial infections also be cured without intervention?

    Acorn: No, bacterial infections require antibiotics.


  • In this “information age” we still have so many myths and misunderstandings about basic self-care. No, being chilled won’t bring on a URI, and no, antibiotics won’t cure or speed up the recovery from a virus, but yes, antibiotics are required to treat bacterial infections. It seems to be like politics; patients and professionals behave according to habits, beliefs and emotions unfettered by fact. Thank you for providing yet another opportunity to examine what we think we know.

  • Instead of always relying on antibiotics it’s time medical people learn more about natural probiotics to prevent illnesses in the first place. We kill 100% bacteria when we take antibiotics, and guess what? More than 70% of the bacteria that our body has are good bacteria so why are we killing them? I recommend reading and check out why we need to learn about probiotics, particuarly BLIS K12, the only probiotic for the mouth and the throat. Kill the harmful bacteria at the gateway (mouth) before the bad ones travel further.

  • It’s good to see a doctor bringing up this subject, which has been very frustrating in my experience.

    I have spent the last 3 years suffering from some very strange health problems, which I have been forced to self diagnose because no doctor I have seen can work it out (I have made more than 100 doctor visits to various specialist in the last three years). I have suffered peripheral neuropathy, diarrhoea, extreme fatigue, constant sore throat, mild confusion spells (sometimes not being able to understand English), forgetfulness, fever symptoms, sleep apnea, and sound sensitivity to name most of the big ones.

    I was told it was stress, or I was getting old, it would go away, or worse: it was all in my head.

    Eventually the big clue came when I asked for antibiotics for a sore throat that lasted 6 months. All the symptoms went away rapidly (within a week). The antibiotic was erythromycin, which I have since found out isn’t absorbed well by the body, so tends to hang around in the gut. So it turned out all along my wildly bizarre and broad symptoms were caused by gut flora. Unfortunately the effects only lasted 3 months, and when I asked for it again, the irony is that I have been refused it ever since by multiple doctors because I asked for it and apparently there is no medical evidence it will help with my unnamed and undiagnosed health problems, grrr.

    SO here’s the interesting bit: how did I end up in this state in the first place? Well, I think I’ve worked it out. The penny dropped one day, I was given oxytetracyclin for acne for 2 years when I was younger. I remember at the time my stomach got more sensitive to certain foods. Add to that a few years of mid twenties poor diet, alcohol and convenience foods, my gut flora went mad with nothing to keep it in check.

    I’m now on the road to recovery with the gaps diet, lots of garlic, and kefir, but the 3 years when I didn’t know what was wrong with me were horrific. Gut disorders seem to be poorly understood by the medical establishment in the UK.

  • Yes we have so many myths about basic self care but being cold actually makes you more prone to getting sick, not as a cause itself but as an opportunity for the germs to invade your body more easily. Here is an interesting article: I am always amused when I see mothers in winter, all bundled up and their kids in snickers and without hats… And then they are surprised that the kids catch cold so easily…

    Justina: Hmmm. Maybe. I need to see more studies.


  • The way I am understanding is you’re asking why does our body become immune to some antibiotics and thus making them stop working? My son’s doctor told me it was because if you keep using the same antibiotic over and over again the bacteria can start to resist it because it is used to it being present in the body. For example my 16-month-old son has MRSA. I work in a drug facility, so I am around the jailed population a lot, and I guess I brought it home with me; since he is so young he often gets outbreaks and they need to be treated with IV antibiotics; but the problem with MRSA is that there are only 3 or 4 antibiotics that work on it. Clindamycin and Vancomycin are the 2 they usually give my son. I would say he has had about 6 outbreaks since he was 6 months old, and its been very hard because at any time those medications can stop working. That’s why his doctor tries alternating the two hoping that his body does not become immune to one of them, because then we would run out of options very quickly. I hope this was helpful.

  • Alex,

    I followed your link from 2009 NYT piece about C-Diff, “A Deadly Germ Unleashed by Antibiotics.” Thanks for your great article, and am so pleasantly surprised to find an active thread of comments.

    I was hoping to gain insight into whether probiotics can mask test findings and deliver false negatives, specifically in the c-diff test (as I await results of my own test), and/or whether it depends on the amount of probiotics being taken e.g. 30 billion active live cultures per capsule vs. 2 billion.

    Am also interested to learn whether, as I have read, a patient with a mild case of c-diff can be successfully treated w/o antibiotics, through probiotics, kefir and diet. I understand (from my physician) that the antibiotic flagyl most often used to treat C-Diff holds significant risks including neuropathy, and worse, once a patient is diagnosed w/C-Diff and treated w/flagyl, they will never be prescribed any other antibiotic but flagyl in the future.

    Would be so grateful if you could comment!

    Catherine: Taking probiotics will not cause a false negative c.diff test. The probiotic Florastor, interestingly, has been shown to decrease the rate of relapse of c.diff but only when used after a first relapse (it doesn’t help when you’re being treated for the first time), and only in combination with an antibiotic like Flagyl or Vancomycin. And no, once given Flagyl, you can still receive other antibiotics to treat c.diff. The risk of Flagyl is actually quite low (it’s what I took to cure c.diff when I got it).


  • Keep in mind that certain medications can cause yeast infection by killing the good bacteria in the vagina that help to prevent yeast infection. Antibiotics, medications for urinary tract infection and birth control pills are just a few of these culprits. If you have problems with yeast infections, consult your doctor and ask about alternative medications that may not cause problems.

  • I was wondering if I could gauge the effectiveness of an antibiotic on an infection by rating the presence of a yeast infection. For example, if I get a raging, terrible yeast infection, does that mean the upper respiratory infection is going to go away?

    I’ve been on two Z-pac Rx and now on doxycycline but it doesn’t appear to be helping much.

    SouthernNM Teacher: Unfortunately, no, you get yeast infections because health bacteria get whacked by antibiotics, so that doesn’t tell you anything about the effectiveness of the antibiotic against the bacteria you’re actually trying to eradicate. The likely reason you aren’t getting better is that you have a viral infection, not a bacterial infection. But you should definitely follow up with your doctor.


  • So your saying that every person that got a bacterial infection before antibiotics died. I do not believe the body cannot fight off some infections.

    Brad: Not sure where you’re getting that from my post. Strep throat will generally improve even in the absence of antibiotic treatment, though antibiotics are given to decrease the risk of infectivity and of complications (glomerulonephritis, etc.). But, in general, before antibiotics, even mild bacterial infections did, in fact, often prove fatal.


  • Earlier this month I became ill. Since it was around a holiday weekend I took a few days off and went back to work. At work people commented that I “sounded like I was dying” and after a few days it became very obvious that I was seriously sick. For the past 10 years I have never been too sick to miss more than 2 consecutive days of work, and that maybe every 3 months at most.

    So I took the rest of the week off. I came back the next week, no better really, and at this point I spoke to a doctor who finally prescribed my some antibiotics. I went back for a day and several people hearing me hacking and coughing told me I probably had bronchitis, and it was likely bacterial because of the length of time I was sick. After the treatments and some rest I healed very quickly, still not 100% but a complete world of difference.

    I am certain without the antibiotics I’d still be very sick and probably would have died/had chronic illness. Our bodies simply can not fight bacteria; it’s why penicillin was such a huge difference maker in society. We can heal against most viruses, but our bodies just don’t have much of a solution for bacteria (and fungus).

    If you’ve never had a bacterial respiratory illness you just wouldn’t understand how dangerous it is to lose use of your lungs. A bacterial infection in your lungs takes away their use, that bacteria is actively growing in and destroying your lung tissue. If that isn’t cleared quickly enough that is going to be permanent; it’s not just going to fix itself. We aren’t lizards or cyborgs that can rebuild our bodies. We’re human beings, and we are actually quite weak.

  • I agree with AnonS. I know my body and know when to ride out a cold or know when I need to get on antibiotics. And if I know I have a bacterial infection well I dont have time to be sick at work for three weeks hoping it will go away when I know it gets worse. It’s not like I’m on them twelve months out of the year. I get sick maybe once or twice a year…I remember having a sinus issue and I waited one week and my boss was like, you look and sound like you are dying, so I decided it was time to go to the doc…and I kid you not the second dose of antibiotics I took made me feel awesome compared to before and everything started to clear up.

  • Thanks for sharing this information . This article I must say provide lot of information abt antibiotics .

  • I am confused now … I have always been very much against taking antibiotics, or even going to the doctor, but I had a raging conjunctivitis, acute pharyngitis, and acute sinusitis all at once. The eyes were of the most concern, so I went to an urgent care facility. Of course I was prescribed antibiotics without any cultures taken. After taking two I felt much better and the third one got me almost back to 100%. I was referred to an ophthalmologist who prescribed a steroidal drop which has been pretty successful too. Does the success with the antibiotics mean that it actually WAS a bacterial infection? And that I should take the full course? I have had chronic trouble with candida and I don’t want to exacerbate that. We all know that over the counter probiotic pills are mostly worthless. I also read (I’ve been up reading scholarly articles for hours in the middle of the night because the sinusitis seems to actually have gotten a little worse) that the current recommendation for antibiotic courses for upper respiratory maladies is 5 days rather than the usual 10 which I was prescribed. This is only the 5th course of antibiotics I’ve been prescribed in my 61 years, so I don’t feel like I’ve contributed to the superbug problem … but I don’t want to contribute to my fungal problem either. What to do?

    Mary: For some reason, your comment made it into my spam filter, so I’m only seeing it several days after you posted it. From what you describe above, it sounds like you most likely had a viral infection (but take that diagnosis with a large grain of salt because I’m making it across the Internet). Just because you got better after taking antibiotics doesn’t mean the antibiotics are what made you better. The truth is there’s no way to tell. Also, the length of antibiotics is determined by the specific antibiotic you’re given as well as the type of infection you’re given it for, so I can’t answer your last question. Hope by now you’re feeling better!


  • This was a great read and I will be purchasing your book because I find your topics quite refreshing and interesting, especially your facts about Ebola. On this topic, however, I do need to make mention my experience with antibiotics. When I was younger the use of antibiotics was always pushed on me by my medical doctors (this was about 20 years ago). My grandfather, who was then head of a pharmaceutical company, would accept the medication and then throw them out when we got home. As I grew older I found that the medical doctors I went to rarely wanted me to take antibiotics. I recall being quite ill and asking a doctor for a prescription and she flatly said that my condition didn’t warrant it. Interesting the change in attitude towards antibiotics—highlighting the importance of patients to get educated and take responsibility for their health choices.

  • Honestly, there were no antibiotics available until post WW2 to general population. So these statements that your body can’t fight off bacterial infection are nothing but pure propaganda of pharmaceutical industry. I would go as far as medical professionals clearly over prescribe them. They should be considered last resort nuclear option. Western population suffers with so many autoimmune illnesses and allergies almost non-existent in countries that have no access to antibiotics so there is clear correlation between two. It is very sad that despite all advancements in science pharma holds healthcare industry indirectly hostage in this specific area of research/approach.

    Robbiel: I’m sorry but I can’t agree. It’s true that antibiotics are a recent development, but what happened in the pre-antibiotic era to people with serious bacterial infections is that they died. Definitely, antibiotics are overprescribed for what are in fact viral infections, but that doesn’t by any means mean they should be a “last resort nuclear option.” They should be used when a bacterial infection is diagnosed.