Respiratory System

Antibiotics – When You Need Them and When You Don’t

In the era before antibiotics were available one third of all deaths were from infectious disease. The introduction of antibiotics starting with penicillin represented a tremendous advance in the treatment of infectious diseases. We soon learned, however that overuse of antibiotics led quickly to the development of bacteria that became resistant to that antibiotic. Penicillin, for example can only be used for a small number of infectious diseases now including strep infections and syphilis. In this post I will write about both individual and societal harms of overuse of antibiotics and will also discuss conditions for which they should be and should not be used.

Harms of Antibiotics

Bacterial Resistance

Overuse of antibiotics can lead quickly to resistance. Unfortunately, resistance has eventually developed to nearly all currently available antibiotics. Some bacteria, called gram negative bacteria have developed resistance to almost all antibiotics. Antibiotic resistance in the United States kills approximately 23,000 patients a year and incurs over $20 billion in additional medical expenses.

Overuse of antibiotics

The information below comes from an excellent paper from the journal Pharmacy and Therapeutics: The Antibiotic Resistance Crisis.

 in 2010, the last year that we have complete data, 22 doses of antibiotics were prescribed per person in the U.S. In many other countries, antibiotics are unregulated and available over the counter without a prescription. This lack of regulation results in antibiotics that are easily accessible, plentiful, and cheap, which promotes overuse.

Inappropriate Prescribing

Many studies have shown that antibiotic therapy is not necessary in 30% to 50% of cases! Even in intensive care units 30% to 60% of the antibiotics prescribed have been found to be unnecessary, inappropriate, or at inadequate doses.

Extensive Agricultural Use

In both the developed and developing world, antibiotics are widely used as growth supplements in livestock.  About 80% of antibiotics sold in the U.S. are used in animals, to promote growth and to prevent infection. Molecular detection methods have shown that resistant bacteria in farm animals reach consumers through meat products. This happens through the following sequence of events:

1) Antibiotic use in food-producing animals kills or suppresses susceptible bacteria, allowing antibiotic-resistant bacteria to thrive

2) Resistant bacteria are transmitted to humans through the food supply

3) These bacteria can cause infections in humans that are resistant to most antibiotics

Consequences of Antibiotic Resistant Infections

A 2011 national survey of infectious-disease specialists found that more than 60% of the infectious disease doctors had seen a pan-resistant, untreatable bacterial infection within the previous year. Many public health organizations have described the rapid emergence of resistant bacteria as a “crisis” or “nightmare scenario” that could have “catastrophic consequences.”

Antibiotic Effects on Human Microbiome

It is well established that the gut microbiome plays an important role in health.  It prevents disease causing bacterial colonization, regulates gut immunity, provides essential nutrients and metabolites, and is involved in control of energy. A healthy gut microbiome has lots of diversity. Broad‐spectrum antibiotics reduce gut bacterial diversity. While killing the disease causing bacteria of concern antibiotics can also kill beneficial bacteria.

Studies report changes in gut bacterial composition that last for up to 12 weeks after antibiotic treatment has ended with the incomplete restoration of bacterial composition and emergence of antibiotic‐resistant strains.  In one study one short term course of clindamycin (7 days) resulted in significant disturbances in the gut bacterial community that remained for up to 2 years post‐treatment!

When Antibiotics Are Not Necessary

Viral Infections

The vast majority of infections are caused by viruses. Antibiotics do nothing to shorten viral infections or to relieve symptoms. Here are some examples.

Upper respiratory infections

Symptoms are typical cold symptoms, including runny nose, nasal congestion, sore throat and cough. There may or may not be fever. Fever, sometimes high fever is more common in children. Green or brown discharge from the nose is common with viral upper respiratory infections and does not indicate bacterial infection. Viral upper respiratory infections usually last about 10 days, but can persist for several weeks.

Bronchitis

In otherwise healthy people, bronchitis is another example of a viral infection. The only exception to this is people with chronic obstructive lung disease, in which bronchitis may be caused by bacteria. The main symptom of bronchitis is cough, which may be dry or may be productive of sputum. Yellow or green sputum can occur and does not mean that the bronchitis is bacterial. There is usually no fever. Viral bronchitis can last for weeks. RSV virus can cause a severe bronchitis in children and older adults. There is a vaccine for children and adults that prevents RSV virus infections.

Sinusitis

Most sinus infections are viral and antibiotics are not helpful for these. Symptoms can include thick nasal discharge and some discomfort over the maxillary sinuses (underneath the eyes). Occasionally sinusitis can be bacterial and require antibiotics. I will discuss this later under conditions for which antibiotics are appropriate.

GI Viruses

There are other viruses that affect the gastrointestinal system. Symptoms are usually nausea and vomiting and/or diarrhea. Norovirus is the most common one. Staying hydrated is the only treatment for these viruses. Rotavirus affects children, but there is a an oral vaccine for infants that prevents this disease.

Ear Infections (Otitis Media)

Infections behind the ear drum are called otitis media. These occur almost exclusively in children and can be viral or bacterial. We used to treat all inner ear infections in children with antibiotics. We have now learned that most ear infections in children, even the bacterial kind get better without antibiotics. We now use antibiotics only for children with severe ear infections who more commonly have fever and/or severe pain.

When Antibiotics Should Be Used

Most bacterial infections require antibiotics to get better. It is not always possible for you to know whether you have a viral or bacterial infection. If you are concerned that you might have a bacterial infection you need to see your doctor who will decide whether you need antibiotics or not.

Strep Throat

Although many sore throats are viral, sore throat can also be caused by strep (streptococcus). Strep throat does not cause other symptoms like cough and runny nose. It is diagnosed by a rapid strep throat swab which your doctor can do in his/her office.

Bacterial Sinusitis

This usually happens after a viral upper respiratory infection. The most common sequence is that you start to feel better after a week or so and then get worse. Typically pain from bacterial sinusitis is one side, not both sides. The affected sinus becomes very tender to touch. Fever may or may not be present.

Infection in the ear canal (otitis externa)

This kind of infection is different from infections behind the ear. It can be painful and usually there is some pussy discharge from the ear. It usually responds to topical antibiotic ear drops, but when severe can require oral antibiotics

Pneumonia

Pneumonia can be viral, but it is not easy to tell that kind from the more serious bacterial pneumonia. All pneumonias should be treated with antibiotics. Symptoms of pneumonia are fever, sometimes high fever, cough (usually productive) and shortness of breath. A chest x-ray will show fluid in the air sacs in the lungs.

Urinary tract infection

Bladder infections are common, especially in women. The symptoms are frequent urination and pain or burning with urination. Your doctor will send a urine culture to make sure you are on the right antibiotic.

Kidney infections (also called pyelonephritis) are a more serious type of urinary tract infection. Symptoms can include fever, flank pain and feeling very ill. Sometimes kidney infections require getting IV antibiotics in the hospital.

Soft tissue infections (cellulitis)

A scrape or cut on the skin can sometimes get infected. Usually the area around the injury becomes red and painful. This kind of infection usually requires antibiotics. Again, this is a decision your doctor needs to make.

Sepsis

Sometimes a localized infection will spread through the blood stream and affect other organs. This is a medical emergency and requires hospitalization, IV antibiotics and fluids to maintain blood pressure.

Bottom Line

Overuse and inappropriate use of antibiotics has led to bacterial infections that are increasingly resistant to many and sometimes all antibiotics. Antibiotics, even when used appropriately lead to long standing adverse effects on the gut microbiome. The vast majority of infections are viral and do not improve with antibiotics. Bacterial infections do often require antibiotics. Decision about whether antibiotics are appropriate should be made by your doctor. Requesting antibiotics from your doctor can sometimes lead to inappropriate prescribing.

Chronic Inflammation and the Respiratory System

The respiratory system, which includes the trachea, the bronchi and the lungs can be a source of chronic inflammation that not only affects the respiratory system itself, but can affect other organs as well. The inflammatory process in the respiratory system involves activation of the immune system just like chronic inflammation in any part of the body. It includes pro-inflammatory cytokines, macrophages and lymphocytes.

Causes of respiratory system inflammation

Nitrogen Oxides

Nitrogen oxides, particularly nitrogen dioxide (NO2) is a respiratory irritant that causes inflammation of the bronchi. Exposure to NO2 can cause or exacerbate asthma.  In addition, several epidemiological studies have demonstrated associations between NO2 exposure and premature death, chronic lung disease, heart disease, stroke, decreased lung function growth in children, respiratory symptoms, emergency room visits for asthma, and intensified allergic responses. A comprehensive review of the health effects of NO2 exposure, both acute and chronic, can be found at this website: The Health Impacts of NO2 Pollution. The biggest outdoor source of NO2 is  through reactions between nitric oxide (NO) and other air pollutants (mostly from automobile exhaust) that require the presence of sunlight. The biggest source of NO2 in home air is the use of unvented natural gas stoves.

Particles

In addition to gases like NO2, air pollution also contains particles. Large and medium size particles lodge in the nose and upper airways and are usually cleared by the airway protective system which includes mucus and cilia that move these particles up and out of the airways. Fine and ultra fine particles (those that are 2.5 microns and smaller) can get all the way down to the alveoli (the air exchange sacks) in the lungs. These tiny particles bypass the lung protective system and cause inflammation in the lungs. They can also sometimes get directly into the circulation and can cause damage in the heart and other organs. According to the EPA, a large body of scientific evidence shows that exposure to fine and especially ultra fine particles can cause heart attacks, heart failure, and strokes, which results in hospital admissions, emergency department visits, and, in some cases, premature death. The scientific evidence shows exposure to fine and ultra fine particles is also likely to cause respiratory effects, including asthma attacks, reduced lung development in children, and increased respiratory symptoms such as coughing, wheezing, and shortness of breath. Prolonged exposure can cause chronic lung disease such as COPD and pulmonary fibrosis. There is more limited scientific evidence for developmental and reproductive effects, lung cancer and other cancers.

Sources of fine and ultra fine particles

Outdoor sources of fine and ultra fine particles come primarily from automobile exhausts as well as some factories. They tend to be much higher in cities, particularly inner city neighborhoods.

Indoor sources are tobacco smoke, wood burning fireplaces, gas space heaters and natural gas stoves. The way food is cooked can also produce fine and ultra fine particles. Frying in hot oil or broiling generates lots of these particles even on electric ranges. Boiling or steaming generates many fewer particles. Air fryers also generate very few particles.

Reducing Indoor Air Pollution

Natural gas is 99% methane, so burning it in a stove in addition to generating dangerous levels of NO2 and fine and ultra fine particles, is also the most potent greenhouse gas. That means that not only are gas stoves bad for your health, they are also bad for the environment. If you have a gas stove, the best option is to replace it with at electric stove with an induction cooktop. Induction cooking is much more efficient than a traditional electric burner. It uses only 60% as much electricity and heats the pot directly rather than the burner itself. Heating with induction burners are actually faster than heating with gas burners. This is of course not practical for everyone. Replacing a stove is expensive and requires an electrician to install a 220 volt outlet if you don’t have one. It is also impossible for renters. If you can’t replace your gas stove and it has a hood that vents to the outside, turn it on high every time you cook. If the hood is not vented to the outside, then opening a window helps substantially decrease NO2 and particles. Whether you have either kind of stove, using a portable air fryer is much safer than frying in hot oil on the stove. Another much less expensive option is to purchase an induction hot plate. Good ones range from 60 to 200 dollars and can plug into a regular 110 volt outlet. Induction burners only work with pots that a magnet will stick to. That includes cast iron skillets and most stainless steel cookware. Inexpensive induction compatible cookware is available at a very reasonable cost from almost all big box stores such as Walmart and Target.

Reducing Outdoor Air Pollution

There is nothing an individual can do by themselves to reduce outdoor air pollution. Working to promote affordable electric vehicles is the only long term solution for automobile exhaust pollution in cities.

Bottom Line

Chronic inflammation of the respiratory system results from air pollution both outdoors (especially in inner cities) and indoors. Smoking tobacco is also a major cause of chronic inflammation of the respiratory system. Chronic inflammation of the respiratory system leads to many chronic lung diseases as well as heart disease and possible lung cancer. Indoor air pollution is caused primarily by unvented natural gas stoves as well as gas space heaters and wood burning fireplaces. The major causes of lung inflammation are nitrogen dioxide (NO2) and fine and ultra fine particles. Indoor pollution can be mitigated by ventilation using either a hood connected to outside or opening a window while cooking. Using electric induction burners are safer and heat even more quickly than gas. Portable electric air fryers are much safer than frying in oil on any kind of stove top. Purchasing an induction hot plate is a much less expensive way to do induction cooking. Reducing outdoor air pollution requires societal change.