Three Myths About Antibiotics We Really Need to Retire
Sneezes, penicillin allergies, and those strangely sacred 5- and 7-day courses.
As a proud infectious-diseases geek — the kind who genuinely delights in obscure microbe names and the latest antifungal (there’s one called ibrexafungerp, believe it or not) — I also have the day-to-day pleasure of encountering certain myths about infections that simply refuse to die.
They pop up everywhere — in clinic, at parties, in texts from worried friends, and sometimes in places that frankly should know better:
Treating sneezes with antibiotics? C’mon, Capsule Pharmacy — you really know how to make an ID doctor mad!
Let’s start with three myths most central to this ad: antibiotic myths.
Myth #1: “I’m allergic to penicillin, so that’s off-limits for life.”
This is one of the most common ID myths out there. Millions of adults walk around believing they’re permanently barred from penicillin (and all related drugs) because of something that happened in childhood — a rash, an upset stomach, or a warning passed along by a worried parent.
Often the event that triggered the allergy label is long forgotten. It remains as difficult to shed as an embarrassing childhood nickname that your school friends still insist on using — linked to you permanently in an inconvenient way.
But here’s the reality: more than 90% of people who think they’re allergic actually aren’t. It’s probably closer to 95%, or even higher. People outgrow allergies, or it was never truly an allergy in the first place, or the “allergic” rash was caused by a virus rather than the drug, or some combination of the above.
Asked years ago the question, “What common lack of knowledge about the immune system would you like to correct?”, here was my answer:
Adults who had a childhood allergic reaction to penicillin often think they’re still allergic when they’re not. Studies show more than 90 percent of adults who think they are allergic to penicillin can take it safely.
Yes, I’ve been singing this tune for a while.
Getting mislabeled as penicillin-allergic means missing out on safe, effective, first-line antibiotics for the rest of your life. Importantly, it’s not just penicillin itself; it’s all the antibiotics that end with “-cillin” (such as amoxicillin), and the entire class of drugs called cephalosporins, which are related. Every healthcare provider will, on seeing the penicillin allergy in your record, pause before using these drugs no matter how vague or remote the “allergic” reaction.
Most importantly, there is abundant evidence that having a penicillin allergy on your chart makes care worse, less efficient, and more expensive. A simple skin test can often clear that label, reopening a whole category of medicines you thought were off-limits forever. And if your “allergy” sounds especially low risk, we may not even bother with skin testing — a supervised “test dose” often settles things quickly.
If you don’t believe me, here’s an hour-long podcast on the topic:
Myth #2: “You must finish every last antibiotic dose or the infection will come back, and the bacteria will outsmart you.”
Ever wonder how we came up with that magical length of antibiotic therapy that must be completed for the antibiotics to work, and to avoid resistance? Here’s the secret: it’s pretty much made up.
Yes, the prescriptions we write require a precise antibiotic “course”. We must designate the specific medication, the dose, how often it’s taken, and the duration, in days. Replacing the last of these with Long Enough or Until You Are Better just won’t cut it, though it’s medically more accurate.
If I’m famous for anything in the ID world — and we’re talking extremely niche fame here, folks — it’s for making fun of the arbitrary way we define an appropriate antibiotic course, and our odd devotion to the numbers 5 and 7. Here’s the punchline, taken from the original post on my NEJM Group blog:
Taking antibiotics longer than needed, or when not needed at all (as when treating “sneezes” — looking at you, Capsule Pharmacy!), is what drives resistance — not stopping too early. Think of that duration of therapy, so clearly defined on the prescription, as a general guideline, not a mandated rule driven by some arcane fact about bacterial life-cycles.
Were you given a 10-day course of antibiotics, and feel totally fine by day 7? Would you like permission to stop? Check in with us, and we’ll most likely give you the A-OK.
Myth #3: “Antibiotics will help this cough/congestion/sinus pressure that just won’t quit.”
Back to the leadoff image in this post — the (now) infamous Capsule Pharmacy subway ad, implying that antibiotics will treat sneezes. If only! Alas, they have no activity against respiratory viruses, the cause of cough and cold illnesses.
(They also have no activity against allergies, another common cause of sneezes. Oh well.)
There are several reasons why this myth is a tough one to bust.
Bad colds are a miserable experience. We understandably think there must be something that we can do to make them better. That’s why the cough/cold aisle at your pharmacy is packed with various nostrums. We’re desperate.
They last a long time, but people forget. For some reason, most people think colds get better in a few days. But carefully done studies show that symptoms linger for 7-14 days, sometimes longer. Then, once we finally recover, a strange amnesia sets in, prompting us all to believe (wrongly) that colds only last a few days — and the cycle begins anew.
When ultimately prescribed an antibiotic for prolonged colds, people get better. Of course those same people have no way of knowing whether it was the antibiotic, or just “tincture of time” — but studies using placebos overwhelming show that it was the latter, as recovery time is identical for people receiving the antibiotic and the dummy pill. In other words, they would have gotten better anyway if they just waited it out. Yet in real life (not clinical studies), the magic prescription gets the credit, reinforcing the myth that “Antibiotics will help this cough/congestion/sinus pressure that just won’t quit.”
The distinction between viruses and bacteria is a tricky concept to master. Surprisingly, a higher educational background does not fully protect against the misconception that antibiotics treat colds. If we go back (again) to the advertisement at the top of the post, you can see that even some pharmacies get it wrong. To their credit, I’ve heard that Capsule Pharmacy discontinued their “antibiotics for sneezes” ad.
There, three myths down, countless others to go. But let’s take it one step at a time. Next time we leave antibiotics behind and head to picnics, travel, and the hazards of crossing a street in Vietnam.
See you then — and please, save the antibiotics for when they actually help.
Very informative. Does Capsule pharmacy have pharmacists or physicians that were involved with that ad? That ad just ramps up the public’s belief that an antibiotic treats all.
I always share your abx duration article with the residents!