Most of us have taken one at some point but the misperception of antibiotics as “harmless” medications is being tackled by infection experts.
Professor Martin Cormican is the HSE's clinical lead for antimicrobial resistance and infection control and a professor of bacteriology at NUI Galway. A consultant microbiologist who has trained in Ireland, the UK, and the US, he says he and others have been “banging the drum” about antibiotic overuse for over 20 years.
“People often want antibiotics because life is busy and they have things they need to do and they think that the antibiotic will make them get better faster, but all the studies show that that isn’t the case. The vast majority of sore throats and ear infections are viral, will go away by themselves, and get better just as fast without antibiotics,” Cormican says, adding that rest, plenty of fluids and paracetamol will help make someone more comfortable if they are suffering with a viral infection.
An enhanced understanding of the differences between a bacterial and viral infection has probably been one of the few positive effects of our experience with Covid-19, Cormican says.
They are real medicines with real side effects, some of which are very serious
“We will have to see how long that understanding lasts but everything to do with infection has been in the public’s mind for the past two years, whether it’s what a virus is or what medications can do. This kind of information used to be a small part of people’s lives but now it is central to our lives,” he says.
The reality is that most common infections get better without antibiotics.
Yet for many people, a sore throat is thought of as a sign that they require an antibiotic, only to find themselves stumped when the GP doesn’t agree.
“There is a good awareness that if people have a cold, they understand antibiotics won’t make any difference, but there are a lot of people who think an antibiotic is needed for a sore throat.”
Cormican believes this is due, at least in part, to the fact that historically a case of strep throat was strongly associated with the onset of rheumatic fever, and so a doctor would prescribe a course of penicillin to prevent this.
“Rheumatic fever has now largely disappeared and is very rare in developed countries, but it is understandable that anyone over 65 would feel that an antibiotic is always necessary because they may still have this fear about a sore throat and the connection with rheumatic fever from childhood.”
One of the main contributors to antibiotic overuse is their perception as being medicines that have no risk of harm, Cormican continues.
“You hear people say they want to take an antibiotic just in case, the idea is that they’ve nothing to lose. But a key part of what we are saying is that you do have something to lose, they are real medicines with real side effects, some of which are very serious,” he says.
Understanding impacts
These side effects come in two forms – antibiotics can have a direct harmful effect, or they can cause problems by disturbing the body’s good bacteria. Certain antibiotics can, rarely, cause serious toxicities – for example clarithromycin can cause disturbances of the heart, while ciprofloxacin can impact the heart, but it can also cause tendons to rupture. When you need an antibiotic the benefit is greater than the risk of a rare side effect but if you don’t need any antibiotic you take the same risk without any benefit.”
Cormican notes some other antibiotics can cause skin rashes and all antibiotics will have an impact on the body’s “good bacteria” or microbiome, upsetting the natural balance. “The old-fashioned penicillin like amoxicillin do less to the microbiome while many of the newer ones like co-amoxiclav will do more to disturb your microbiome.”
As a result, antibiotics are categorised into “red” and “green”, with red antibiotics guilty of doing most damage to the microbiome. “We tell prescribers and doctors that if a green antibiotic will work, that’s what you should be using, and only use a red antibiotic if really needed,” Cormican says, adding that GPs and pharmacists work on their team to develop the guidance, and this has helped to drive a “really positive shift” towards the use of green antibiotics in recent years.
If you go to your doctor and they say you don't need an antibiotic, that is good news
The message about antibiotic overuse may finally be penetrating, but Cormican admits it can be a delicate balance to achieve as antibiotics are essential medications when properly used.
“The situation we are managing now is complicated – it’s positive because there is much greater understanding among people that there is an upside and a downside to taking antibiotics, but we don’t want people becoming so preoccupied with the downside that they think they shouldn’t take them at all.
“We of course want you to have an antibiotic if it will help you get better faster, or if it will stop you from getting sicker. There are instances where the right antibiotic is needed and must be used,” Cormican says. If you have sepsis or blood stream infection it is vital that you get an effective antibiotic fast. The same is true for bacterial pneumonia or bacterial meningitis. Antibiotics also are very important with many other bacterial infections such as kidney infection and they are needed to support some types of surgery.
“Our message to everyone, whether you’re prescribing or taking an antibiotic, is you have to think of the risks and the benefits. That’s the challenge with antibiotics, they are wonderful drugs when you need them. We just need to make sure that the people who need them, and who will benefit from them get them promptly.”
“If you go to your doctor and they say you don’t need an antibiotic that is good news – it means you can expect to get better just as fast on your own steam.”
Find out more about common winter illnesses and how to treat them - www.hse.ie/winter