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Comment by rscho | Hacker News Reader

This issue is not as easy as it seems. Doctors used to give them for a cold, and still do (even in the best medical practices). There are two important things to be aware of:

- Differentiating "common cold" (viral infection) from a bacterial infection, which would be a correct indication for antibiotics, is often impossible. If you want the best chance for your particular patient, what will you do? Now, if you want the best chance for the whole patient population, what will you do? Not the same thing.

- If you don't give antibiotics, things turn wrong, and the patient's family comes back wielding pitchforks, what do you do? This is less of a problem nowadays, but in small communities and rural environments can still be a very real question.

This is also a bit of a cultural issue. Now, I agree completely that OTC antibiotics make no sense at all.

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Both your points are technically correct (the best kind of correct), but miss the mark in practice. There's no real reason most of the time to differentiate between the common cold and other upper respiratory infections, unless complications ensue. Simply put, a healthy, non-immunocompromised person will fight off basically any upper respiratory infection without a problem.

A healthy person, absolutely if he is 30 years old. Now how will you handle the healthy 80 yo patient? Will you take the risk of a bacterial infection that may kill him, although he is now perfectly healthy and still doing hiking on a regular basis? Now what, if he is 1 year old? I think you underestimate the potential impact of common infections. This is a grey zone. There is no correct answer. Everything depends on where you put your safety/futility cutoff for the treatment decision, which is what doctors are paid for.

Had my father made it to 80, I strongly suspect he'd've wanted to take the risk to help preserve the antibiotics for younger people.

Of course this doesn't necessarily generalise, but there's plenty of older english people with the "I don't want to be a bother" mindset so it might do better than you think.

I don't agree with the premise. It's hospital-acquired pneumonia that is the greatest concern and the biggest incubator for resistance. There's really no need for GPs to withhold antibiotics from at-risk groups to take at home.

> non-immunocompromised person will fight off basically any upper respiratory infection without a problem.

I am curious if this is true, ie: does medical science hold above as an accepted fact by general consensus?

I ask because my understanding is that the 1918 flu (aka Spanish flu) which was an H1N1 (upper respiratory infection in humans , intestinal tract in birds) predominantly killed young adults, ie: healthy non-immunocompromised people. Here's the wikipedia remark:

https://en.wikipedia.org/wiki/1918_flu_pandemic

"the 1918 pandemic predominantly killed previously healthy young adults."

"a rapid progressive respiratory failure and death through a cytokine storm (overreaction of the body's immune system). It was then postulated that the strong immune reactions of young adults ravaged the body, whereas the weaker immune systems of children and middle-aged adults resulted in fewer deaths among those groups"

But there's some conflicting explanations: "special circumstances (malnourishment, overcrowded medical camps and hospitals, poor hygiene) promoted bacterial superinfection that killed most of the victims typically after a somewhat prolonged death bed "

Flu is actually a systemic infection, not s respiratory infection. It's not very treatable, except symptomatically, anyway. If the Spanish flu came back today, we'd have almost as hard a time dealing with it now as we did then.

If it's the flu, it's not treatable with antibiotics. Antivirals, general care, symptom relief, and vaccines are the best we've got.

You've got to remember, too, that it wasn't an especially virulent strain of influenza alone that caused the deaths from 1917-1919. It spread quickly among the war-weary, crowded, exposure-riddled young men who lived with chickens and hogs at the battlefronts. It was common practice at the time to logistically set up small-pen animals close to the long, mostly stable fronts as a source of local food rather than shipping in so much preserved food. Those young men then travelled far and wide across the continent and even overseas as their service rotations came and especially when hostilities ceased.

https://virus.stanford.edu/uda/ tells the story about as well and succinctly as any source. http://ww1centenary.oucs.ox.ac.uk/body-and-mind/the-spanish-... and https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2862337/ have lots of information.

As is common, the war's conditions and aftereffects killed far more people than died in combat. It was a nasty flu, but humans helped it out about the best we could.

Sure. And when they're, you know, ten, with a sore throat, some cervical lymph node tenderness, no cough, no tonsillar exudates? In other words, every case of sore throat that walks in the door?

1/5 chance it's Group A strep and worth throwing abx at. And... then what? We know the stats, we have a non-specific presentation, and the traditional reason to throw abx at this patient is because we want to minimize the chance of a subsequent heart or kidney disease (post-infectious immune hypersensitivity rxn). 4/5 chance they don't need abx; 1/5 chance that they'll benefit, but not a lot. But, hey,... how do you even attach a utility analysis to "and a small reduction in the likelihood of heart and/or kidney damage"? The magnitude of the risk is hard to comprehend, subjectively, in the face of the small reduction in incidence. And you will see those consequences play out; you're going to see so many sore throats that the small odds will manifest.

This isn't one of those, "stupid doctors, they don't know what they're doing!" things. It's something that doesn't readily yield to utility metrics.

That's when you do a throat culture. It used to be common 30 years ago. It's simple, accurate, non invasive, and basically risk free.

Except that the throat culture takes 48 hours to come back, plus the time to get the patient started on the abx after that, on an infection that has a 5 day course to begin with, which got into your office somewhere on day 2. You wait 48+ hours on the backup culture, and you've missed your window to do anything with it.

...which is a big part of why it used to be common, and isn't now.

Rapid strep test backed up by throat culture is what you would do now. The rapid strep test is about 70-80% sensitive.

When I went to the doc with a cold and high fever they didn't give me antibiotics, they first looked for bacteria. It's not that hard to do, it just costs more than writing a prescription.

Rapid tests are not available for all types of infections. Furthermore, the doc may not want to risk superinfection with another bug if treating a fragile patient. Rapid tests for strep throat are regulated by guidelines, and are part of standard care.

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