Antibiotic Stewardship – Natural Approaches to Avoid Overuse
Meredith Murray, ND
As the temperature drops, we begin to see a rise in symptoms of colds, cases of flu, and upper respiratory infections (URIs). Unfortunately, it is all too common for people to seek outpatient treatment for issues like these and receive antibiotics when the illness is viral in origin.
A 2015 study found that in a two-year period, 77% of adults with a respiratory tract infection seen at an outpatient clinic were given antibiotic therapy for their symptoms, which was inappropriate in 64% of those cases. .
Antibiotic stewardship is the term for the coordinated effort to only use antibiotics in the optimal and appropriate manner—including choice, dosing, route, and duration of use. The goal of this initiative is to both improve patient outcomes and reduce the consequences of antibiotic overuse—antibiotic resistance, toxicity, and serious infections such as C.difficile. It is now recommended that practitioners truly understand and practice recommended guidelines to help determine when antibiotics are appropriate and when they can be passed for symptomatic management instead. Integrative practitioners can fill an important role in this effort—both in educating patients about when to seek out antibiotic therapy and in offering many supportive therapies for symptomatic relief when antibiotics are not indicated.
Sinusitis affects an average of 1 in 8 Americans yearly. Twenty percent of antibiotic prescriptions written in America are for symptoms of sinusitis; however, it is commonly caused by a virus. The definition of rhinosinusitis is “symptomatic inflammation of the paranasal sinuses and nasal cavity”. The symptoms it presents with are purulent nasal drainage accompanied by nasal obstruction and/or fullness/pressure/pain of the face. It is deemed acute rhinosinusitis (ARS) if the duration is less than four weeks and chronic if lasting more than 12 weeks. There are both viral and bacterial forms of acute rhinosinusitis and antibiotics are only appropriate for the bacterial form. One cannot distinguish viral from bacterial just based on purulent nasal discharge alone. Acute bacterial rhinosinusitis (ABRS) is the diagnosis when the symptoms of ARS (see above) persist without improvement for at least 10 days beyond the onset of URI symptoms or there is a double-worsening. Double-worsening means that the signs of ARS initially improve but worsen again within 10 days of the initial improvement. If it is established that the infection is bacterial, watchful waiting and symptomatic relief is encouraged first for uncomplicated cases. The first-line antibiotic therapy is amoxicillin or amoxicillin/clavulanate.
Cough (Acute Uncomplicated Bronchitis)
Cough is the most common complaint that sends people to their PCP and it usually resolves within 1–3 weeks without any intervention. After signs and symptoms of pneumonia are ruled out (tachycardia, fever, abnormal lung exam), it is not recommended to use antibiotics but to offer symptomatic therapy. It should also be noted here, similarly to ARS, that colored sputum does not necessarily indicate a bacterial infection. Occasionally, acute bronchitis can be due to bacterial, but it has been shown that even in that instance antibiotics are not helpful.
Common Cold or Nonspecific Upper Respiratory Infection
There are known to be at least 200 viruses that can result in the “common cold”. While the symptoms of runny nose, congestion, headache, and sore throat can be bothersome—antibiotics will not likely resolve the situation any sooner. Practitioners utilizing supportive therapies can be tremendously helpful at providing relief and education.
A sore throat can be part of the symptom picture of the common cold. However, a sore throat can also be a sign of strep throat. Strep throat is a bacterial infection and does require antibiotic treatment. If suspected, a strep culture is recommended following the Centor Criteria: tonsillar exudate, tender anterior cervical lymphadenopathy, fever by history, and absence of cough.
Acute Otitis Media (AOM)
Ear infections can happen to both adults and children. However, they occur more frequently in children. Acute otitis media (AOM) can be caused by both bacteria and viruses and while bacteria is a more common cause, antibiotic therapy is not always necessary immediately. The Centers for Disease Control and Prevention (CDC) recommends the following: “Watchful waiting without antibiotics for 2–3 days is a good treatment option for children with mild AOM (as mild AOM is often viral). Children with mild AOM who are not better in 2– 3 days also may need antibiotic treatment. Immediate antibiotic treatment is recommended for children with severe AOM (as this is more likely bacterial)”. Current conventional guidelines strongly recommend that if the child is less than six months old, immediate antibiotic therapy is used. An ear infection is a situation where antibiotic therapy may be appropriate and it is necessary to have a trained clinician make that decision.
Supportive Recommendations for Watchful Waiting
Many of the above conditions, especially viral illnesses, are considered self-limiting conditions and watchful waiting is indicated. But here are some suggestions which can help ease the discomforts:
- It is not beneficial to your body or those around you if you continue your daily activities and work.
- Drink plenty of water and healthy fluids (ideally without sugars or dyes).
- Use a mist vaporizer or saline nasal spray for congestion. One way to help with decongestion is to brew a nice cup of tea with immune supportive and respiratory focused herbs (echinacea, thyme, licorice) —and breathe in the vapors gently while the tea cools before drinking it. Also, using the steam from a shower or essential oils from a diffuser can be other helpful ways to ease congestion.
- For adults and children older than one-year-old, honey can be used as an effective way to relieve a cough. This method is also recommended by the CDC and other conventional medical avenues. Again, do not give honey to infants less than one-year-old. There are many herbal cough syrups that combine antimicrobial herbs (elderberry, thyme) with honey that can be soothing as well as promote expectoration.
- Elderberry—(Sambucus nigra) has been used traditionally for immune support and has been found to have antibacterial and antiviral properties. A recent study found it can help reduce the duration and severity of cold symptoms in passengers who travel frequently. Elderberry can be taken as tea, lozenges, extract, and syrup.
- EPs 7630—an extract from the roots of Pelargonium sidoides has been found in a few studies to be successful in the resolution of acute non-streptococcal pharyngitis in children. I personally use it in my clinical practice for adults and find it effective.
- Zinc—Oral zinc (10-15 mg) has been researched and shown to have the ability to reduce the number of colds per year. This would be helpful in the situation where one was around many other sick individuals and wanted to try a preventative measure.
- Botanical sinus and lung-directed formulas—which include immune supportive and antimicrobial extracts of elecampane, usnea, osha, Oregon grape root, and Echinacea—may be very supportive during the watch and wait period to help during recovery.
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