Priority Topic: Antibiotics & Priority Topic: Fever

Priority Topic: Antibiotics
Key Feature 2: In patients with a clinical presentation suggestive of a viral infection, avoid prescribing antibiotics.
Skill: Clinical Reasoning
Phase: Treatment

Priority Topic: Fever
Key Feature 2: In a febrile patient with a viral infection, do NOT prescribe antibiotics. 
Skill: Clinical Reasoning 
Phase: Treatment

Well, I have survived my first cold and flu season as a resident without catching one of those bugs myself. This winter season I saw many runny noses, a high degree of low grade fevers, and plenty of coughing fits. I anticipated that may of these patients would be presenting to ask for antibiotics, as I was taught in medical school there is a significant proportion of the population who irrationally believe that antibiotics will cure their symptoms. In fact, I have not encountered this phenomenon. 

Viral infections are one of the most common causes - if not the most common cause - of fever. In an otherwise well person without significant comorbidities or other risk factors, viral infections are self-limited, which means there's not a lot that human intervention can do to alter the course of the disease (i.e., we are dependent on our immune systems to command the battle against the foreign infiltrator). But we must be on the lookout for the symptoms and signs that suggest human intervention is warranted, such as for other infections from bacteria or fungi, or for noninfectious inflammatory processes that can occur that can also cause fever, such as rheumatic disease or cancer. 

Antibiotic stewardship is not a new thing; it's been a hot science and medicine topic for years. Patients are also frequently aware of this issue, and seemingly share in the general understanding that antibiotics shouldn't be prescribed willy-nilly, and that they're not always indicated. If we prescribe an antibiotic for a cause of infection that is not bacterial, it simply won't work. Furthermore, as with all medications, antibiotics can have unpleasant side effects, causing common issues such as diarrhea or rash, and sometimes having more deleterious side effects such as C diff infection or an anaphylactic reaction. On a larger scale, the haphazard use of antibiotics can promote development of antibiotic-resistant superbugs, serious threats to the human species (see the World Health Organization Antibiotic Resistance webpage if you're dubious about this).

The patients I see tend to be a reasonable bunch. They typically present to clinic because they are in physical or emotional discomfort from their symptoms, and they are typically as keen to start an antibiotic as they are to receive reassurance that an antibiotic is not needed given their cluster of symptoms and signs. Of course, if I attribute symptoms and signs as being a consequence of a viral illness, it's always important to provide instructions as to when to return for medical care. The current presentation may represent a brewing bacterial infection that has yet to declare itself, or  there may not be a bacterial infection yet, but this could be something that develops further along the disease course (viral infections can pave the way for a bacterial superinfection). In any case, unless a patient is unwell (as in the physician's sense of the word "unwell" meaning really super duper sick), or unless they have risk factors that make them less likely to be able to fight off an invasive infection should they develop it, we generally have time on our side, and as such we can avoid the impulsive use of antibiotics and their potential negative sequelae, in a classic first do no harm approach.