Why you did not get antibiotics, and what we watched for instead

Nobody takes a day off work, waits in a clinic and pays for a visit in order to be told to drink fluids. So when we say an illness is viral, it lands badly, and I understand why.

This is the reasoning, in the same order we use it at the bedside, along with the part that usually gets skipped: what we are asking you to watch for.

The scale of the problem

Somewhere around a third of antibiotic prescriptions written in United States outpatient settings are not needed. Urgent care is one of the worst offenders in that data, largely because of volume, time pressure and the reasonable human desire to send a patient away feeling helped.

The cost is not abstract. Antibiotics cause rashes, diarrhoea and thrush routinely, and Clostridioides difficile colitis occasionally. Every unnecessary course also contributes to resistance, which is how a straightforward urinary infection turns into one that needs an intravenous drug.

Sore throat: we score before we swab

Most sore throats are viral. The Centor criteria, modified for age, give a structured way to estimate the chance that a particular throat is group A streptococcus: fever in the history, tonsillar exudate, tender anterior cervical nodes, and the absence of a cough.

A throat with none of those features has a low enough probability that testing is usually not worthwhile. A throat with several gets a rapid antigen test, which returns in about ten minutes. In children a negative rapid test is backed up by a culture, because the antigen test misses some true infections. A positive test earns penicillin or amoxicillin for ten days, and the ten days matter, because the reason we treat strep at all is to prevent acute rheumatic fever.

Sinus pain: the ten day line

Almost every acute sinus infection starts viral, and most stay viral. The commonly used thresholds for suspecting a bacterial cause are symptoms persisting beyond about ten days without improvement, severe symptoms with fever above 39 degrees Celsius and purulent discharge for three or more consecutive days, or a clear pattern of getting better and then getting worse again.

Purulent green discharge on day four is not evidence of anything except that your immune system is working. It is the single most common reason people expect a prescription, and it does not predict a bacterial infection.

Bronchitis, which is where most of the waste happens

Acute bronchitis in an otherwise healthy adult is viral in the overwhelming majority of cases, and the cough lasts a median of around eighteen days whether or not you take an antibiotic. What we can do is treat the cough properly, check your oxygen saturation, listen carefully for the focal findings that suggest pneumonia, and get a chest film if there is any doubt.

So what are we watching for

Here is the part of the visit that matters most. When we say no antibiotic, we should also be giving you a list. If you did not leave with one, this is it.

• Fever that returns after you had been improving for a day or more
• Shortness of breath, or an oxygen saturation you measure at home below 94 percent
• A cough producing blood, or chest pain that is worse with a deep breath
• Sinus symptoms that persist beyond ten days without any improvement
• Severe one-sided facial swelling, or swelling around an eye
• A stiff neck, a rash that does not fade under pressure, or new confusion, which mean an emergency department now

What we can still do

Symptom treatment is not a consolation prize. Intranasal steroids for sinus pressure, adequate analgesia, a short course of the right antiemetic, an inhaler when there is wheeze, and a properly written work note all change how the week goes.

And if the picture changes, come back. A recheck within fourteen days for the same problem is a reduced fee, and we would much rather see you again on day six than have you avoid us because the first answer was not the one you wanted.