“I’ve got bronchitis and my doctor gave me a Z-Pak.”

I hear this from friends, from family members, and from my patient who went to the urgent care over the weekend.  I smile and don’t say what I am really thinking:

Bronchitis:  noun  -  inflammation of the mucous membrane in the bronchial tubes. It typically causes bronchospasm and coughing Translation: a loose cough.

This is one of the most common tricks we use as doctors: stating the obvious using a Latin or Greek word to describe the symptoms and call it the diagnosis.  The suffix -itis refers to inflammation. Dermatitis is one I frequently use: someone comes with a rash (skin inflammation) and I tell them it’s dermatitis, which simply means...drum roll please... it’s a rash.  If you have sore throat, we call it pharyngitis, which means inflammation of the back of the throat. The suffix -algia, which which means “painful” is also quite useful.  Headaches can be called cephalgia, joint pain, arthralgia, and proctalgia is a pain...where the sun don’t shine.

In all of these circumstances, of course, the person is quite aware of their cough, rash, sore throat, headache, joint pains, and pain in the butt.  Why call it by it’s fancy name?  Two reasons: 1.  it sounds better when we tell the patient, and 2. we can bill for it.  It does not, however, say anything about prognosis, treatment, or expected course; it simply states what is obvious.

Which brings me back to the Z-Pak.  Zithromax (Azithromycin) is truly a great drug, and the friend of many doctors.  It treats strep throat, skin infections, sexually transmitted disease, whooping cough, and certain kinds of, yes, bronchitis.  It is very easy to take, requiring a total of 5 doses over 5 days, and it comes in a handy-dandy pack with a catchy name.  When a patient tells their friends and family, "I got a Z-Pak," they are much more impressed than if they say, "I got an antibiotic."

The problem with Zithromax, however, is that it spends very little time in the blood stream, going directly inside the cells of the body and spending a very long time there, often away from the infection itself.  This is OK for certain types of infections, but not so good for ones that involve infected extra-cellular fluid, such as infected mucous (AKA sputum, green snappers, loogies, whatever you want to call them).  This means that it’s a fairly weak drug for middle-ear infections or sinusitis, and only marginally good against many forms of bacterial bronchitis.  These, of course, are the main things for which the drug is prescribed.

Why?  Why do people get a medication for conditions that are not well-treated by that medication?  For most of these conditions, bronchitis included, the real cure for them is simple: breathing.  You just have to keep breathing long enough while your body fights off the infection like it was designed to do and the infection will go away.  Skeptics out there who want to try not breathing will soon find out that this approach is not successful.  Trust me.

So what difference does it make to take a Z-Pak while you breathe?  In many, if not most cases, it has no benefit.  It does, however, makes the patient feel like the doctor is doing something for the patient, who paid the co-pay and waited 2 hours in the office.  There are still a good number of people who are dissatisfied when they spend their tie and money only to be told to breathe. Plus, modern medicine has indoctrinated doctors and patients with the belief that doing something is always better than just breathing for a little longer.  This untrue, but highly profitable belief is hard to dispel.  The patient got a Z-Pak and they got better!  Both doctor and patient make this causal connection, and both are happier for it, but breathing gets the shaft because the Z-Pak gets all the credit for what it did.

I once cynically said that Zithromax is the antibiotic you prescribe when you don’t think the person needs an antibiotic.  While that’s not completely true (I think it’s a good choice for strep, and for a chronic cough), I do think it’s the reality seen in primary care offices, urgent cares, and emergency rooms across this great land.  In fact, my PA told me on the week leading up to Christmas that she had joked with a colleague that they call this week “Zithromax Week,” as many prescriptions are written “just in case,” or “to make sure they are healthy for the holiday.”  I’m sometimes guilty for that one.  I do run a business, you know.

Of course, there is definite risk in taking an antibiotic when it’s not needed.  I’ve read (but am to lazy to find the citation) that overuse of macrolide antibiotics (of which Zithromax is the dominant drug) is one of the main sources of antibiotic resistance.  People can have side effects from the medication as well.  But as is the case with donuts, not exercising, spending time reading blogs when you should be otherwise productive, or watching reality TV, the inertia of the bad choice in the moment totally overwhelms any desire to do the right thing.  "Come on," the doctor says to himself, "The world won't fall apart if I give a Z-Pak to this one patient!"  Krispy Kreme donuts is depending on you to make a similar argument.

So, when you have a cough and go to the doctor, get the diagnosis of bronchitis, and get a Z-Pak think of me.  You may want to ask if you really need the antibiotic, or if you can wait to see if it will go away without it.  In many, if not most cases, you might just as well meditate with the word “Zithromax” as your mantra, or burn the pills in a sacrifice to the Greek god Z-pacchus.

God bless America, land of the Z.

*Obligatory disclaimer: This is not meant to convince people to not take prescribed medications.  I don’t know about your own personal medical conditions.  It is just meant to make you appropriately skeptical, and perhaps ask your doctor, “can I wait to take this?” or “do I really need this?”  If they say “yes, you do need it,” take the dang Z-Pak!

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