Often, the most difficult part of my job is deciding whether my patient has a viral or a bacterial infection. The second most difficult job is explaining to a patient who has a viral infection why an antibiotic will not work. Patients suffering from respiratory tract infections (URI) want me to cure them. They want antibiotics, the supposed cure-all! In my early years in practice, it was impossible to differentiate between a virus and bacteria. Antibiotics were considered relatively harmless and everyone who suffered from a URI received one. Since my patients got well (because of or despite taking an antibiotic), they grew to believe that, without an antibiotic, they would not get well. Over the last decade, antibiotic-resistant bacterial infections have dramatically increased due to the overuse of antibiotics. In the decades to come, appropriate use of antibiotics will be imperative.

In the real estate business, it’s “location, location, location.” I often hear, “Doc, I’ve got a sinus infection and need an antibiotic.” “Doc, I’m coughing up green sputum and need an antibiotic.” Sinusitis, bronchitis, tonsillitis, pharyngitis, gastritis and cystitis are all infections in certain locations within your body. The easy step in diagnosing an illness is determining where the infection is. The hard step is determining what “bug” (virus vs. bacteria) is causing the infection at the given location.

“Bugs” can all cause the same symptoms. A sinus infection, complete with facial pressure, green discharge, fever and chills, can be viral or bacterial. A viral sinus infection is treated with symptomatic measures and eventually goes away by itself. Once your body recognizes the virus, specialized killer cells (lymphocytes) are produced and then hunt and kill the virus. Antibiotics assist your body in getting rid of bacterial infections. Once your body identifies an invading bacterium, it makes specialized killer cells (neutrophils) that eradicate bacteria.

In the early stages of any URI, mucoid secretions are clear. As the infection worsens, they often turn yellow, grey then green. Green is actually good. Green is the color of white cells (lymphocytes or neutrophils) engaging the enemy. Green means your body has found the invader and is attempting to heal you. Mucous, in itself, is a problem. It nurtures and shelters the invading “bug.” Symptomatic treatment is aimed at helping you clear mucous. Mucinex is my favorite agent. My instructions also call for saline nasal sprays and the ingestion of copious amounts of fluids. Please avoid orange juice. While it contains vitamin C, it also contains citric acid. The acid content further irritates the throat and increases mucous production.

So, how do I determine if you have a bacterial or viral? As stated above, it’s not easy. Bacterial infections tend to cause higher fevers and tend to be associated with more severe physical findings. Viral infections tend to cause severe symptoms with milder physical findings. In the early stages of a communal illness, diagnosis tends to rely on highly educated guess work. That may sound shocking, but it’s true. Once I have seen 10 or more cases, it becomes easier. The disease takes on its own personality and becomes predictable. 

I used to rely heavily on the ability to do blood counts in the office as an aid in diagnosing viral vs. bacterial infections. Low white counts are usual for viruses and high white counts are seen in bacterial infections. Normal white counts may indicate an infection with a mycoplasm infection (modified bacterium/bug).

In person, it is difficult to accurately diagnose a URI or any other medical problem. Diagnosing over the phone is often impossible. Sometimes, it takes several visits to solve the mystery of what is infecting you. One reason I keep an open, extended-hour schedule is so that you can easily be seen. Please come in when you are sick. The life you save may be your own!

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