Your Favorite Pack of Antibiotics Is Essentially Dead
Russell W. Raskin, MD · Board-Certified Emergency Medicine & Internal Medicine · R.W. Raskin Health Protocols, LLC
The five-day azithromycin prescription has been one of the most recognized in American medicine for decades. You or someone you know has received it. The reflex is deeply embedded: get sick, go see a doctor, come home with the pack.
Here is the problem. For the vast majority of conditions that prescription gets written for, no antibiotic is warranted at all. In the unlikely instance one might be appropriate, a different antibiotic is almost always the better choice. This is not a fringe opinion. The evidence settled this years ago.
Why You Think You Need This
You're not wrong for thinking you need this. Decades of prescribing patterns have shaped that belief — one prescription at a time, for generations of patients who got better and concluded the antibiotic was responsible. It is more than likely you walked out of that appointment with a prescription for antibiotics you didn't need — with consequences you may never fully understand. For the full story of how that belief was built, see Look Behind the Curtain. Here's a brief look at some common situations where this prescription still gets written most often.
If your sore throat is bacterial, penicillin and amoxicillin have seventy years of evidence behind them. Azithromycin is a last resort for specific penicillin allergies only — and even then, it's the third or fourth medication that should be chosen. Most sore throats are viral anyway. No antibiotic helps a viral sore throat.
Guidelines changed years ago. Better first-line options exist now. Azithromycin ranks second or third at best, only for specific allergy situations. For most people, watchful waiting is the right call before any antibiotic starts.
Sinus Infection
Bacterial sinusitis is far rarer than it's diagnosed. Even when it genuinely is bacterial, there are a number of treatments that come before any antibiotic — nasal steroid sprays, decongestants, drainage measures. If an antibiotic eventually becomes appropriate, this one ranks last among choices — and lacks an indication for the way it's being prescribed.
Antibiotics don't shorten cough or bronchitis, don't reduce symptoms, don't improve outcomes. Decades of data confirm this. The prescription still exists partly because patients expect it. Patient expectation is not an acceptable reason to prescribe.
If You Have One of the Uncommon Conditions It Actually Treats
Azithromycin has a legitimate role in specific, uncommon lower respiratory tract infections — the kind caused by organisms called atypicals, in confirmed pneumonias. Not colds. Not routine coughs. Not sinus infections. Even then, azithromycin is not the first drug your doctor should be reaching for.
R.W. Raskinism
You don't need an antibiotic for a cold. You need a plan.
An educated patient is the best kind. If you leave an appointment with a five-day azithromycin prescription for a sore throat, a cough, or a sinus infection in 2026, you now have what the system was never designed to give you: the information to ask whether that decision was right.
Raskin Immune Protocol
The Offense
ZnPaC
Acute Protocol
For the one that inevitably gets through — sometimes a good defense isn't enough.
Your doctor should be getting this right. Now you'll know when they may not be.
If your provider continues to reach for this Rx, get a new provider.
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For informational and educational purposes only. Does not constitute medical advice.
Clinical Perspective · Antibiotic Stewardship
Your Favorite Pack of Antibiotics Is Essentially Dead
Stop Writing This. The Evidence Made the Decision Years Ago.
Russell W. Raskin, MD · Board-Certified Emergency Medicine & Internal Medicine · R.W. Raskin Health Protocols, LLC
Let me be precise about what I mean by essentially.
The five-day azithromycin regimen still exists. The molecule still works — in specific, narrow, well-defined situations. But as a general-purpose intervention for the sick adult in the urgent care exam room? That regimen is done. It's been done for years. Many providers haven't noticed. Others know and write it anyway. Most fall somewhere in between — trained on outdated protocols, never revisiting them, unaware that the evidence shifted, or simply unwilling to.
There is the visit to a PCP, urgent care, or emergency room — for reasons far short of a true emergency — by patients who have often already decided what they need before they walk through the door. And there are the providers who oblige them — because the conversation takes time they don't have, because the patient pushes back, because a prescription is easier than an explanation. Then telemedicine arrived and completed the transformation. What was once a clinical encounter became a transaction. A prescription vending machine — available around the clock, no exam required. The patient feels served. The provider clears the queue. The antibiotic was never the point. The throughput was. For a full accounting of how this system was built, see Look Behind the Curtain.
Worse, I have recently noticed certain celebrity physicians hocking “peace of mind in a box” with prescription antibiotics to have at home for use at your own discretion, calling them life-saving prescriptions. The cultural normalization of antibiotic self-prescribing is not a side effect of this system. It is the system working as designed.
It Seemed of Benefit
I was trained to write it. Early in my career it seemed more than reasonable — it seemed of benefit. The coverage was broad, the tolerability was good, the patients left with something. Then the science got clearer. When the evidence changed, I changed.
The Format Was Marketing
There was a time when nothing was easier to write for. The regimen fit the workflow perfectly. It had its own branded identity, its own pre-printed prescription pad, its own patient demand by name. The form factor was marketing. A pill is a pill — but the packaging and the cultural moment made it feel like the modern choice. Then a three-day version arrived, briefly, quietly, and disappeared. Not because the evidence didn't support it. Because the five-day format had already won the culture. That moment has passed. The science moved. The prescribing hasn't. Not yet.
Upper Respiratory Is Not Lower Respiratory
Here is where we need to draw a line precisely. Upper respiratory tract infections — pharyngitis, otitis media, sinusitis, bronchitis — are a different conversation entirely from lower respiratory tract infections, which means pneumonia. The five-day regimen lives culturally in the URI space. That is where the damage is done. That is where this argument belongs. And as we will address shortly, the damage extends beyond URIs — the molecule has lost ground even where it once had firm standing. And that is exactly where this platform has built an alternative. A complete framework for the URI patient that doesn't require a prescription pad at all. Which means the five-day regimen doesn't just become indefensible on the evidence. It becomes unnecessary.
What This Regimen Was Never Supposed to Cover
The cultural identity of this regimen obscures what was always true about it: it was never indicated for the most common presentations that drive its prescription.
Never indicated — never was
Colds
Acute bronchitis
Acute sinusitis — no longer indicated as initial therapy (2025 AAO-HNS)
“Just in case” — this was never an indication
R.W. Raskinism
Just in case what?
What It Is Actually For
There are real indications. Azithromycin retains genuine clinical utility in a specific and narrow list of situations.
Atypical CAP — adjunctive with beta-lactam in hospitalized patients
COPD exacerbation prophylaxis — confirmed by 2026 GOLD guidelines
Non-CF bronchiectasis — frequent exacerbators, after NTM exclusion
Traveler's diarrhea
That is a short and specific list. None of it is the patient sitting across from you with five days of congestion and colored mucus. Yellow, green, or brown — colored mucus is not a bacterial signal. It is an immune system signal. The distinction matters every time your patient correlates color with needing an antibiotic.
URIs: Indication by Indication
Pharyngitis
Azithromycin is not first-line. Penicillin and amoxicillin remain the standard for streptococcal disease. When penicillin allergy is present, cephalosporins and clindamycin are the preferred alternatives — both with superior evidence and better resistance profiles than azithromycin. If azithromycin must be used as a last resort in a penicillin-allergic patient, a three-day course would suffice. The five-day course has no defensible role here.
Otitis Media
The guidelines shifted years ago. Amoxicillin-clavulanate is first-line. Azithromycin is second or third line — and even then, only for specific allergy scenarios. When azithromycin is warranted, a single dose or a three-day course are both supported options. The five-day regimen has no defensible role here.
Sinusitis
Bacterial sinusitis is continuously overdiagnosed. When the evidence overwhelmingly suggests secondary bacterial superinfection — not presumed, but supported by clinical findings — antibiotic therapy becomes reasonable. But even then, the antibiotic is fourth line. Nasal steroid sprays are first. Decongestants are second. Oral steroids are third. Azithromycin ranks even lower among antibiotic choices. Most providers skip straight to the antibiotic alone, bypassing the entire management framework. Overdiagnosis of bacterial sinusitis drives overuse of antibiotics that address neither the inflammation nor the obstruction patients actually need treated.
Bronchitis
Uncomplicated bronchitis — see full article. Antibiotics do not shorten duration, do not reduce symptoms, do not improve outcomes. Decades of data confirm this. In the rare setting of complicated bronchitis — COPD with suggested secondary bacterial infection — doxycycline is the better choice in most scenarios. Most bronchitis is viral and uncomplicated. Most prescriptions for the five-day regimen are unnecessary.
The Doxycycline Displacement
For patients who can swallow pills and have mature dentition — which is most patients over age twelve — doxycycline is the superior alternative across nearly every outpatient indication where azithromycin is being considered. Better tissue penetration, better atypical organism coverage, superior resistance profile. There is no clinical reason to reflexively choose azithromycin when doxycycline is available and tolerated. For hospitalized community-acquired pneumonia, the evidence is less clear — recent data suggest equivalent or possibly superior outcomes with azithromycin alongside beta-lactam therapy. [7]
When doxycycline is truly contraindicated — pregnancy, young children, specific allergies — azithromycin becomes a reasonable choice. But that lane is narrow. If prescribing were aligned with evidence, azithromycin volume would drop by seventy-five to ninety percent, in my estimation. The reflex prescribing does not live in the legitimate indications. It lives everywhere else.
The Resistance Problem — Framed Correctly
I don't lead with resistance messaging when I talk to patients, and I won't lead with it here either. Research by Ritchie and colleagues demonstrated that patient-facing expectation-setting before the clinical encounter reduces the desire to receive antibiotics for a common cold. This platform exists precisely for that moment — an educated patient arrives at the visit already prepared.
But since we are speaking clinically: macrolide resistance has made this regimen unreliable for the organisms it was once trusted to cover. GAS macrolide resistance is rising. Macrolide-resistant Mycoplasma pneumoniae has become highly prevalent in parts of East Asia and the Western Pacific. [8] U.S. pneumococcal macrolide resistance now exceeds thirty percent. [9] The American Thoracic Society and IDSA responded accordingly: azithromycin monotherapy is no longer a first-line option for community-acquired pneumonia in the United States. It was an incredible tool. Haphazard prescribing for upper respiratory infections for decades devastated its utility — but not its use.
R.W. Raskinism
The molecule hasn't changed. What changed is everything we thought it covered.
What's Filling the Void
When this regimen became untenable, a vacuum formed. Some providers filled it with amoxicillin-clavulanate. Some with doxycycline. Some with an early course of prednisone. None of these are indicated for the basic URI either — and the steroid substitution concerns me as much as the antibiotic substitution.
What I think is actually happening: the providers doing this know their patients don't need antibiotics. They are not confused about the diagnosis. They are managing the visit — filling the space where the regimen used to go with something that feels like an intervention. The problem is not clinical reasoning. It is the vacuum.
And there is one more layer worth carrying with you: when that prescription happens to be a five-day azithromycin regimen, it is not just unnecessary. For a viral URI or acute bronchitis, it is the wrong drug for the wrong diagnosis. The “just in case” prescription failed on two levels simultaneously.
The Visit Itself as the Intervention
This is the argument I have been making for nearly fifteen years in urgent care. The consultation is not a delivery mechanism for a prescription. It is the intervention.
Expectation-setting — walking a patient through where they are in the arc of their illness, naming the phase, telling them what comes next — can dramatically reduce antibiotic prescribing without reducing patient satisfaction. In my experience, the reduction can be substantial. Harris et al., Annals of Internal Medicine, 2016 supports the framework.
The plan is the active ingredient. Barrett and colleagues demonstrated this in primary care: patients who left with a clear plan — even without a prescription — reported outcomes equivalent to those who received antibiotics.
R.W. Raskinism
Your words matter more than you think. The plan is the active ingredient.
The Behavior Gap
Knowledge and behavior are not the same thing. The regimen persists because it is embedded in every layer of the system — the template you open, the patient's expectation, the attending's teaching, the path of least resistance in a system that rewards throughput over the practice of good medicine. Asking clinicians to pause, reconsider, and go deep on every prescription decision is a reasonable expectation that an unreasonable system makes seemingly impossible. Changing the evidence wasn't enough. For most, the workflow remained the same.
When a provider reaches for the five-day azithromycin regimen for a patient with an upper respiratory infection today, something remarkable is happening. An antibacterial agent is being prescribed for a condition we once believed warranted it — and have since learned does not. Even if the clinical picture convincingly suggested bacterial involvement, this would not be the correct choice today. The resistance profile alone disqualifies it. A superior alternative exists at every turn. And yet the prescription still gets written.
Most providers know this. They write it anyway. I don't. You shouldn't. And the gap between knowing and doing is exactly what this platform exists to close.
The Scope of the Problem
If azithromycin were used only for its legitimate indications, prescribing volume of this drug would drop by seventy-five to ninety percent, in my estimation. That is not a rounding error. That is the scope of the problem.
The Policy Path Forward
The five-day course still exists because it became woven into the fabric of medical practice — the template, the training, the patient expectation, the path of least resistance. The blister pack, the dosing card, the branded identity — these were marketing decisions, not pharmacologic ones. The fix: retire the five-day format entirely. Manufacture only 500 mg scored tablets. For the narrow indications that warrant azithromycin at all, the three-day course is the evidence-supported option. A three-day course removes the identity. No more pack. No more reflex. The category ceases to exist in the way it currently does.
A Word on ZnPaC
ZnPaC sounds like it. That was intentional. It is designed to be the thing patients reach for when they would otherwise reach for an antibiotic — phonetically, visually, in format. A protocol. Something that feels like an intervention.
ZnPaC does not replace the conversation. It supports it. It gives the patient something to reach for while you do the part only you can do. The regimen is not coming back. But the visit does not have to end in a void.
R.W. Raskinism
You don't need an antibiotic for a cold. You need a plan.
References
Kenealy T, Arroll B. Antibiotics for the common cold and acute purulent rhinitis. Cochrane Database Syst Rev. 2025;11:CD000247.
Harris AM, Hicks LA, Qaseem A. Appropriate Antibiotic Use for Acute Respiratory Tract Infection in Adults. Ann Intern Med. 2016;164(6):425–434.
Barrett B, Brown R, Rakel D, Rabago D, Marchand L, Scheder J, et al. Placebo effects and the common cold: a randomized controlled trial. Ann Fam Med. 2011;9(4):312–322.
Ritchie SR, Rakhmanova L, Out-O'Reilly E, Reay S, Thomas MG, Sajtos L. The use of a poster to reduce expectations to receive antibiotics for a common cold. Eur J Clin Microbiol Infect Dis. 2019;38(8):1463–1469.
Payne SC, McKenna M, Buckley J, et al. Clinical Practice Guideline: Adult Sinusitis Update. Otolaryngol Head Neck Surg. 2025;173 Suppl 1:S1–S56.
Global Initiative for Chronic Obstructive Lung Disease. 2026 GOLD Report.
Odeyemi YE, Tekin A, Schanz CC, et al. Comparative Effectiveness of Azithromycin Versus Doxycycline in Hospitalized Patients With Community-Acquired Pneumonia Treated With Beta-Lactams. Clin Infect Dis. 2026;82(4):639–647.
Kim K, Jung S, Kim M, Park S, Yang HJ, Lee E. Global Trends in the Proportion of Macrolide-Resistant Mycoplasma pneumoniae Infections: A Systematic Review and Meta-analysis. JAMA Netw Open. 2022;5(7):e2220949.
Munson E, Lavey SC, Lasure MR, Fox BC. Changes in Streptococcus pneumoniae Susceptibility in Wisconsin: Implications for Clinical Treatment Decisions for Respiratory Infections. Clin Med Res. 2022;20(4):185–194.
Raskin Immune Protocol
The Offense
ZnPaC
Acute Protocol
For the one that inevitably gets through — sometimes a good defense isn't enough.
The patient version is the plain-language take on the same topic — no jargon, no prescription pad. Built to hand a patient after the visit, so the conversation keeps going after they leave.