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Scientists from the UK caused quite a stir this week, when they announced that we don't necessarily need to complete a full course of antibiotics in order to treat infections properly. It's a provocative message, but sceptics say their advice is grossly premature — and even reckless.
Antimicrobial resistance (AMR) is not caused by putting an early stop to a prescribed course of antibiotics, but by antibiotic overuse, argue a team of infectious disease experts in The British Medical Journal. The team, led by Martin Llewelyn of the Brighton and Sussex Medical School, is asking doctors, educators, and policy makers to "stop advocating 'complete the course' when communicating with the public."
Which, wow. This is a complete turn-around from what we've been told for years — that we need to finish our bottles right down to the last pill in order to properly treat our infections and prevent the proliferation of microbial resistant bacteria. According to these experts, we've been wrong about this, and what's more, the "complete the course" culture may be responsible for the rapid decline in antibiotic effectiveness.
But the experts Gizmodo spoke to said the BMJ opinion piece, while important, may be sending the wrong message. They say a lot more research needs to be done before doctors can confidently start telling their patients to ease off their medications, and that the sweeping statement presented by the BMJ researchers fails to take the complex, multi-faceted nature of bacterial infections into account. In a word, they described the opinion piece as "dangerous."
Llewelyn and his colleagues say the convention of prescribing long treatments is based on an outdated notion.
"Traditionally, antibiotics are prescribed for recommended durations or courses," write the BMJ authors. "Fundamental to the concept of an antibiotic course is the notion that shorter treatment will be inferior. There is, however, little evidence that currently recommended durations are minimums, below which patients will be at increased risk of treatment failure." Today's prescription culture, they argue, is "driven by fear of undertreatment, with less concern about overuse."
At the same time, the authors say there's growing evidence that short course antibiotics — treatments lasting just three to five days — work just as effectively in treating an assortment of bacterial infections, and that we should move away from "blanket" prescriptions. But Llewelyn and his colleagues admit there are exceptions, citing the need to prescribe more than one type of antibiotic to TB infections, which are notorious for developing resistance.
The authors also admit it's not going to be easy to change the culture, as the idea of taking a full course of antibiotics is "deeply embedded, and both doctors and patients currently regard failure to complete a course of antibiotics as "irresponsible behaviour." But Llewelyn's team is optimistic that the public will accept short-duration treatments if the medical profession openly acknowledges this shift in opinion, and that the public "be encouraged to recognise that antibiotics are a precious and finite natural resource that should be conserved."
Skin bacteria. (Image: AP)
"I think the article is exciting, for so many practices in medicine it's important to ask the origins and whether they are helping or harming patients," said Harvard Medical School researcher Michael Baym, an expert in antibiotic resistance who wasn't involved with the BMJ opinion piece. "The article establishes very well that the traditional seven-day course of antibiotic is not well founded, and that, consistent with evolutionary theory, a longer course does not lessen the emergence of resistance."
That said, Baym says that replacing the general advice to finish a course with general advice to not finish a course is likewise based on insufficient evidence.
"I think the real conclusion is that we need to get away from the idea that all antibiotics and all infections require uniform thinking, and instead do specific studies to find out ideal treatment regimens for specific infections and specific antibiotics," Baym told Gizmodo.
Maha R. Farhat, Assistant Professor of Biomedical Informatics at Harvard Medical School, agrees with Baym, saying the authors made an ambitious statement that isn't currently founded in sufficient evidence.
"Most infectious disease doctors and antibiotic resistance specialists would like to see less use of antibiotics but the reality is that we we don't yet have enough evidence to throw a blanket statement as the authors did," Farhat told Gizmodo. "It's true that collateral resistance is an issue, but what this should call for is more research and not a premature change in public health recommendations and awareness campaigns as the authors suggest."
Farhat says the authors also failed to discuss evidence showing that antibiotic noncompliance — i.e. not necessarily shorter therapy, but interrupted therapy — is a key driver of resistance in both the patient and the larger population.
"Doctors, including myself, often emphasise the 'take as prescribed' statement because of a larger fear of the former [the patient] — which is more likely — than the latter [the larger population, or collateral resistance]."
Vaughn Cooper, a microbiologist at the University of Pittsburgh School of Medicine, says we most certainly need to reconsider the the "one-size-fits-all" approach to antibiotic prescriptions, but he describes the new editorial as being "clearly dangerous."
"Arguing that antibiotic course duration is not sufficiently evidence-based is worthwhile, but the editorial essentially argues that patients should not finish their course of antibiotics," Cooper told Gizmodo. "This, too, is not evidence-based and increases the likelihood of adverse outcomes for patients disregarding medical advice when a course of antibiotics is clearly warranted."
Some parents, wary of antibiotics, often cut their child's ear infection treatments short. A new study finds that standard-duration treatments, some of which last as long as 10 days, result in better outcomes and — contrary to popular belief — do not increase a child's level of antibiotic resistance.
Cooper says the BMJ authors conveniently ignored what scientists already knew about antibiotics in terms of duration and efficacy, pointing to a New England Journal of Medicine study from last year showing that standard duration treatments — some lasting as long as ten days — do not increase a child's level of antibiotic resistance (at least for kids with ear infections), and that children who are taken off antibiotics early exhibit worse outcomes.
"Suggesting patients not complete the recommended treatment course...is hazardous, for several reasons," said Yonatan H. Grad, Assistant Professor of Immunology and Infectious Diseases at Harvard TH Chan School of Public Health. "Not all infections are the same. For some infections, like TB, it is critically important to complete the treatment course, because, as has been demonstrated all too many times, not doing so promotes antimicrobial resistance in TB and recurrence of infection."
Grad takes issue with the paper's suggestion that patients stop taking antibiotics when they start to "feel better," saying it's too vague and subjective a recommendation. He also worries that a growing batch of unfinished bottles in the medicine cabinet will promote the inappropriate use of antibiotics, and have the exact opposite effect of what was intended.
"The critical problem of antimicrobial resistance should encourage us to revisit how we approach antibiotic use, as there are many opportunities for improvement," Grad told Gizmodo. "As this opinion piece suggests, we need more clinical trials to determine the effectiveness of shorter duration treatments."
Until that happens, you'd best finish your medications "as prescribed."