The antibiotic course has had its day?

Schermafbeelding 2017-07-27 om 10.19.00

In a recent BMJ article, Llewelyn et al. argue that the old dogma of completing a prescribed course of antibiotics to prevent antibiotic-resistance is a myth, not based on evidence.  Actually the opposite, namely taking antibiotics for longer than necessary, increases the risk of resistance.

While I love breaking down old dogmas  (we actually had a poll on this topic some time back), many of today’s papers in the Netherlands (and I am pretty sure elsewhere, too) misinterpret the study, by slaughtering the message to patients to “always complete the full prescription”.  One of the Netherlands most influential newspapers the Volkskrant, already wrote: “Finishing antibiotic course? Nonsense.”

What people seem to overlook is the fact that not the message to complete the full prescription is wrong, but the reasoning that was given (development of antibiotic resistance). Clearly, policy makers and doctors, need to keep in mind that a shorter course of antibiotics can be as effective as the long course from the past, but the main reason to give antibiotics is not to prevent development of resistance but to offer our patients the most effective treatment and for many of those treatments patients need to finish the full course of antibiotics to avoid relapse or other complications.

The message of “antibiotic resistance” seems to overwrite all the good reasons while we started antibiotic stewardship, namely to offer patients the most effective antibiotic, in the correct dosage, the needed application form, for a proven length of course, with as little side-effects and interaction with other medications as possible. In doing we may prevent resistance development, but our primary goal was and should stay to offer the best treatment to our patients.

The message “Finishing antibiotic course? Nonsense” is cutting a lot of curves and unfortunately will lead to “throwing out the baby with the bathwater”.

References

Llewelyn et al. The antibiotic course has had its day. BMJ 2017;358:j3418 doi: 10.1136/bmj.j3418 (Published 2017 July 26) ,

Ellen de Visser, De Vokskrant, Thursday 27 July 2017

Picture source: http://www.chicagonow.com/urban-landlady/files/2017/07/Baby-with-Bathwater-pic.jpg
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6 thoughts on “The antibiotic course has had its day?

  1. There was a good piece on BBC Breakfast today. Prof Peto presented the research and put forward the argument that taking antibiotics after you are well can only add to the risk of developing resistance. However, he was talked by a very competent argument from the Chair of the Royal College of GPs who pointed out that this is just another piece of research that will eventually be evaluated properly before being incorporated into guidance, if it is good enough. She gave good argument about the courses are as short as they can be in the current guidance (e.g. UTI in females treated for only 3 days; I can other shorter examples). Her authoritative advice to clinicians and patients was to follow current guidance which is based on the best fully-evaluated evidence and not change practice based on this paper until it is evaluated by experts and incorporated into guidance (if needed) in the correct way.

    I think that was a positive and timely response to this paper.

    With kindest regards.

    Mustafa

    Dr F M Awad-el-kariem MBBS, MSc, PhD, FRCPath Consultant Microbiologist Department of Microbiology, Basildon and Thurrock University Hospitals NHS Foundation Trust Nethermayne Basildon Essex SS16 5NL

    Tel: 01268 524900 ext: 1136 Mobile: 07785-342571

    E-Mail: elfatih.awad-el-kariem@btuh.nhs.uk

    Formerly: Welcome Research Career Development Fellow, Imperial College, London.

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  2. The challenge is encapsulated by the phrase “for a proven length of course” – for many (most?) antibiotics, in many (most?) indications, we don’t have evidence what the *optimal* duration is. What we have is course durations that have been used historically when resistance was less of a concern than failure. And where we do have randomised evidence, shorter courses are almost always equally effective (eg Spellberg JAMA Int Med “The new antibiotic mantra – shorter is better” http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2536180).

    At least in the UK, the myth that stopping antibiotics before the end of a course inevitably drives resistance is so pervasive – it comes up frequently as a major concern when discussing research to investigate shorter antibiotic courses or tailored antibiotic treatment with patients and doctors. True for TB of course, but not for other serious infections – anything that anyone can do to debunk this myth very welcome!

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  3. Excellent comment Andreas Voss. The new mad fashion is cutting use and dosing of medicines, especially antibiotics and opiates, ignoring patient’s individual parameters; e.g. immune deficiency.

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  4. Discussing antibiotic resistance as though details of dosing humans were the sine qua non is absurd. Vast abuse by profit-maximizing corporatist agriculture, especially in USA, is scariest threat. FDA has declined to go beyond nibbling around the edges of the problem; it is hard to imagine this changing given power of farm lobby in US politics.

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