Antibiotics Why your doctor’s advice to take all your antibiotics may be wrong. Completing antibiotic courses is a medical advice myth that may make bacterial resistance worse (2017) The antibiotic course has had its day

Michael Harrop

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Article: http://www.independent.co.uk/news/health/antibiotic-courses-complete-bacterial-resistance-worse-medical-myth-scientists-doctors-pills-a7861351.html - "Researchers say it may be best for patients to stop taking their medicine when they feel better."
Paper: https://doi.org/10.1136/bmj.j3418 - full version via sci-hub: https://sci-hub.tw/https://www.bmj.com/content/358/bmj.j3418

Other articles on this story:
One from earlier in the year:
Why your doctor’s advice to take all your antibiotics may be wrong https://www.statnews.com/2017/02/09/antibiotics-resistance-superbugs/

It cites this WHO report: http://www.who.int/selection_medicines/committees/expert/21/applications/s6_antibiotic_awareness_campaigns.pdf?ua=1 which says:
Awareness campaigns often include the message that it is important to finish the prescribed course of treatment to prevent the development of antibiotic resistance. However, this advice is not directly connected to the fight against antibiotic resistance. The objective of continuing the treatment beyond the resolution of symptoms is to prevent relapses rather than to prevent resistance. Because the rate of antibiotic resistance tends to increase with the total amount of antibiotics used,16 the general rule might be: the shorter the course, the lower the risk of resistance.

Clinical studies have indeed shown that longer courses of therapy can result in a more likely emergence of antibiotic resistance.17 18 19 Shorter antibiotic treatment lower the opportunity for bacteria to become resistant, as well as reducing adverse side-effects. In otherwise healthy people, significantly reducing but not totally eliminating the bacteria causing the infection can allow the body’s natural defences to take over and destroy the remaining few.20 There are some circumstances when it is necessary to eliminate all the bacteria – when the patient’s natural defences are damaged for any reason, or when the infection is in an area less inaccessible to antibiotics and to white blood cells and when bacteria are slow-growing (such as tuberculosis).

But in many cases an argument can be made for stopping a course of antibiotics immediately after a bacterial infection has been ruled out or is unlikely (for instance in case of viral respiratory tract infections); or when the signs and symptoms of a mild infection have disappeared.21 Hence, in communication campaigns against antibiotic resistance, the “complete the course” message might be confusing, in comparison with other messages that are more directly connected to the objective of decreasing antibiotic resistance. No to skip antibiotic doses, might be a message that has a more direct link with antimicrobial resistance, although it is probably challenging to convey these subtle differences effectively to the greater public.

A few quotes from the BMJ article:
“Complete the course”: a barrier to antibiotic conservation

The fallacious belief that antibiotic courses should always be completed to minimise resistance is likely to be an important barrier to reducing unnecessary antibiotic use in clinical practice and to developing evidence to guide optimal antibiotic use. The idea is deeply embedded, and both doctors and patients currently regard failure to complete a course of antibiotics as irresponsible behaviour.31 32

What should we advise patients?

The “complete the course” message has persisted despite not being supported by evidence and previous arguments that it should be replaced.18 38

There are reasons to be optimistic that the public will accept that completing the course to prevent resistance is wrong if the medical profession openly acknowledges that this is so, rather than simply substituting subtle alternatives such as “exactly as prescribed.”

Research is needed to determine the most appropriate simple alternative messages, such as stop when you feel better. Until then, public education about antibiotics should highlight the fact that antibiotic resistance is primarily the result of antibiotic overuse and is not prevented by completing a course.

Key messages

Patients are put at unnecessary risk from antibiotic resistance when treatment is given for longer than necessary, not when it is stopped early

For common bacterial infections no evidence exists that stopping antibiotic treatment early increases a patient’s risk of resistant infection

Antibiotics are a precious and finite natural resource which should be conserved by tailoring treatment duration for individual patients

Clinical trials are required to determine the most effective strategies for optimising duration of antibiotic treatment
 
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