Finishing a Full Course of Antibiotics: New Medical Myth Exposed?

pillsAntibiotics are currently used by millions of people all over the world to treat numerous amounts of infections. However, many bacteria are evolving to become resistant to antibiotics. As a result, many common, easily-treatable infections have now become difficult to treat. There is no doubt that the misuse and overuse of antibiotics have given rise to antibiotic-resistant bacteria, but how can we combat this when we need these medications?

On July 26th, a group of researchers in England published an article on the advice we often get from doctors about “finishing a full course” of our medication. They argued that there is no evidence that supports that finishing a “full course” of antibiotics helps fight antibiotic resistance, and doctors should stop advising people to do so. However, Martin Llewelyn and his colleagues fail to provide examples of extensive research supporting this fact. While antibiotic-resistance is becoming a larger problem for public health, I think this claim that doctors should stop telling their patients to “finish a full course” was made prematurely due to the lack of research, and patients should still finish their medication regardless of how serious their illness is just to err on the side of caution.

After this article was published, the web was bombarded by many high-profile news sites reporting on this with headlines like “Rule that patients must finish antibiotics course is wrong, study says” or “’Don’t finish the course of antibiotics’ – experts turn medical advice on its head”. While the original article goes into detail about the research on this topic and acknowledges that more research must be done, these news sites simply summarize the issue. There is no doubt that these headlines have already misled people into thinking that they no longer need to follow their doctor’s advice.

Lance Prince, a microbiologist and the director of the Antibiotic Resistance Action Center at The George Washington University has said, “I think they go too far in saying we need to stop this messaging…to say, ‘Let’s pull the plug on this messaging without providing a reasonable, actionable counter message’ is totally irresponsible.” In the article, some phrases are given as examples for substitutes for the current “full course” message, but Llewelyn and his colleagues only provide small amounts of research to back this “shorter course” theory. Lauri Hicks, director of the Office of Antibiotic Stewardship at the CDC, has said that stopping antibiotics, “needs to be a decision made with input from the provider” and cautions that patients should not stop taking their medications without approval. Like Prince said, it’s irresponsible to advise that shorter courses of medications can be more effective without adequate evidence blanketing a wide variety of infections and their respective medications.

Llewelyn and his colleagues are not completely wrong, in fact, they make many valid points in their article. They are right that the “full course” advice is not supported by research and instead was most likely, “driven by fear of under treatment, with less concern about overuse.” They explain how this idea originated:

When Howard Florey’s team treated Albert Alexander’s staphylococcal sepsis with penicillin in 1941 they eked out all the penicillin they had (around 4 g, less than one day’s worth with modern dosing) over four days by repeatedly recovering the drug from his urine. When the drug ran out, the clinical improvement they had noted reversed and he subsequently succumbed to his infection.12 There was no evidence that this was because of resistance, but the experience may have planted the idea that prolonged therapy was needed to avoid treatment failure.

The article also uses the example of pyelonephritis. Usually it is treated for two weeks, but shorter courses of certain medications have shown to be effective in trials. However, there is no data for β-lactams, the main antibiotic used to treat this infection. The only reason 10-14 days of treatment is recommended with this antibiotic is, “based purely on absence of data for shorter courses.” Llewelyn and colleagues also use trial data in cases of pneumonia that have shown that shorter treatments have the same outcome as longer treatments and are associated with lower infection recurrence rates as well as antibiotic resistance. They argue that,

“The concept of an antibiotic course ignores the fact that patients may respond differently to the same antibiotic, depending on diverse patient and disease factors. Currently, we largely ignore this fact and instead make indication specific recommendations for antibiotic duration that are based on poor evidence.”

This is proven to be true in the article which has links to all the trial data. However, I could also argue the same for the opposite argument.

Because every patient is different and because of the diverse disease factors, it’s irresponsible to say that shorter courses will work for everyone. Hicks says how it’s okay to only take antibiotics until you feel better for some infections, but some infections like staph can be life-threatening if it’s not treated properly. Depending on the patient and what he/she has, stopping treatment early can be counter-productive and end up killing them. While some infections may not need to be treated by finishing the full course of medication, all infections are not made equal. Therefore, doctors should stick with their current medical advice “finishing a full course” as opposed to saying “stop when you feel better” because that advice can’t blanket a wide variety of situations.

Dearbhla Lenehan, an Infection Biology PhD student, states in her article that “Antibiotic resistance is recognized as one of the greatest potential threats to both human and animal health worldwide.” She uses the example of how Gonorrhea is becoming harder to treat because how it has evolved to be resistant to antibiotics leaving many with an incurable strain of the STD, the symptoms of which van be very painful. She also points out that for a long time antibiotic resistant bacteria didn’t seem like a big enough threat because there was this assumption that there are other medications that would work or new treatments would be found. However, this isn’t the case now.

The rise of antibiotic resistance in bacteria is no doubt a huge threat to public health. However, should doctors be prescribing shorter courses of antibiotics instead of defaulting to longer treatments? Without more research on shorter courses of antibiotics, switching over could also be termed a “default”. Also, I think switching the messaging from “complete course” to an alternative like “stop when you feel better” will do more harm than good. Doctor’s will read this article and see it as a controversial proposal. However, the public may read this and take it as fact, applying it to their own situations and medications when they shouldn’t. Telling all patients to finish a full course of medicine is safer and ensures that no one gets mixed messages. I completely support more research being conducted, but until then please take your medicine properly!

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