So wrong, for so long: No, you don’t have to finish that long course of antibiotics. Stop when you feel better and do so in consultation with your physician. Better yet, get yourself a short course of antibiotics instead.

Prescription

 

To borrow from the great Patsy Cline: “I’ve been so wrong, for so long … I was wrong, oh, so wrong,” could well be a new meme for docs across the country when it comes to their advice about taking antibiotics. We all know the rule: Always finish your course of antibiotics even if you’re feeling better because it’ll ensure that you kill all those bad bugs and, (not that you care) it helps prevent antibiotic resistance.

And that’s flat wrong. Compelling evidence from a group of scientists published July 26 in the prestigious BMJ says it’s not only wrong – the exact opposite is correct:

We … encourage policy makers, educators, and doctors to stop advocating ‘complete the course’ when communicating with the public. Further, they should publicly and actively state that this was not evidence-based and is incorrect …

The key argument for changing how we discuss antibiotic courses with patients is that shorter treatment is clearly better for individual patients. … In hospital acquired pneumonia, for example … data indicate that short treatment strategies have equivalent clinical outcomes to longer courses and are associated with lower rates of infection recurrence and antibiotic resistance. (My emphasis)

 

Good grief – so how did we get it so wrong for so long?

Enter Brad Spellberg, MD, an infectious disease specialist and chief medical officer of the mighty Los Angeles County + USC Medical Center, and who, as you might expect, comes with a sterling resume. But here’s the thing: When deciding how much weight to attach to the words of guys like Spellberg (this is, after all, a paradigm shifting issue) understand that his views are really the synthesis of the best and brightest, not just in his hospital or even across the country but across the world. If somebody’s doing interesting ID work in, say, Boston, New York, London, Paris, or Tokyo, he can call them and inquire – and they’ll take his call asap. And I suspect this has been the case much of his storied professional life – RHIP.

So, what does he say?

That we’ve made two mistakes. The first was to misinterpret a foundational study on the subject, which he said almost a year ago in this paper.:

The modern concept that we should continue treating bacterial infections past the time when signs and symptoms have resolved can be traced to 1945. Meads et al wrote that they administered penicillin to patients with pneumonia, ‘until there was definite clinical improvement and the temperature had remained below 100°F for 12 hours…then given for another two to three days.’ The perceived need to treat beyond resolution of symptoms was driven by a desire to prevent relapses. However, the recurrent infections seen in the case series were caused by isolates with distinct bacterial serotypes, indicative of reinfection rather than relapse. It is unclear how this confused desire to prevent reinfections subsequently transformed into the illogical dogma that antibiotic resistance could be prevented by continuing therapy beyond resolution of symptoms.

 

So how does this big misread turn into a come hell or high water ritualistic 7 or 14-day course of antibiotics? This second mistake turns on how our species tracks time. It’s both funny and sad and deserving of Spellberg’s mockery:

The truth is, we do not know how long a course of antibiotics is necessary to treat most types of infections. Even in the modern scientific era, the primary basis for the duration of most courses of antibiotics is a decree Constantine the Great issued in A.D. 321 that the week would consist of seven days. That’s why your doctor gives you seven or 14 days’ worth of antibiotics!

If good old Constantine had decreed four days in a week, doctors would be prescribing antibiotics in four- or eight-day courses, rather than seven- or 14-day courses. I refer to seven- or 14-day antibiotic courses as “1 or 2 Constantine units” to underscore the absurdity of the basis for these durations.

 

That’s from his piece this week in the online journal The Conversation. And of the 3 articles mentioned above, this one is easily the most readable. The best part is that he concludes with spot-on practical advice on how we should handle this “to stay the course or not” issue, reprinted below. But before we get there we need to consider this looming storm cloud called antibiotic resistance, which the BMJ paper spent most of its time on. Yes, we’d all rather go clean our oven than get into this, but it’s a Huge Deal, so we’ll try an analogy (and no fancy words).

Imagine – for everyone who lives on your block there’s just one car that has to last for the foreseeable future. It’s a community car so its use is based on need – emergencies first, work or university second, food shopping third and so on. It’s a precious resource because we know that one day it will run down and no longer work. So we have to take good care of it: use only when necessary, keep a record of its use, keep it fueled & maintained, and don’t abuse it – no drag racing. Because one day you might to need to rush your bleeding child to the local hospital a mile away. Should that day ever come you don’t want to jump in turn the key and … uh-oh … it won’t start. It’s out of gas. Now what?

Antibiotics are the only kind of drug on the planet that are a community drug, just like that car is a community car: The more we use them the less effective they become. And that’s because with bugs, the more they’re exposed to the drugs, the more they develop tricks, or “body armor,” to defeat them. Bugs are funny that way, like us they too resist efforts to be killed – except they’re better at it. For example, a blueprint for a new anti-antibiotic weapon that one bug develops can be shared with his buddies and suddenly they’re all invincible. A cartoon nicely captures this unique biological ability (if you’re curious, see here).

Horiz transfer 3

 

But this really isn’t funny. Antibiotics are woven into the fabric of the everyday practice of medicine, here and across the world. Just a glimpse: Cancer patients live on antibiotics because radiation and chemo destroys their immune cells along with their cancer cells. For every serious surgery, say an organ transplant or a hip replacement, antibiotics are used to prevent or treat an infection. Neonates & children, and the elderly, are especially at risk for infection because the immune system isn’t fully formed in the young and isn’t as strong as we want it to be in the old.

But a numbers analysis doesn’t capture the heartbeat of the issue. Ultimately it’s a personal, intense reckoning. You’ll notice the shadow over your doctor’s face as he walks to your hospital bed. You tense up. I’m sorry, he says … the antibiotics aren’t working. You put on a brave face: We out of gas, doc?

Spellberg and company are doing their best to avoid that reckoning. But they need help. We the People, have to be antibiotic-smart: Use them only when necessary and even then, a shorter course is better. Here’s his game plan, titled: “So, what should we do about antibiotic courses”?

Medicine in the 21st century is a team sport. You and your physician need to be partners in decision-making. If you are sick and your doctor mentions antibiotics to you, the first thing you should say is, “Hey, doc, do I really need the antibiotic?”

Doctors may otherwise prescribe an antibiotic even when you don’t need one, out of fear that you will be unhappy without the prescription. Flip the script on them. Help them to know that you’d prefer not to take the antibiotic unless it is really necessary.

If your doctor says, “Yes, I believe you have a bacterial infection and you need the antibiotic,” the next question is, “Okay, can we treat for a short course?”

Third, after you begin taking the antibiotics, if you feel much better before you complete the course, give your doctor a call and ask if you can safely stop therapy.

So, the bottom line is, doctors should prescribe as short a course of antibiotics as possible to treat your bacterial infection. If you feel completely well before you finish that course, you should be encouraged to call your physician to discuss if it is safe to stop early.

 

Which means doctors have to be willing to have that conversation. And as Spellberg said to the journal STAT: “You should call your doc and say ‘Hey, can I stop?’ … If your doctor won’t get on the phone with you for 20 seconds, you need to find another doctor.”

Because that, too, would be wrong – oh, so wrong.

 

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