Why finishing your Antibiotics is still important

Please dont stop using Antibiotics because of todays news

 

Today the Telegraph and many other newspapers published a top of the frontpage article in which the headline suggested patients shouldn’t complete their courses of Antibiotics, but stop Antibiotics when they feel better. I believe this is irresponsible journalism considered the public health implications such a message carries.

The initial statement was based on a professional publication in the BMJ. This publication was intended to inform a debate between professionals, not intended for public education. I also believe 2 of the 4 key messages in the BMJ are not evidence supported and will write to the BMJ about this.

The BMJ argues the basic argument why we complete our Antibiotics is, apparently, not based on sound research, but on a statement of Sir Alexander Fleming, the inventor of Penicillin, at his Nobel Price speach in 1945 (he recommended to finish courses of Antibiotics to reduce resistance). The Telegraph unfortunately created a rather dramatic headline, taking the message out of context.

And of course Fleming had a strong argument. He had seen what had happened to one of his colleagues that had not enough Penicillin available and died. The BMJ writes: “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”. Only as recently as 2014 the prescribing guidelines for children for Penicillin and Amoxicillin, 2 of the most commonly prescribed Antibiotics, were doubled in all doses.

In fact, some of the BMJ article contains indeed very good and important information. It may be that the argument to stop Antibiotics earlier proves correct in time to come and after (a lot) more research. However, I dont think this can be generalised, I just believe that we need to get more specific advice for different conditions and patient groups.

And it may actually be correct that in some illnesses we could recommend to treat only until patients feel well. This may be the case for example in simple urine infections. It is also true in a lot of the viral illnesses that we take Antibiotics for without any good reason (in fact we should not have them in the first place).

Another argument sometimes quoted for stopping antibiotics early is that Antibiotics do not have to kill every last pathogen (=bacteria, bugs), but only enough for the immune system to get rid of it and therefore they do not need to be finished. This may be true in some infections in healthy individuals, but not in patients with co-morbidities (different chronic diseases) and reduced function of the immune system i.e. patients with diabetes, Rheumatoid Arthritis or older patients.

However, a good example where Antibiotics should not be stopped is an abscess. Particularly in dental abscesses the only thing that usually cures the abscess is removing the pus by removing the tooth or draining it through a root canal treatment. All antibiotics usually do is stop the spreading of the pus into the blood stream and therefore stopping blood poisoning. If you stopped the Antibiotics after you feel better you would usually soon feel worse again, the fevers and shivers and the pain would start again.

Another example may be tonsillitis. Pus can get stuck in crypts (little holes) in the tonsils and it is actually still recommended to take a 10 day rather than a 7 day course. Many patients that finish a course early or have been given too short a course are coming back with a recurrence of symptoms.

A lot of patients have to have very long courses of Antibiotics. Conditions that spring to mind are TB, HIV and even a condition as simple as acne. Also, other patients are on Antibiotics preventatively i.e. for the prevention of urine infection or after a splenectomy (removal of their spleen).

My plea is therefore to wait until new research and guidelines are released that support some of the scientifically scantily supported assumptions made in the press today and still to continue Antibiotics as prescribed by health professionals. For the moment the simple message ingrained into the mind of the public and health professionals remains: Do finish your course of Antibiotics unless advised to the contrary.

Please share or re-publish this article at liberty.

Dr M Kittel, 27/7/2017

PS: For the people interested in the academic part of the BMJ article: The 4 key messages of the BMJ and my first thoughts.

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
    My response: The first part of the sentence is likely to be correct although the evidence is based on relatively small trials and lots of assumptions. But the second part of the sentence “not when stopped early” only considers risk from Antibiotic resistance to patients. It doesn’t consider the benefits antibiotic treatment gives patients when taken correctly and for right amount of time not the risk of re-infection and an even bigger course of Antibiotics if they have to be restarted. It also puts generally healthy individuals into the same category as sick and immunosuppressed patients.

  • For common bacterial infections no evidence exists that stopping antibiotic treatment early increases a patient’s risk of resistant infection.
    My response: No evidence exists to the contrary neither. The absence of evidence is not evidence of absence. Simply identifying a lack of direct evidence, or randomized controlled trials, is not sufficient to overturn decades of clinical practice. And why change the guidelines and put vulnerable individuals at risk before we don’t have such evidence? Finally, potential antibiotic resistance in the future may be less of concern in an individual that is very sick at present?

  • Antibiotics are a precious and finite natural resource which should be conserved by tailoring treatment duration for individual patients. My response: This is 100% correct.

  • Clinical trials are required to determine the most effective strategies for optimising duration of antibiotic treatment. My response: I believe this is correct, therefore the strong recommendations within the BMJ article should be withdrawn and science should be supported to do the research needed to get us the answers to the questions that have been raised.