Arnold Solof, MD
The other night I heard a report on the evening news on what listeners were led to believe were the results of a study in the British Medical Journal, concluding that antibiotic courses should be stopped early in order to decrease the emergence of drug resistant pathogens. This sounded “off” to me because it was to much of a generalization. There are so many different pathogens and so many different antibiotics and so many different scenarios I didn’t see how they could make such a generalized conclusion. So I looked into it.
The news article was about an article in the British Medical Journal entitled “The antibiotic course has had its day”. I read through the article carefully and would like to comment on it because the impression one gets listening to the media relate/distill it for its viewers is very misleading.
The first issue I want to point out is that this was not a study. It was an opinion statement/editorial. There is no new information in the article. The article is well written and makes many important valid points, though you don’t get that from the evening news. Most of the authors are experts in their field (Infectious Diseases, Microbiology, etc.). However, I am puzzled why they included “Cliff Gorton, retired building surveyor” as one of the authors.
They rightly point out that there is a dogma in medicine stating that “you must complete the full course of antibiotics, even if you are feeling better”. One thing I find interesting is they don’t point out the origin of the dogma. Medical students are taught that by THEM, the infectious disease specialists; either directly in medical school lectures, or in the textbooks and articles they write.
I also want to make another point here which is that over the past several years there has been a trend in medicine to prescribe/recommend much shorter courses of antibiotics for many infections (or no antibiotics at all), compared to the past. Or, at least to state that doing so is/may be an acceptable option.
They state that there is a major deficit in controlled studies documenting evidence based facts for the recommended duration of treatment for many infections. That is true. I find it ironic, however, that there is the same deficit of information backing their unqualified recommendation that treatment courses be shorter.
The main focus of their argument is in preventing the emergence of drug resistant pathogens by using the shortest course of antibiotics necessary. In the past, it was argued that even if the patient were better from the infection, you would increase the emergence of the resistant bacteria if you shortened the recommended course. They do play the “Devil’s Advocate” and point out that there is evidence for increasing antibiotic resistance if you shorten the antibiotic course for what they refer to as “professional pathogens” eg. mycobaterium tuberculosis, HIV, malaria, gonorrhoea, and Salmonella typhi; but not other pathogens. (I believe the term “professional pathogens” is their term and not generally accepted). They point out other problems that occur the more you prolong the antibiotic course (alteration of gut flora, opportunistic infections, etc.).
From the primary care physician’s point of view, emerging drug resistance, although a factor, is not the primary factor in the decision for how long to treat a patient for an infection. The primary factors are at what dose and for how long you need to treat the infection so that the patient recovers. The primary care doctors did not make the treatment guidelines. The infectious disease specialists, including the authors of the British Medical Journal Article, are the ones who make the guidelines the rest of us follow. If they wanted to change the guidelines for the treatment of, say, pyelonephritis (kidney infection) to 3 days after the fever goes away, instead of 14 days (or whatever), that’s what we would do.
I’ve spent my career following these guidelines, modifying them at times when necessary or appropriate.
Another factor to consider is this article is part of the trend of shorter treatment courses I referred to above. Not all specialist will agree with this recommendation day one. Also, as more studies are done and the effectiveness (or lack thereof) of shorter treatment courses are documented, these recommendations will be again modified.
Then there is the malpractice consideration. I’ll illustrate by example. When the first guidelines for treatment of uncomplicated Lyme disease came out, 7 days of treatment were considered adequate. Then it went to 10 days. Then it went to 14 days. Then it went to 21 days. Then it went to 1 month. As a primary physician, I had seen multiple patients easily cured with 7 days treatment. If I treated someone today for 7 days and the person later complained of headaches, it wouldn’t be hard to find a lawyer and an infectious disease specialist to crucify me in court, independent of the medical facts. So, do you think I’m going to use the short course?
So, to conclude, I’d like to reword the author’s recommendation to say that “it may be acceptable and advantageous to shorten a traditional course of antibiotic treatment for several reasons, including lessening the emergence of drug resistant organisms, but each case should be individualized”.
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