14 ms·

Taking a full course of antibiotics doesn’t help prevent spread of resistance

141 points by raldi 9y ago

TorKlingberg 9y ago
The author here clearly has an axe to grind. Is this an established fact now, or an exaggeration of one study?
- jameskilton 9y ago
  Pretty sure the point of the article is that the idea that we need to take the full round of antibiotics is itself an exaggeration of one study that's now known to be wrong, and dangerously so. If we've been creating resistant bacteria because we've been following this "take it all" mentality, then I don't really blame the author for getting a little worked up over this.
- zellyn 9y ago
  If by "grinding an axe" you mean "trying to ensure that humanity preserves some of its best weapons against disease instead of squandering them". Seems fine to be emphatic about that.
- DennisP 9y ago
  From the article: "in the last two decades, we actually have had dozens of clinical trials published demonstrating that shorter courses of antibiotics are just as effective as longer courses." And from the linked WHO page: "There has been a lot of research into how long antibiotic courses should be, to determine the shortest possible length of course needed to completely kill all bacteria....Evidence is emerging that shorter courses of antibiotics may be just as effective as longer courses for some infections....They also reduce the exposure of bacteria to antibiotics, thereby reducing the speed by which the pathogen develops resistance." http://www.who.int/features/qa/stopping-antibiotic-treatment/en/ http://www.who.int/features/qa/stopping-antibiotic-treatment...
  - Retric 9y ago
    'Reducing the speed' Is this being measured or just an assumption? Because resistance shows up extremely quickly with short dosage. But, it seems like a dangerous experiment.
deskamess 9y ago
Meta comment: The HN headline is difficult to parse. The original headline is a lot better.
- raldi 9y ago
  The first half of the original headline is clickbait; the second is too long for an HN title. What text would you suggest?
dhimes 9y ago
This is a shit article that provides no insight into what we learned that changed our mind about how antibiotic resistance arises. He simple derides as silly and stupid the idea that we ever thought that resistance could possibly arise if we quit taking antibiotics before the bacteria were all dead, leaving a population with better survival characteristics to rebuild the population. Interesting finding if true, but don't waste your time with this article.
- bitexploder 9y ago
  Experts, such as the author should be listened to. Because they are experts. And you should listen to them /s I dislike when someone needs to inflate the worth of their ideas by repeatedly reminding us they are experts. Show me facts. Briefly, and I mean briefly, introduce your background up front and let your evidence and ideas talk, not "I am an expert, trust me". Especially on issues such as this one. This is not to say credible people should always be challenged constantly for facts, but said credible don't need to make such a deal out of it.
  - yborg 9y ago
    I dislike the general feeling among some in the HN community to conflate tone with message and, generally within one paragraph of a linked article, determine that the style of delivery is not within the community standard of humorlessness and pedantry and thus requires a metaphorical (or literal) downvote. Actually reading this article, we discover that the author refers to himself exactly once as an 'expert'. He cites a number of other professionals, mostly in order to provide linked journal references supporting his position. It's generally difficult to get published in a peer-reviewed journal without some kind of credentials in a field, so if the presence of opinions by professionals in an area is offensive, it's going to be hard to find anything of substance to read.
    - dhimes 9y ago
      I read the entire article before I posted. Despite the downvotes, I stand by my original claim. This article sheds no insight on the mechanism, and takes a supercilious tone towards those who believed in the "old" ideas. This is akin to someone announcing a paper that shows evidence of a "fifth force" (baryonic) after all (30 years or so later) and dismisses everybody who believed in the old law of mass attraction (gravity only) as being silly. IMHO, it's a shitty way to be, especially when you don't even bother to present the new insight.
dzdt 9y ago
There is a systematic property of the modern medical system to overtreat. At the first level, if a patient goes to a doctor the expectation is the doctor should do something to help. If the doctor says, "sorry there is nothing I can do" the patient will likely leave unhappy and try a different doctor. This leads to things like prescription of antibiotics for viral infections. There is no effective treatment, but patients leave happier with a useless treatment than with a denial. One thing ignored in the article is that, in this role as a placebo prescription, a longer course of antibiotics outperforms a short course. That is because a longer course gives a viral infection a longer time to clear up on its own.
- nkrisc 9y ago
  Of course what should happen is that if a patient with a viral infection goes to 1,000 doctors, they should be denied antibiotics 1,000 times.
- ant6n 9y ago
  Doctor could give a note that results in sick days. That's something they can always do.
- Cerium 9y ago
  I understand that is the expectation for some, but I personally am happy when the doctor tells me I'll be better on my own. It keeps me form worrying that I have something more serious.
- scrooched_moose 9y ago
  I'd be more accepting of that if they actually tested before saying "there's nothing we can do". I had a seven week bout with bronchitis recently because the first three doctors I went to insisted "it's viral, there's nothing we can do" without doing a sputum test. When I finally found someone who would give me a Z-pak it cleared up in three days after weeks of misery. It's also a problem when the system has swung so far the other direction that you can't get medication you actually need.
  - astura 9y ago
robbiep 9y ago
This has been well established in medical circles for at least 5 years now, the difficulty is in ensuring that people in the community cease at an appropriate time (i.e. Not before it is fully cleared) because that is potentially worse than taking a 'whole' un-needed course
- danmaz74 9y ago
  Is there any reliable self-managed way to determine what is the appropriate time?
monochromatic 9y ago
> 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?” This will of course never happen. Tragedy of the commons and all that.
- maxerickson 9y ago
  Never happen universally. Of course there are already lots of people that would rather not take antibiotics in cases where they aren't needed and especially in cases where they won't do any good.
- saint_fiasco 9y ago
  What is the benefit of taking an antibiotic you don't need? Even if people are perfectly selfish, they should want to not bother with useless medicine.
  - emiliobumachar 9y ago
    It's hard to be sure it's a viral infection unless you have a positive test for a specific virus.
    - saint_fiasco 9y ago
      I see. Benefits for the individual and costs for the collective is a recipe for a tragedy of the commons. But antibiotics have some individual costs too. They are bad for your gut flora, and I think you can't drink alcohol while you are on antibiotics. Maybe these individual costs should be raised. Perhaps via a special tax on antibiotics for people who don't have a positive test for a specific bacteria.
    - mrfusion 9y ago
      Plus viral infections can cause bacterial infections. Sinus infections from a cold are a common one.
      - 9y ago
neohaven 9y ago
The problem with stopping early is that you may have to start again. A whole course, since feeling better doesn't mean you have a low enough population of the bacteria to not reinfect you. Surely, repeated/massive bottlenecks in a viral population aren't a good thing for antibiotic resistance. Of course, the absolute best scenario to avoid resistance is to treat exactly as needed (say, kill 95% of the bacterial population, let the immune system clear the last 5%, done) but really, you can't realistically do that right now. So you have two choices : Either you tell patients "Take it until the end even if you feel better!" which leads to some antibiotic resistance, or you tell them "Take them until you feel better!" which probably leads to reinfection and use of a second course of the same antibiotic. Taking exactly enough > Taking more to make sure it's dead > Stopping too early, requiring the process to be done again.
- zeroxfe 9y ago
  Why not: "take it until two days after you feel better"?
  - AckSyn 9y ago
    Last time I needed to take them, they lasted about a day and a half before I felt truly 100%. Haven't been sick (at all, not even the sniffles) in almost a decade. Just an anecdote and definitely doesn't consider other illnesses I never fell to, but it's all I've got.
  - gforge 9y ago
    That's what I tell my patients, seems to work
- horsawlarway 9y ago
  Doesn't adaptive immunity come into play here, though? The goal of the antibiotics is to prevent the infection from killing you while buying time for your immune system to kick in and handle things. Secondly, why would a second course be more harmful if the duration of the two courses combined is less total time than the initial prescribed amount? If you feel better after 4 days of antibiotics, stop, get sick again and take 4 more days of antibiotics, you're still only dosing for 8 days. That's far better than a default of 2 weeks (14 days), and only barely worse than a 7 day course. Now factor in the number of people who would have been just fine after 4 days, with no re-occurrence, and I'm really struggling to see why your advice is any better than: Treat when sick, stop when well. Even if you get sick again: treat when sick, stop when well.
chewbacha 9y ago
Actual article (the BMJ peer reviewed analysis) is behind a paywall. But my thoughts as a microbiologist are that this is more a situation when the "course" that's been prescribed is generally wrong or the diagnosis is wrong. In either case, the risk for increased resistance is high, while the value for treatment low. Without a positive biochemical assay to assert a bacterial agent, antibiotics should not be prescribed, but likely are. Knowing how long a course to prescribe takes empirical evidence, which seems to indicate shorter courses are needed. Since I don't have access to the actual research, I'm guessing that it's more like "old, long antibiotic prescriptions were generally over prescribed, doctors should prescribe shorter doses and confirm with lab that bacterial agent present" It's been a decade since I've need antibiotics, but the last time I took a z-pak which is only 3 doses. Since initial immune response normally takes longer to ramp up and normally is a few days, this seems reasonable.
- exikyut 9y ago
  > Actual article (the BMJ peer reviewed analysis) is behind a paywall. I might be barking up the wrong tree here but if you're referring to http://www.bmj.com/content/358/bmj.j3418 http://www.bmj.com/content/358/bmj.j3418 then that page has an open(-access) link to http://www.bmj.com/content/358/bmj.j3418.full.pdf http://www.bmj.com/content/358/bmj.j3418.full.pdf.
  - chewbacha 9y ago
    Still paid wall, you only get the abstract.
danmaz74 9y ago
The message could be right, but the unnecessarily condescending and derisive tone of this article undermines its effectiveness. I for one don't feel any more informed about the data showing that longer courses of antibiotics create enhance the chances of creating resistant bacteria, nor about why this happens.
- gozur88 9y ago
  He describes himself as an expert two or three times in the short article. When I see that it makes me wonder if it's really true. It's like when people repeatedly describe themselves as strong or independent - who are they trying to convince? Based on his cv he probably really is an expert, but still, it's bad writing.
- mikk14 9y ago
  I think the mechanism might work like this (disclaimer, I'm not a doctor, I'm just making a theoretical guess): What can an antibiotic do? Kill bacteria that are not resistant to it. If a bacterium is resistant to it, it will be unaffected. Now, if you stop taking it "early" the antibiotic didn't have the time to kill 100% of non-resistant bacteria. You leave your body in a mixed environment where non-resistant and resistant bacteria have to compete. If you keep taking it once you feel better maybe you killed all the non-resistant bacteria. So you leave your body in an homogeneous environment where only resistant bacteria live, don't have to compete, and can prosper undisturbed.
  - danmaz74 9y ago
    Makes sense; in the end, only experimental data could show how this works compared to the other mechanism, ie, that strains that aren't yet fully resistant, but have some genes that help resistance, are favored by a partial course, and thus have "time" to develop full resistance (especially if the patient then uses the same antibiotic again).
autokad 9y ago
I'm not going to be able to explain my point clearly, but I will try. you keep seeing rhetoric like this, 'we have antibiotic resistance because doctors were prescribing it willy nilly' all the time, but it just doesn't line up. take a look at the list of diseases that formed / are forming resistance. they are all diseases you absolutely should have been taking antibiotics for. they werent diseases that gained super powers because someone was taking penicillin for the flu. then you have things like MRSA, which was discovered almost immediately after antibiotics, however, it was probably discovered because people were experimenting with antibiotics and that made it show its face. In other words, it was always around. its documented that people died of such infections before, we just dont look too much past it because they didnt have antibiotics at the time.
- devmunchies 9y ago
  85% of all antibiotics sold are for livestock. The volume of antibiotic given to animals, and the cramped and dirty living conditions of many farms results in a damn good engine for creating antibiotic resistant bacteria
  - autokad 9y ago
    not just livestock, one of our most powerful antibiotics (tetracycline), was used en-mase to wash down produce such as grapes. still, things like antibiotic resistant gonorrhea, syphilis, and tuberculosis scare me the most, and they have nothing to do with livestock. we are in a bit of a catch 22, we want to treat these diseases, but in doing so the diseases are getting stronger in an arms race against our technology. meanwhile our bodies de-evolve due to its dependence on our technology to defend it.
    - devmunchies 9y ago
      > meanwhile our bodies de-evolve due to its dependence on our technology to defend it I saw in a documentary a couple years ago that skulls of our ancient hunter-gatherer ancestors had little to no dental cavities—their teeth were intact. It was attributed to their very diverse bacteria exposure (being hunter gatherers) and no sterilization. This changed with farming. I'm a bigger fan of probiotic research rather than this antibacterial "arms race".
triplesec 9y ago
Please, after reading this, don't take this as advice not to finish your prescribed antibiotic courses. You personally do not know if a shorter course would work for you.
lprubin 9y ago
If you're worried about antibiotic resistance, consider cutting back or eliminating animal agriculture products from your diet. According to the FDA, 80% of antibiotics used in the US are given to farm animals. This is because it is cheaper to give antibiotics to every farm animal just in case rather than giving the medical care needed to properly diagnose and treat. Bird flu or swine flu has a decent probability of being the next epidemic because of this practice. http://www.sustainabletable.org/257/antibiotics http://www.sustainabletable.org/257/antibiotics EDIT: My mistake, bird and swine flu are caused by viruses not bacteria and are therefore not affected by the antibiotic stuffing of farm animals. But the crowding and conditions of factory farms do contribute to potential bird and swine flu outbreaks. See my comment below.
- lidlin 9y ago
  > 80% of antibiotics used in the US are given to farm animals These antibiotics are not the same ones used to treat human infections, and the correlation between the rise in antibiotic resistant infections and antibiotic use in livestock does not indicate causation. > Bird flu or swine flu has a decent probability of being the next epidemic because of this practice. Influenza is caused by a virus, and is unaffected by antibiotics.
  - DennisP 9y ago
    It's simply not the case that we use totally different antibiotics for agriculture. Here's an article in Scientific American about the health risks of agricultural antibiotics. One quote: "One study reported that more than 90 percent of E. coli in pigs raised on conventional farms are resistant to tetracycline." https://www.scientificamerican.com/article/how-drug-resistant-bacteria-travel-from-the-farm-to-your-table/ https://www.scientificamerican.com/article/how-drug-resistan... I guess it's possible that the rise of both antibiotic use in livestock and antibiotic resistance in their bacteria is completely coincidental, but given the well-understood causal connection it seems quite unlikely.
  - pbhjpbhj 9y ago
    But aren't influenza infections often associated with secondary bacterial infections, eg https://academic.oup.com/jac/article/64/5/889/716264/Swine-flu-and-antibiotics https://academic.oup.com/jac/article/64/5/889/716264/Swine-f..., where to treat the patient "with flu" prescription of antibiotics is a normal and beneficial course of action?
Benjamin_Dobell 9y ago
> 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. Not suggesting this is bad advice in general, but man, elsewhere in the world do doctors still speak to patients on the phone? I remember it being possible as a child, but living as an adult in Australia I'm yet to find a doctor who takes phone calls. They won't speak to you at all unless you book an appointment.
- maneesh 9y ago
  I email my doctor or call them whenever I have an issue. I'm in Boston.
  - mikeash 9y ago
    My insurance company has a phone number set up just for medical advice. You initially talk to a nurse, but they'll send me to my doctor if it's necessary. It's much cheaper for them to take a phone call than have me visit in person.
- adanto6840 9y ago
  I email or even text my doctor, depending on the urgency. It's a rarity for sure, but keep looking until you find one that isn't solely working for their "career" -- they do exist, though they're hard to find and commonly are not taking new patients (diamonds in the rough). You can also look into finding a "concierge doctor", I believe its a somewhat newer business model but is one I had been looking towards for a while until I found my current doctor. I'm in the southwestern U.S. FWIW.
- cicero 9y ago
  When I call my doctor's office, I speak with a nurse, or I leave a message and a nurse calls me back. After talking to me, the nurse may consult with the doctor and call me back, or if necessary, the doctor might call me. I can also email, and I have no idea if emails are directly answered by the doctor or if there is some kind of delegation going on there too.
- 9y ago
kusmi 9y ago
What? It's to prevent reinfection not resistance.
kusmi 9y ago
The antibiotic problem has nothing to do with young people. It's old people that are always in the hospital and will die if infection is not treated immediatly with antibiotics. That's where resistance incubates, not in a bunch of 30 something's with cold.
gnicholas 9y ago
> That’s why your doctor gives you seven or 14 days’ worth of antibiotics! This makes it seem like courses of antibiotics are always 7 or 14 days, but they're not. I just filled a prescription for a 5-day course. It may have been more uniform at 7/14 in the past, but it isn't now.
alkonaut 9y ago
> Doctors may otherwise prescribe an antibiotic even when you don’t need one, out of fear that you will be unhappy without the prescription. This is the argument for single provider right there. Patients are not customers and a doctors job is not to make the customer "happy" - the job is to make them well.
- Dove 9y ago
  I think this idea is a lot more appealing if we imagine someone else being unhappy with their doctor and wanting to go elsewhere, than if we imagine ourselves in that position. I think we have all had doctors who we did not like, who we thought missed something, whose philosophy of care we didn't share, and been grateful for the opportunity to go somewhere else.
graycat 9y ago
Warning: A scientific result that a treatment "doesn't help" is always suspicious: (A) The study may have neglected to measure all the ways the treatment might help. (B) Getting a result of "doesn't help" is always easy -- just use a silly means, e.g., insensitive or nearly irrelevant, of evaluation.
YSFEJ4SWJUVU6 9y ago
He sure can't help calling himself an expert.
joveian 9y ago
Maybe gut bacteria are quite a bit different from bacteria elsewhere in the body, but I had an experience that makes me wonder about antibiotic effectiveness in general. My sister gave me a couple of ubiome gut bacteria kits and I took one a few weeks before my first course of antibiotics (that I can recall - possibly I had to take them at some point decades ago) and one after two weeks on Amoxicillin/clavulanic acid, which was sampled right at the point where I would have taken the next pill if I wasn't stopping. In the "microbiome diversity" score, I was at 7th percentile before the antibiotics and 15th percentile after (inverse Simpson's Diversity Index normalized to 10 score went from 6.05 to 6.69). I did a couple of times notice ubiome presenting obviously incorrect information (and they never made a substantial response to reporting the first one) so one possible explanation that I could believe is that ubiome simply presents incorrect data. Another is that gut motility changes and/or somehow due to the diarrhea I got earlier in the treatment there was a larger collection of dead bacteria from meals in my gut the second time. I guess a third is that when alive some bacteria are not only killing others that arrive from meals but destroying them beyond recognition. Still, this makes me wonder a tiny bit if even two weeks of antibiotics doesn't fully kill non-antibiotic resistant bacteria in the gut. I was taking the antibiotics to try to calm down overactive gut bacteria (it helped for a few months), so even if this is the case for me it might not be generally true, but if it is true for anyone than we could be the ones breeding antibiotic resistant bacteria in our gut.
gforge 9y ago
I'm a little late to the game but I would like to point out that this doesn't apply to infected implants and some other special orthopaedic infections where you just as with TB need to treat for a long subclinical period. Otherwise I think it is an excellent article that many of my colleagues should read. I've actually also always wondered where this myth comes from.

141 points by raldi 9y ago

TorKlingberg 9y ago

The author here clearly has an axe to grind. Is this an established fact now, or an exaggeration of one study?

jameskilton 9y ago
Pretty sure the point of the article is that the idea that we need to take the full round of antibiotics is itself an exaggeration of one study that's now known to be wrong, and dangerously so. If we've been creating resistant bacteria because we've been following this "take it all" mentality, then I don't really blame the author for getting a little worked up over this.
zellyn 9y ago
If by "grinding an axe" you mean "trying to ensure that humanity preserves some of its best weapons against disease instead of squandering them". Seems fine to be emphatic about that.
DennisP 9y ago
From the article: "in the last two decades, we actually have had dozens of clinical trials published demonstrating that shorter courses of antibiotics are just as effective as longer courses." And from the linked WHO page: "There has been a lot of research into how long antibiotic courses should be, to determine the shortest possible length of course needed to completely kill all bacteria....Evidence is emerging that shorter courses of antibiotics may be just as effective as longer courses for some infections....They also reduce the exposure of bacteria to antibiotics, thereby reducing the speed by which the pathogen develops resistance." http://www.who.int/features/qa/stopping-antibiotic-treatment/en/ http://www.who.int/features/qa/stopping-antibiotic-treatment...
- Retric 9y ago
  'Reducing the speed' Is this being measured or just an assumption? Because resistance shows up extremely quickly with short dosage. But, it seems like a dangerous experiment.

deskamess 9y ago

Meta comment: The HN headline is difficult to parse. The original headline is a lot better.

raldi 9y ago
The first half of the original headline is clickbait; the second is too long for an HN title. What text would you suggest?

dhimes 9y ago

This is a shit article that provides no insight into what we learned that changed our mind about how antibiotic resistance arises. He simple derides as silly and stupid the idea that we ever thought that resistance could possibly arise if we quit taking antibiotics before the bacteria were all dead, leaving a population with better survival characteristics to rebuild the population. Interesting finding if true, but don't waste your time with this article.

bitexploder 9y ago
Experts, such as the author should be listened to. Because they are experts. And you should listen to them /s I dislike when someone needs to inflate the worth of their ideas by repeatedly reminding us they are experts. Show me facts. Briefly, and I mean briefly, introduce your background up front and let your evidence and ideas talk, not "I am an expert, trust me". Especially on issues such as this one. This is not to say credible people should always be challenged constantly for facts, but said credible don't need to make such a deal out of it.
- yborg 9y ago
  I dislike the general feeling among some in the HN community to conflate tone with message and, generally within one paragraph of a linked article, determine that the style of delivery is not within the community standard of humorlessness and pedantry and thus requires a metaphorical (or literal) downvote. Actually reading this article, we discover that the author refers to himself exactly once as an 'expert'. He cites a number of other professionals, mostly in order to provide linked journal references supporting his position. It's generally difficult to get published in a peer-reviewed journal without some kind of credentials in a field, so if the presence of opinions by professionals in an area is offensive, it's going to be hard to find anything of substance to read.
  - dhimes 9y ago
    I read the entire article before I posted. Despite the downvotes, I stand by my original claim. This article sheds no insight on the mechanism, and takes a supercilious tone towards those who believed in the "old" ideas. This is akin to someone announcing a paper that shows evidence of a "fifth force" (baryonic) after all (30 years or so later) and dismisses everybody who believed in the old law of mass attraction (gravity only) as being silly. IMHO, it's a shitty way to be, especially when you don't even bother to present the new insight.

dzdt 9y ago

There is a systematic property of the modern medical system to overtreat. At the first level, if a patient goes to a doctor the expectation is the doctor should do something to help. If the doctor says, "sorry there is nothing I can do" the patient will likely leave unhappy and try a different doctor. This leads to things like prescription of antibiotics for viral infections. There is no effective treatment, but patients leave happier with a useless treatment than with a denial. One thing ignored in the article is that, in this role as a placebo prescription, a longer course of antibiotics outperforms a short course. That is because a longer course gives a viral infection a longer time to clear up on its own.

nkrisc 9y ago
Of course what should happen is that if a patient with a viral infection goes to 1,000 doctors, they should be denied antibiotics 1,000 times.
ant6n 9y ago
Doctor could give a note that results in sick days. That's something they can always do.
Cerium 9y ago
I understand that is the expectation for some, but I personally am happy when the doctor tells me I'll be better on my own. It keeps me form worrying that I have something more serious.
scrooched_moose 9y ago
I'd be more accepting of that if they actually tested before saying "there's nothing we can do". I had a seven week bout with bronchitis recently because the first three doctors I went to insisted "it's viral, there's nothing we can do" without doing a sputum test. When I finally found someone who would give me a Z-pak it cleared up in three days after weeks of misery. It's also a problem when the system has swung so far the other direction that you can't get medication you actually need.
- astura 9y ago

robbiep 9y ago

This has been well established in medical circles for at least 5 years now, the difficulty is in ensuring that people in the community cease at an appropriate time (i.e. Not before it is fully cleared) because that is potentially worse than taking a 'whole' un-needed course

danmaz74 9y ago
Is there any reliable self-managed way to determine what is the appropriate time?

monochromatic 9y ago

> 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?” This will of course never happen. Tragedy of the commons and all that.

maxerickson 9y ago
Never happen universally. Of course there are already lots of people that would rather not take antibiotics in cases where they aren't needed and especially in cases where they won't do any good.
saint_fiasco 9y ago
What is the benefit of taking an antibiotic you don't need? Even if people are perfectly selfish, they should want to not bother with useless medicine.
- emiliobumachar 9y ago
  It's hard to be sure it's a viral infection unless you have a positive test for a specific virus.
  - saint_fiasco 9y ago
    I see. Benefits for the individual and costs for the collective is a recipe for a tragedy of the commons. But antibiotics have some individual costs too. They are bad for your gut flora, and I think you can't drink alcohol while you are on antibiotics. Maybe these individual costs should be raised. Perhaps via a special tax on antibiotics for people who don't have a positive test for a specific bacteria.
  - mrfusion 9y ago
    Plus viral infections can cause bacterial infections. Sinus infections from a cold are a common one.
    - 9y ago

neohaven 9y ago

The problem with stopping early is that you may have to start again. A whole course, since feeling better doesn't mean you have a low enough population of the bacteria to not reinfect you. Surely, repeated/massive bottlenecks in a viral population aren't a good thing for antibiotic resistance. Of course, the absolute best scenario to avoid resistance is to treat exactly as needed (say, kill 95% of the bacterial population, let the immune system clear the last 5%, done) but really, you can't realistically do that right now. So you have two choices : Either you tell patients "Take it until the end even if you feel better!" which leads to some antibiotic resistance, or you tell them "Take them until you feel better!" which probably leads to reinfection and use of a second course of the same antibiotic. Taking exactly enough > Taking more to make sure it's dead > Stopping too early, requiring the process to be done again.

zeroxfe 9y ago
Why not: "take it until two days after you feel better"?
- AckSyn 9y ago
  Last time I needed to take them, they lasted about a day and a half before I felt truly 100%. Haven't been sick (at all, not even the sniffles) in almost a decade. Just an anecdote and definitely doesn't consider other illnesses I never fell to, but it's all I've got.
- gforge 9y ago
  That's what I tell my patients, seems to work
horsawlarway 9y ago
Doesn't adaptive immunity come into play here, though? The goal of the antibiotics is to prevent the infection from killing you while buying time for your immune system to kick in and handle things. Secondly, why would a second course be more harmful if the duration of the two courses combined is less total time than the initial prescribed amount? If you feel better after 4 days of antibiotics, stop, get sick again and take 4 more days of antibiotics, you're still only dosing for 8 days. That's far better than a default of 2 weeks (14 days), and only barely worse than a 7 day course. Now factor in the number of people who would have been just fine after 4 days, with no re-occurrence, and I'm really struggling to see why your advice is any better than: Treat when sick, stop when well. Even if you get sick again: treat when sick, stop when well.

chewbacha 9y ago

Actual article (the BMJ peer reviewed analysis) is behind a paywall. But my thoughts as a microbiologist are that this is more a situation when the "course" that's been prescribed is generally wrong or the diagnosis is wrong. In either case, the risk for increased resistance is high, while the value for treatment low. Without a positive biochemical assay to assert a bacterial agent, antibiotics should not be prescribed, but likely are. Knowing how long a course to prescribe takes empirical evidence, which seems to indicate shorter courses are needed. Since I don't have access to the actual research, I'm guessing that it's more like "old, long antibiotic prescriptions were generally over prescribed, doctors should prescribe shorter doses and confirm with lab that bacterial agent present" It's been a decade since I've need antibiotics, but the last time I took a z-pak which is only 3 doses. Since initial immune response normally takes longer to ramp up and normally is a few days, this seems reasonable.

exikyut 9y ago
> Actual article (the BMJ peer reviewed analysis) is behind a paywall. I might be barking up the wrong tree here but if you're referring to http://www.bmj.com/content/358/bmj.j3418 http://www.bmj.com/content/358/bmj.j3418 then that page has an open(-access) link to http://www.bmj.com/content/358/bmj.j3418.full.pdf http://www.bmj.com/content/358/bmj.j3418.full.pdf.
- chewbacha 9y ago
  Still paid wall, you only get the abstract.

danmaz74 9y ago

The message could be right, but the unnecessarily condescending and derisive tone of this article undermines its effectiveness. I for one don't feel any more informed about the data showing that longer courses of antibiotics create enhance the chances of creating resistant bacteria, nor about why this happens.

gozur88 9y ago
He describes himself as an expert two or three times in the short article. When I see that it makes me wonder if it's really true. It's like when people repeatedly describe themselves as strong or independent - who are they trying to convince? Based on his cv he probably really is an expert, but still, it's bad writing.
mikk14 9y ago
I think the mechanism might work like this (disclaimer, I'm not a doctor, I'm just making a theoretical guess): What can an antibiotic do? Kill bacteria that are not resistant to it. If a bacterium is resistant to it, it will be unaffected. Now, if you stop taking it "early" the antibiotic didn't have the time to kill 100% of non-resistant bacteria. You leave your body in a mixed environment where non-resistant and resistant bacteria have to compete. If you keep taking it once you feel better maybe you killed all the non-resistant bacteria. So you leave your body in an homogeneous environment where only resistant bacteria live, don't have to compete, and can prosper undisturbed.
- danmaz74 9y ago
  Makes sense; in the end, only experimental data could show how this works compared to the other mechanism, ie, that strains that aren't yet fully resistant, but have some genes that help resistance, are favored by a partial course, and thus have "time" to develop full resistance (especially if the patient then uses the same antibiotic again).

autokad 9y ago

I'm not going to be able to explain my point clearly, but I will try. you keep seeing rhetoric like this, 'we have antibiotic resistance because doctors were prescribing it willy nilly' all the time, but it just doesn't line up. take a look at the list of diseases that formed / are forming resistance. they are all diseases you absolutely should have been taking antibiotics for. they werent diseases that gained super powers because someone was taking penicillin for the flu. then you have things like MRSA, which was discovered almost immediately after antibiotics, however, it was probably discovered because people were experimenting with antibiotics and that made it show its face. In other words, it was always around. its documented that people died of such infections before, we just dont look too much past it because they didnt have antibiotics at the time.

devmunchies 9y ago
85% of all antibiotics sold are for livestock. The volume of antibiotic given to animals, and the cramped and dirty living conditions of many farms results in a damn good engine for creating antibiotic resistant bacteria
- autokad 9y ago
  not just livestock, one of our most powerful antibiotics (tetracycline), was used en-mase to wash down produce such as grapes. still, things like antibiotic resistant gonorrhea, syphilis, and tuberculosis scare me the most, and they have nothing to do with livestock. we are in a bit of a catch 22, we want to treat these diseases, but in doing so the diseases are getting stronger in an arms race against our technology. meanwhile our bodies de-evolve due to its dependence on our technology to defend it.
  - devmunchies 9y ago
    > meanwhile our bodies de-evolve due to its dependence on our technology to defend it I saw in a documentary a couple years ago that skulls of our ancient hunter-gatherer ancestors had little to no dental cavities—their teeth were intact. It was attributed to their very diverse bacteria exposure (being hunter gatherers) and no sterilization. This changed with farming. I'm a bigger fan of probiotic research rather than this antibacterial "arms race".

triplesec 9y ago

Please, after reading this, don't take this as advice not to finish your prescribed antibiotic courses. You personally do not know if a shorter course would work for you.

lprubin 9y ago

If you're worried about antibiotic resistance, consider cutting back or eliminating animal agriculture products from your diet. According to the FDA, 80% of antibiotics used in the US are given to farm animals. This is because it is cheaper to give antibiotics to every farm animal just in case rather than giving the medical care needed to properly diagnose and treat. Bird flu or swine flu has a decent probability of being the next epidemic because of this practice. http://www.sustainabletable.org/257/antibiotics http://www.sustainabletable.org/257/antibiotics EDIT: My mistake, bird and swine flu are caused by viruses not bacteria and are therefore not affected by the antibiotic stuffing of farm animals. But the crowding and conditions of factory farms do contribute to potential bird and swine flu outbreaks. See my comment below.

lidlin 9y ago
> 80% of antibiotics used in the US are given to farm animals These antibiotics are not the same ones used to treat human infections, and the correlation between the rise in antibiotic resistant infections and antibiotic use in livestock does not indicate causation. > Bird flu or swine flu has a decent probability of being the next epidemic because of this practice. Influenza is caused by a virus, and is unaffected by antibiotics.
- DennisP 9y ago
  It's simply not the case that we use totally different antibiotics for agriculture. Here's an article in Scientific American about the health risks of agricultural antibiotics. One quote: "One study reported that more than 90 percent of E. coli in pigs raised on conventional farms are resistant to tetracycline." https://www.scientificamerican.com/article/how-drug-resistant-bacteria-travel-from-the-farm-to-your-table/ https://www.scientificamerican.com/article/how-drug-resistan... I guess it's possible that the rise of both antibiotic use in livestock and antibiotic resistance in their bacteria is completely coincidental, but given the well-understood causal connection it seems quite unlikely.
- pbhjpbhj 9y ago
  But aren't influenza infections often associated with secondary bacterial infections, eg https://academic.oup.com/jac/article/64/5/889/716264/Swine-flu-and-antibiotics https://academic.oup.com/jac/article/64/5/889/716264/Swine-f..., where to treat the patient "with flu" prescription of antibiotics is a normal and beneficial course of action?

Benjamin_Dobell 9y ago

> 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. Not suggesting this is bad advice in general, but man, elsewhere in the world do doctors still speak to patients on the phone? I remember it being possible as a child, but living as an adult in Australia I'm yet to find a doctor who takes phone calls. They won't speak to you at all unless you book an appointment.

maneesh 9y ago
I email my doctor or call them whenever I have an issue. I'm in Boston.
- mikeash 9y ago
  My insurance company has a phone number set up just for medical advice. You initially talk to a nurse, but they'll send me to my doctor if it's necessary. It's much cheaper for them to take a phone call than have me visit in person.
adanto6840 9y ago
I email or even text my doctor, depending on the urgency. It's a rarity for sure, but keep looking until you find one that isn't solely working for their "career" -- they do exist, though they're hard to find and commonly are not taking new patients (diamonds in the rough). You can also look into finding a "concierge doctor", I believe its a somewhat newer business model but is one I had been looking towards for a while until I found my current doctor. I'm in the southwestern U.S. FWIW.
cicero 9y ago
When I call my doctor's office, I speak with a nurse, or I leave a message and a nurse calls me back. After talking to me, the nurse may consult with the doctor and call me back, or if necessary, the doctor might call me. I can also email, and I have no idea if emails are directly answered by the doctor or if there is some kind of delegation going on there too.
9y ago

kusmi 9y ago

What? It's to prevent reinfection not resistance.

kusmi 9y ago

The antibiotic problem has nothing to do with young people. It's old people that are always in the hospital and will die if infection is not treated immediatly with antibiotics. That's where resistance incubates, not in a bunch of 30 something's with cold.

gnicholas 9y ago

> That’s why your doctor gives you seven or 14 days’ worth of antibiotics! This makes it seem like courses of antibiotics are always 7 or 14 days, but they're not. I just filled a prescription for a 5-day course. It may have been more uniform at 7/14 in the past, but it isn't now.

alkonaut 9y ago

> Doctors may otherwise prescribe an antibiotic even when you don’t need one, out of fear that you will be unhappy without the prescription. This is the argument for single provider right there. Patients are not customers and a doctors job is not to make the customer "happy" - the job is to make them well.

Dove 9y ago
I think this idea is a lot more appealing if we imagine someone else being unhappy with their doctor and wanting to go elsewhere, than if we imagine ourselves in that position. I think we have all had doctors who we did not like, who we thought missed something, whose philosophy of care we didn't share, and been grateful for the opportunity to go somewhere else.

graycat 9y ago

Warning: A scientific result that a treatment "doesn't help" is always suspicious: (A) The study may have neglected to measure all the ways the treatment might help. (B) Getting a result of "doesn't help" is always easy -- just use a silly means, e.g., insensitive or nearly irrelevant, of evaluation.

YSFEJ4SWJUVU6 9y ago

He sure can't help calling himself an expert.

joveian 9y ago

Maybe gut bacteria are quite a bit different from bacteria elsewhere in the body, but I had an experience that makes me wonder about antibiotic effectiveness in general. My sister gave me a couple of ubiome gut bacteria kits and I took one a few weeks before my first course of antibiotics (that I can recall - possibly I had to take them at some point decades ago) and one after two weeks on Amoxicillin/clavulanic acid, which was sampled right at the point where I would have taken the next pill if I wasn't stopping. In the "microbiome diversity" score, I was at 7th percentile before the antibiotics and 15th percentile after (inverse Simpson's Diversity Index normalized to 10 score went from 6.05 to 6.69). I did a couple of times notice ubiome presenting obviously incorrect information (and they never made a substantial response to reporting the first one) so one possible explanation that I could believe is that ubiome simply presents incorrect data. Another is that gut motility changes and/or somehow due to the diarrhea I got earlier in the treatment there was a larger collection of dead bacteria from meals in my gut the second time. I guess a third is that when alive some bacteria are not only killing others that arrive from meals but destroying them beyond recognition. Still, this makes me wonder a tiny bit if even two weeks of antibiotics doesn't fully kill non-antibiotic resistant bacteria in the gut. I was taking the antibiotics to try to calm down overactive gut bacteria (it helped for a few months), so even if this is the case for me it might not be generally true, but if it is true for anyone than we could be the ones breeding antibiotic resistant bacteria in our gut.

gforge 9y ago

I'm a little late to the game but I would like to point out that this doesn't apply to infected implants and some other special orthopaedic infections where you just as with TB need to treat for a long subclinical period. Otherwise I think it is an excellent article that many of my colleagues should read. I've actually also always wondered where this myth comes from.