5 ms·

Is it time to stop counselling patients to “finish the course of antibiotics”?

48 points by lelf 6y ago

epakai 6y ago
No. [1] The article makes the case for prescribing shorter courses of antibiotics for some infections, and they're probably right. You would need to show there is more harm from obeying doctor's orders before you write an absurd headline like this that leads people to second-guess medical advice for little good. [1] https://en.wikipedia.org/wiki/Betteridge%27s_law_of_headlines https://en.wikipedia.org/wiki/Betteridge%27s_law_of_headline...
- jlmorton 6y ago
  No, it makes the case for not finishing the course. It literally concludes with: > The time has come to challenge the maxim “finish the course.” The article says more research is needed, but suggests patients, perhaps in consultation with their doctors, should discontinue use when they feel better.
  - pdonis 6y ago
    > it makes the case for not finishing the course. It literally concludes with: > The time has come to challenge the maxim “finish the course.” The fact that the article claims that it has made a case for not telling patients to finish the course does not mean that claim is correct. It isn't. > The article says more research is needed, but suggests patients, perhaps in consultation with their doctors, should discontinue use when they feel better. And, as others have already pointed out upthread, this suggestion is not justified by the research discussed in the article. What is justified by that research is prescribing shorter courses of certain antibiotics when a shorter course has been shown to be sufficient for those particular antibiotics for the particular infection being treated. But that is not at all an argument for not telling the patient to finish the course that has been prescribed. In fact it's an argument against it, since the whole point of prescribing a specific course for a specific time is that that is the time that has been scientifically shown to be sufficient. Stopping the prescribed course early just because you feel better, even if it's in consultation with the doctor, goes against the actual science. What the actual science says is to take the specific circumstances into account when prescribing a course of antibiotics in the first place.
  - blendergeek 6y ago
    > No, it makes the case for not finishing the course. It literally concludes with: "The time has come to challenge the maxim 'finish the course.'" Yes, it does conclude with that statement. However, little in the article supports the notion that patients should be second guessing medical doctors. Rather, the article provides some evidence that current dosing is wrong and shorter courses would be better.
- rossdavidh 6y ago
  The intended target of the article appears to be medical professionals.
NikolaeVarius 6y ago
Only 3 citations. No one cares
- tokai 6y ago
  The text is published as an Opinion Commentary. See the second form definition here [0] on what a scientific commentary is. It's not from the same journal, but BMC meds definition is close to what most journals adhere to. [0] https://bmcmedicine.biomedcentral.com/submission-guidelines/preparing-your-manuscript/commentaries https://bmcmedicine.biomedcentral.com/submission-guidelines/...
AtlasBarfed 6y ago
"In fact, it is prolonged exposure to antibiotics that provides the selective pressure to drive antimicrobial resistance; hence, longer courses are more likely to result in the emergence of resistant bacteria" I always wondered about this, but I accepted explanations to the contrary (which IIRC were something like "keeping the overall population of bacteria low so a recurrence of the infection, now with a larger portion of resistant bacteria, wouldn't give the opportunity for the resistant bacteria to spread") It always seemed like a pseudoscience explanation, but things can be complicated at the highly detailed level, so I assumed there were more complicated mechanisms / statistics / science that underlay the "take the whole course". Alas the media will probably do a bunch of sensationalist "the scientists don't know anything" stories typical of American anti-intellectualism.
- ars 6y ago
  Your reply would be a lot better without the last sentence. Just remove it, it doesn't add anything.
avmich 6y ago
"Instead, our focus should shift to ensuring appropriate antibiotic use as well as improving dialogue with prescribers and patients about the harms of antibiotic overuse." Quite an unclear statement and the article as a whole. Article explains well why "finish the course" could be the right thing - Fleming's Nobel lecture is brought as illustration - but then fails explaining how and why this "finishing" is wrong.
- rossdavidh 6y ago
  "Additionally, long durations of therapy put patients at increased risk for adverse effects,16,17 including the development of Clostridium difficile infection,18 which is associated with significant morbidity and mortality." 16. Milo G, Katchman E, Paul M, et al. Duration of antibacterial treatment for uncomplicated urinary tract infection in women. Cochrane Database Syst Rev 2005;2:CD004682. [PubMed] [Google Scholar] 17. Vogel T, Verreault R, Gourdeau M, et al. Optimal duration of antibiotic therapy for uncomplicated urinary tract infection in older women: a double-blind randomized controlled trial. CMAJ 2004;170(4): 469-73. [PMC free article] [PubMed] [Google Scholar] 18. Owens RC, Donskey CJ, Gaynes RP, et al. Antimicrobial-associated risk factors for Clostridium difficile infection. Clin Infect Dis 2008;46:S19-31. [PubMed] [Google Scholar]
ars 6y ago
"In fact, it is prolonged exposure to antibiotics that provides the selective pressure to drive antimicrobial resistance;" I've never understood why a longer course of antibiotics would kill a resistant bacteria, while a shorter one won't. It's either resistant or it's not. Bacteria multiply far far too fast for them to notice multi-day courses of treatment, a bacteria only "notices" the current conditions before it either multiplies or dies. By prolonging medication you wipe out all the susceptible bacteria leaving only the resistant ones. It seems to me that instead we should use just enough antibiotic to keep the patient alive (to turn the corner) and then let the patients immune system do the rest. If I'm wrong about any of the above, I would love responses explaining why.
- arn 6y ago
  Resistance is not as black and white as you suggest. https://litfl.com/minimum-inhibitory-concentration/ https://litfl.com/minimum-inhibitory-concentration/ It’s more of a spectrum of concentrations. A resistant bacteria is one that doesn’t grow above a certain threshold. But longer exposure or higher concentration will change the effectiveness.
- pdonis 6y ago
  > It's either resistant or it's not. Resistance is not a binary thing. Often it simply means that a population of "resistant" bacteria takes longer to be completely eliminated, not that they are completely unaffected. It would be better if a different term were used to describe bacteria that are completely unaffected by a given antibiotic; perhaps "invulnerable" would do. If you are in fact dealing with bacteria that are invulnerable to a particular antibiotic, then you need to switch antibiotics, yes. > Bacteria multiply far far too fast for them to notice multi-day courses of treatment Bacteria multiply far too fast under ideal conditions. But the whole point of giving an antibiotic is to make the conditions as far as possible from ideal. > a bacteria only "notices" the current conditions before it either multiplies or dies Bacteria are not mayflies. They don't have to either multiply or die within a short period of time. > It seems to me that instead we should use just enough antibiotic to keep the patient alive (to turn the corner) and then let the patients immune system do the rest. Antibiotics suppress the patient's immune system, so once you have started them, you need to finish the job with them. If you are going to try to let the patient's immune system fight the infection, then I would think you would not give antibiotics at all; instead you would focus on maximizing supportive care for the patient's immune system (for example, they probably need to eat a lot of protein since the immune system needs protein to make antibodies, T-cells, etc.), and for the patient generally (make sure they stay hydrated, etc.).
zabzonk 6y ago
Depends a lot on the antibiotic and the bacteria. For example, many of the anti-TB drugs require a long course, because mycobateria are very slow growing, and so don't take up the antibiotics that will kill them at all quickly. Speaking as an ex-microbiologist.
variaga 6y ago
The paper's content doesn't support the conclusion ("It is clear that telling every patient to “finish the course of antibiotic therapy, even if you feel better” is outdated." "The time has come to challenge the maxim “finish the course.”") As support they cite that some infections can be reliably cured with shorter courses of antibiotics than the standard course. (they list 3 diseases that can be effectively treated with shorter courses, and 2 that cannot) Assuming that this is true, the correct response is to prescribe shorter courses of antibiotics for diseases where that is indicated, NOT to stop telling patients that they need to finish the prescription.
- uoaei 6y ago
  Exactly, this article seems like it's primarily engineered to manufacture bluster for publicity's sake.
  - tokai 6y ago
    It's a commentary in a journal with medical researchers as the intended audience. It surely seems more reasonable that it is input to an ongoing collegial discussion of treatment with antibiotics, and not bluster.
t0mbstone 6y ago
I've always wondered about this. It felt counterintuitive. Nice to see some proof!
remote_phone 6y ago
What we need is better measuring and quantifying of a patient’s situation. Right now they tell you “take these antibiotics for 10 days”. Instead they need a way to measure the infection and change the instruction to “take these antibiotics until this measurement is below 5”. This is a lot easier for patients to understand and follow vs a coarse “take this for 10 days” even though they feel better. It’s 2020 and we have a lot of tools to track users across the Internet but we don’t have anything besides blood tests to figure out our health. It definitely seems like an industry ripe for disruption.
- bsder 6y ago
  No. Patient compliance is already a problem. You need to decrease the complexity of a treatment, not increase it. For example, if you want Ursodiol for your gallstones, you will have to fight with your doctor. Why? You have to take it--daily, reliably, for more than a year before you will see any improvement. Yes, you may be an engineer with the self-discipline and knowledge to understand that you are basically ungrowing a crystal and that's a slow process, but the majority are not. They will miss treatments, they will double up treatments (useless, in this case), they will get tired of side effects, etc. > we don’t have anything besides blood tests to figure out our health. It definitely seems like an industry ripe for disruption. Spoken like an arrogant techie. A blood test doesn't magically indicate what is wrong with you, and there is a lot of noise in the signal where a blood test indicates something is wrong that really isn't.
  - remote_phone 6y ago
    Your thinking is so primitive and biased towards failure. If you improve the tests and make things easier to understand, then it should be easier to get patient compliance. The unnecessarily opaque nature of medicine and tests are the problem. If we had a futuristic Apple Watch that gathered results somehow and then it told you when you take your medication, etc that’s a win for patients and medicine in general. Stop thinking about what we have right now and be imaginative. Naysayers are always wrong in the long run.
ortusdux 6y ago
https://en.wikipedia.org/wiki/Betteridge%27s_law_of_headlines https://en.wikipedia.org/wiki/Betteridge%27s_law_of_headline...
bpodgursky 6y ago
2017...
pii 6y ago
What? No. Y'all aren't doctors, please listen to your doctors

48 points by lelf 6y ago

No. [1] The article makes the case for prescribing shorter courses of antibiotics for some infections, and they're probably right. You would need to show there is more harm from obeying doctor's orders before you write an absurd headline like this that leads people to second-guess medical advice for little good. [1] https://en.wikipedia.org/wiki/Betteridge%27s_law_of_headlines https://en.wikipedia.org/wiki/Betteridge%27s_law_of_headline...

jlmorton 6y ago
No, it makes the case for not finishing the course. It literally concludes with: > The time has come to challenge the maxim “finish the course.” The article says more research is needed, but suggests patients, perhaps in consultation with their doctors, should discontinue use when they feel better.
- pdonis 6y ago
  > it makes the case for not finishing the course. It literally concludes with: > The time has come to challenge the maxim “finish the course.” The fact that the article claims that it has made a case for not telling patients to finish the course does not mean that claim is correct. It isn't. > The article says more research is needed, but suggests patients, perhaps in consultation with their doctors, should discontinue use when they feel better. And, as others have already pointed out upthread, this suggestion is not justified by the research discussed in the article. What is justified by that research is prescribing shorter courses of certain antibiotics when a shorter course has been shown to be sufficient for those particular antibiotics for the particular infection being treated. But that is not at all an argument for not telling the patient to finish the course that has been prescribed. In fact it's an argument against it, since the whole point of prescribing a specific course for a specific time is that that is the time that has been scientifically shown to be sufficient. Stopping the prescribed course early just because you feel better, even if it's in consultation with the doctor, goes against the actual science. What the actual science says is to take the specific circumstances into account when prescribing a course of antibiotics in the first place.
- blendergeek 6y ago
  > No, it makes the case for not finishing the course. It literally concludes with: "The time has come to challenge the maxim 'finish the course.'" Yes, it does conclude with that statement. However, little in the article supports the notion that patients should be second guessing medical doctors. Rather, the article provides some evidence that current dosing is wrong and shorter courses would be better.
rossdavidh 6y ago
The intended target of the article appears to be medical professionals.

NikolaeVarius 6y ago

Only 3 citations. No one cares

tokai 6y ago
The text is published as an Opinion Commentary. See the second form definition here [0] on what a scientific commentary is. It's not from the same journal, but BMC meds definition is close to what most journals adhere to. [0] https://bmcmedicine.biomedcentral.com/submission-guidelines/preparing-your-manuscript/commentaries https://bmcmedicine.biomedcentral.com/submission-guidelines/...

AtlasBarfed 6y ago

"In fact, it is prolonged exposure to antibiotics that provides the selective pressure to drive antimicrobial resistance; hence, longer courses are more likely to result in the emergence of resistant bacteria" I always wondered about this, but I accepted explanations to the contrary (which IIRC were something like "keeping the overall population of bacteria low so a recurrence of the infection, now with a larger portion of resistant bacteria, wouldn't give the opportunity for the resistant bacteria to spread") It always seemed like a pseudoscience explanation, but things can be complicated at the highly detailed level, so I assumed there were more complicated mechanisms / statistics / science that underlay the "take the whole course". Alas the media will probably do a bunch of sensationalist "the scientists don't know anything" stories typical of American anti-intellectualism.

ars 6y ago
Your reply would be a lot better without the last sentence. Just remove it, it doesn't add anything.

avmich 6y ago

"Instead, our focus should shift to ensuring appropriate antibiotic use as well as improving dialogue with prescribers and patients about the harms of antibiotic overuse." Quite an unclear statement and the article as a whole. Article explains well why "finish the course" could be the right thing - Fleming's Nobel lecture is brought as illustration - but then fails explaining how and why this "finishing" is wrong.

rossdavidh 6y ago
"Additionally, long durations of therapy put patients at increased risk for adverse effects,16,17 including the development of Clostridium difficile infection,18 which is associated with significant morbidity and mortality." 16. Milo G, Katchman E, Paul M, et al. Duration of antibacterial treatment for uncomplicated urinary tract infection in women. Cochrane Database Syst Rev 2005;2:CD004682. [PubMed] [Google Scholar] 17. Vogel T, Verreault R, Gourdeau M, et al. Optimal duration of antibiotic therapy for uncomplicated urinary tract infection in older women: a double-blind randomized controlled trial. CMAJ 2004;170(4): 469-73. [PMC free article] [PubMed] [Google Scholar] 18. Owens RC, Donskey CJ, Gaynes RP, et al. Antimicrobial-associated risk factors for Clostridium difficile infection. Clin Infect Dis 2008;46:S19-31. [PubMed] [Google Scholar]

ars 6y ago

"In fact, it is prolonged exposure to antibiotics that provides the selective pressure to drive antimicrobial resistance;" I've never understood why a longer course of antibiotics would kill a resistant bacteria, while a shorter one won't. It's either resistant or it's not. Bacteria multiply far far too fast for them to notice multi-day courses of treatment, a bacteria only "notices" the current conditions before it either multiplies or dies. By prolonging medication you wipe out all the susceptible bacteria leaving only the resistant ones. It seems to me that instead we should use just enough antibiotic to keep the patient alive (to turn the corner) and then let the patients immune system do the rest. If I'm wrong about any of the above, I would love responses explaining why.

arn 6y ago
Resistance is not as black and white as you suggest. https://litfl.com/minimum-inhibitory-concentration/ https://litfl.com/minimum-inhibitory-concentration/ It’s more of a spectrum of concentrations. A resistant bacteria is one that doesn’t grow above a certain threshold. But longer exposure or higher concentration will change the effectiveness.
pdonis 6y ago
> It's either resistant or it's not. Resistance is not a binary thing. Often it simply means that a population of "resistant" bacteria takes longer to be completely eliminated, not that they are completely unaffected. It would be better if a different term were used to describe bacteria that are completely unaffected by a given antibiotic; perhaps "invulnerable" would do. If you are in fact dealing with bacteria that are invulnerable to a particular antibiotic, then you need to switch antibiotics, yes. > Bacteria multiply far far too fast for them to notice multi-day courses of treatment Bacteria multiply far too fast under ideal conditions. But the whole point of giving an antibiotic is to make the conditions as far as possible from ideal. > a bacteria only "notices" the current conditions before it either multiplies or dies Bacteria are not mayflies. They don't have to either multiply or die within a short period of time. > It seems to me that instead we should use just enough antibiotic to keep the patient alive (to turn the corner) and then let the patients immune system do the rest. Antibiotics suppress the patient's immune system, so once you have started them, you need to finish the job with them. If you are going to try to let the patient's immune system fight the infection, then I would think you would not give antibiotics at all; instead you would focus on maximizing supportive care for the patient's immune system (for example, they probably need to eat a lot of protein since the immune system needs protein to make antibodies, T-cells, etc.), and for the patient generally (make sure they stay hydrated, etc.).

zabzonk 6y ago

Depends a lot on the antibiotic and the bacteria. For example, many of the anti-TB drugs require a long course, because mycobateria are very slow growing, and so don't take up the antibiotics that will kill them at all quickly. Speaking as an ex-microbiologist.

variaga 6y ago

The paper's content doesn't support the conclusion ("It is clear that telling every patient to “finish the course of antibiotic therapy, even if you feel better” is outdated." "The time has come to challenge the maxim “finish the course.”") As support they cite that some infections can be reliably cured with shorter courses of antibiotics than the standard course. (they list 3 diseases that can be effectively treated with shorter courses, and 2 that cannot) Assuming that this is true, the correct response is to prescribe shorter courses of antibiotics for diseases where that is indicated, NOT to stop telling patients that they need to finish the prescription.

uoaei 6y ago
Exactly, this article seems like it's primarily engineered to manufacture bluster for publicity's sake.
- tokai 6y ago
  It's a commentary in a journal with medical researchers as the intended audience. It surely seems more reasonable that it is input to an ongoing collegial discussion of treatment with antibiotics, and not bluster.

t0mbstone 6y ago

I've always wondered about this. It felt counterintuitive. Nice to see some proof!

remote_phone 6y ago

What we need is better measuring and quantifying of a patient’s situation. Right now they tell you “take these antibiotics for 10 days”. Instead they need a way to measure the infection and change the instruction to “take these antibiotics until this measurement is below 5”. This is a lot easier for patients to understand and follow vs a coarse “take this for 10 days” even though they feel better. It’s 2020 and we have a lot of tools to track users across the Internet but we don’t have anything besides blood tests to figure out our health. It definitely seems like an industry ripe for disruption.

bsder 6y ago
No. Patient compliance is already a problem. You need to decrease the complexity of a treatment, not increase it. For example, if you want Ursodiol for your gallstones, you will have to fight with your doctor. Why? You have to take it--daily, reliably, for more than a year before you will see any improvement. Yes, you may be an engineer with the self-discipline and knowledge to understand that you are basically ungrowing a crystal and that's a slow process, but the majority are not. They will miss treatments, they will double up treatments (useless, in this case), they will get tired of side effects, etc. > we don’t have anything besides blood tests to figure out our health. It definitely seems like an industry ripe for disruption. Spoken like an arrogant techie. A blood test doesn't magically indicate what is wrong with you, and there is a lot of noise in the signal where a blood test indicates something is wrong that really isn't.
- remote_phone 6y ago
  Your thinking is so primitive and biased towards failure. If you improve the tests and make things easier to understand, then it should be easier to get patient compliance. The unnecessarily opaque nature of medicine and tests are the problem. If we had a futuristic Apple Watch that gathered results somehow and then it told you when you take your medication, etc that’s a win for patients and medicine in general. Stop thinking about what we have right now and be imaginative. Naysayers are always wrong in the long run.

ortusdux 6y ago

https://en.wikipedia.org/wiki/Betteridge%27s_law_of_headlines https://en.wikipedia.org/wiki/Betteridge%27s_law_of_headline...

bpodgursky 6y ago

2017...

pii 6y ago

What? No. Y'all aren't doctors, please listen to your doctors