Antibiotics: should patients always finish their course?

Posted on 8 September 2017

A recent article published in the British Medical Journal targets the ongoing debate on whether patients should stop taking antibiotics as soon as they feel better – rather than completing the course. The new research provides evidence that the duration of treatment can be reduced safely for specific infections. 

While some healthcare practitioners are wary of this view, stating that its irresponsible and confusing advice: others are wholly supportive. As Professor Mark Woolhouse, Professor of Infectious Disease Epidemiology at the University of Edinburgh says, ‘It is very clear that prescribing practices do need to change; there is every indication that current volumes of antibiotic usage are too high to be sustainable. We need to start to use antibiotics more wisely before it’s too late.’

‘This BMJ article is an outcry for public participation to reduce antibiotic utilisation and holds a powerful message for prescribers about the importance of the appropriate duration of therapy,’ says Andriette van Jaarsveld, Clinical Pharmacy Specialist at Mediclinic Southern Africa.

‘Traditionally, doctors told patients to finish the prescribed course of antibiotics based on the assumption that all the bacteria causing the infection have to be killed, so the surviving minority don’t become resistant,’ she explains. ‘However, we now know that this assumption was not sufficiently supported by evidence.’

Van Jaarsveld adds that a number of studies show that shorter courses of antibiotics are just as effective as longer courses in most cases. In one example, using fever resolution to guide stopping antibiotics in community-acquired pneumonia halved the average duration of antibiotic treatment without affecting clinical success.

In the BMJ report, the point is made that: ‘When a patient takes antibiotics for any reason, antibiotic sensitive species and strains present on their skin, gut or environment are replaced by resistant species and strains ready to cause infection in the future. This ‘collateral damage ’ is the predominant driver of the important forms of antibiotic resistance affecting patients today. The longer the antibiotic exposure these opportunistic bacteria are subject to, the greater the pressure to select for antibiotic resistance.’

Antibiotic resistance is a real threat, van Jaarsveld says. ‘We need to start using our antibiotics better before we have more untreatable infections. There is clear evidence that the rate at which bacteria develop resistance to antibiotics will have dire global consequences.’ These include higher medical costs, longer hospital stays and increased mortality.

This standpoint is embodied in the October 2016 World Health Organisation fact sheet that states: Antibiotic resistance occurs naturally, but misuse of antibiotics is accelerating the process. And a growing number of infections – such as tuberculosis – are becoming harder to treat as the antibiotics used to treat them become less effective. Van Jaarsveld acknowledges certain infections require longer courses of antibiotic treatment.

‘Some bacteria are just more difficult to kill, or the infection area is difficult to penetrate. In these specific cases doctors need to treat the infection for a longer period,’ she says. ‘For example. Mycobacterium tuberculosis needs to be treated for six months to two years. It is a slow replicative organism and spends much of its time in a non-replicating state. Patient non-compliance causes the organisms to develop resistance to the first line therapy. Second line therapy is more expensive and has more adverse effects.’

Brad Spellberg, an author of one of the studies cited in the controversial BMJ report, makes the point that trials comparing short-course with longer course antibiotic therapy for bacterial infections other than tuberculosis have shown that short-course therapy has been just as effective. Plus short-course antibiotic intervention has shown reduced selective pressure driving resistance.

A recent release by the South African Antibiotic Stewardship Programme (SAASP) states that while it supports all evidence-based means of reducing unnecessary antibiotic use, it cannot currently support the BMJ report’s call to stop antibiotics early based on patients’ subjective feelings of improvement.

‘Although many experts believe that stopping antibiotics early (ie when the patients feel better) may be safe, the evidence for this is largely anecdotal,’ it states. ‘Futhermore, current evidence tells us that some types of infections of the blood, brain, heart, skin and bones need long courses of antibiotics whether or not the patient feels better. A major change in advice in the absence of firm evidence is also likely to cause confusion for the public.’

The SAASP urges healthcare professionals to prescribe antibiotics only to patients who have bacterial infections that require treatment. And states that guidelines should be followed where evidence exists that duration of treatment can be safely reduced for specific infections. SAASP joins the international call for more trials and studies to better inform guidelines on a broader range of bacterial infections.

Van Jaarsveld adds that as healthcare practitioners, we need to ensure that antibiotics are only prescribed to patients with bacterial infections that require treatment. ‘We need to urge the public not to pressure their practitioner for an antibiotic prescription, and encourage them to contact their doctor if they feel better to discuss the options to stop antibiotics early.’

References:

  1. http://www.bmj.com/content/358/bmj.j3418
  2. Statement / press release from SAASP
  3. The New Antibiotic Mantra – Shorter is Better, Brad Spellberg, JAMA Internal Medicine, September 2016, Vol 176, Number 9

 

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