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August 10, 2017

A controversy erupts: Do patients really need to finish all of their antibiotics?

Daily Briefing

    A group of British infectious disease experts in a new article argues that doctors should abandon current guidelines directing patients to finish their prescribed course of antibiotics even after their symptoms dissipate—but some say calls to abandon that practice are premature.   

    How to streamline your PA processes for provider administered drugs

    Antibiotic resistance: A growing global concern

    Current guidelines for antibiotics endorse the "finish the course" approach as a way to prevent antibiotic resistance. For instance, CDC recommendations state, "Take antibiotics exactly as the doctor prescribes. Do not skip doses. Complete the prescribed course of treatment, even when you start feeling better." The theory is that if a patient fails to finish the course, some stronger bacteria could survive and reproduce, ultimately breeding a harder-to-fight—or drug-resistant—infection.

    Researchers make a case against the approach

    But a group of infectious disease experts from the United Kingdom are pushing back. In an opinion piece published on July 26 in the BMJ, Martin Llewelyn from the Brighton and Sussex Medical School, Tim Peto from the Oxford Biomedical Research Center, and their co-authors argue that the "complete the course" message is "not supported by evidence."

    Further, they argue that "there is evidence that, in many situations, stopping antibiotics sooner is a safe and effective way to reduce antibiotic overuse." For instance, authors point to recent studies that have found that for certain drug classes, such as quinolones, a shorter course of treatment is as effective of the longer courses conventionally recommended. 

    The authors argue, "Completing the course goes against one of the most fundamental and widespread beliefs people have, which is that we should take as little medication as necessary."

    Still, the authors acknowledged that "research is needed to determine the most appropriate simple alternative message, such as stop when you feel better."

    In addition, the authors call for "public education about antibiotics" that "highlight the fact that antibiotic resistance is primarily the result of antibiotic overuse and is not prevented by completing a course."


    Drug resistance experts praised the questions raised by the opinion piece but voiced skepticism about upending the "finish the course" message without further research.

    Sarah Fortune, a professor of immunology and infectious diseases at the Harvard T.H. Chan School of Public Health, called the shortening of antibiotic treatment a "double-edged sword."  She said research has shown that some infections—such as urinary tract infections and typhoid fever—that are typically treated with a week-long course of antibiotics can be safely defeated with a single day of treatment. But other infections, such as tuberculosis, require the full prescribed treatment course to be effective.

    Helen Boucher, a professor of medicine and infectious diseases at Tufts Medical Center and a spokesperson for the Infectious Diseases Society of America, said, "I think the spirit of this paper is very much line with what IDSA advocates for." She noted that current guidelines are based on clinical trials, but said more research into shorter courses should be conducted. "As part of the strategy to combat the antibiotic resistance crisis, we should think about strategies to use less drugs and use drugs for shorter duration," she said.

    Lance Price, a microbiologist and director of the Antibiotic Resistance Action Center at George Washington University, said that while the researchers' stance is "in some ways correct," he felt they went "too far in saying we need to stop this messaging." For the researchers "to say, 'Let's pull the plug on this messaging without providing a reasonable, actionable countermessage' is totally irresponsible," Price said.  

    Lauri Hicks, director of the Office of Antibiotic Stewardship at CDC, said she agrees that researchers still have much to learn about appropriate drug treatment courses. However, she warned that patients should not make the decision to stop taking antibiotics independently.

    "I recommend that if a patient is feeling better while taking a course of antibiotics, that the patient or the patient's family should consult a physician to see if those antibiotics can be safely stopped," Hicks said. "I think it really needs to be a decision made with input from the provider. In certain circumstances taking the full course is important, and it may not be as important for some other, milder infections."

    And Yonatan Grad of the infectious disease division at Brigham and Women's Hospital said the notion that patients should stop taking antibiotics when they "feel better" is too "vague and subjective a recommendation." He said, "How are you to judge 'feeling better'? Symptoms mostly gone? Entirely gone? Some symptoms, but not others?" (Fine Maron, Scientific American, 7/26; Eunjung Cha, "To Your Health," Washington Post, 7/27; Glatter, Forbes, 7/28; Llewellyn et al., BMJ, 7/26).

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