Antibiotic Course: Conventional Wisdom Challenged!

Antibiotic Course: Conventional Wisdom Challenged!

Dr Guruprasad Mohanta

Professor

Annamalai

Antibiotic Resistance is a global a global health emergency. The World Health Organization warns that the world is running out of antibiotics. In the midst of this crisis, new debate has emerged on the ideal duration of antibiotic treatment. It has been advocated to complete the course of antibiotics to prevent the emergence of bacterial resistance. This conventional wisdom of completing the course is challenged now.

            The British Medical Journal article entitled “Antibiotic course has had its day” published in July 26, 2017, raised serious concern of this advocacy of ‘failing to complete a prescribed antibiotic course contributes to antibiotic resistance”. The authors argued that there is no evidence and it is time for the policy makers, educators, and doctors to drop this message.  The article encourages to debate and come to a consensus in order to avoid confusion. 

The bacterial species that live harmlessly in the gut, on our skin and mucus membranes, or in the environment can also cause disease as opportunist pathogens. For such organisms, resistance selection occurs predominantly during antibiotic treatment of other infections. Resistance in opportunists may be passed easily to other strains of the same species of bacteria or to different species. Key examples include methicillin resistance in Staphylococcus aureus, extended spectrum β-lactamase   producingEnterobacteriaceae and carbapenem resistance in Klebsiella pneumonia. The longer the antibiotic exposure these opportunistic bacteria are subjected to, the greater the pressure to select for antibiotic resistance.  Hence, smaller duration of treatment is advocated. Shorter treatment not only improves medication adherence but also economic too.   However, longer treatments are necessary for infection like Tuberculosis. WHO clarified that feeling better, or an improvement in symptoms, does not always mean that the infection has completely gone. Your doctor has had years of training and has access to the latest evidence – so always follow their advice. It is the prescriber who decides on his/her wisdom that how long antibiotics to be continued.  Some authorities: US Center for Disease Control and Prevention (CDC) and Public Health of England have replaced “complete the course” with messages take antibiotics “exactly as prescribed.” Inappropriate use (prescribing, dispensing or self-medication) is bigger contributor to resistance development than the factors like patients not-completing the course.

There have been conflicting research reports on ideal length of antibiotic use. Just to cite two reports: Study on use of antibiotics in young children’s ear infection showed that stopping of antibiotics after five dayswas reported to be less effective than the standard ten days of treatment. On the other hand, the treatment of kidney infection reported that the seven days of antibiotic therapy was as effective as standard 14 days of treatment.          While the appropriate duration of treatment is not clear, and more evidence need to be generated through research, it may perhaps be appropriate to continue the duration as advised in standard treatment guide or based on clinical wisdom of the prescriber. Let us wait for the current consensus.