Professor Lyn Gilbert started a discussion going with her recent MJA piece.
Health and Wellbeing (ABC) took up the discussion with a further piece teasing out some of these issues- Antibiotics – when is enough enough? Full text below. The community discussion that followed on the ABC News Facebook page was very interesting and diverse!
Also look at this radio interview from Prof Lyn Gilbert on the ABC this week:
Full text of the Health and Well-being story –
How many times have you been told that if you’re prescribed antibiotics, you must always finish the full course, even if you’re feeling better?
The popular notion has always been that if you don’t complete the full course, you’re encouraging the development of antibiotic resistance.
But in recent years, this approach to antibiotic use has changed, and now the view is that we only need take antibiotics for the shortest possible duration needed to get bacterial infection under control, and not a tablet longer.
However there are some important exceptions and experts like Dr Andrew Boyden, from NPS MedicineWise stress you should not stop antibiotics early without talking to your doctor first.
Antibiotic resistance is one of the greatest medical challenges facing us, as it threatens to make our arsenal of antibacterial weapons ineffective against even the most common bacterial nasties. The medical community is therefore re-examining and challenging many long-held assumptions about how to prescribe and take antibiotcs.
“We really want to be short, sharp and directed with antibiotic treatment, wherever possible,” says Dr John Ferguson, infectious diseases physician and microbiologist with Hunter New England Health.
“There’s evidence showing that very short durations of antibiotic treatment are effective in a variety of conditions including urinary tract infections and pneumonia,” says Ferguson.
“For example, with pneumonia, there’s a vast amount of paediatric and adult data showing that three days is enough – if you’ve improved by the three-day point, that’s enough.”
This turn-around has come about because we now understand a lot more about how we should be using antibiotics, not only to treat infections but also to reduce the risk of resistance developing.
Not so benign
One of the important revelations in medicine has been that antibiotics aren’t quite the benign silver bullets they were once thought to be, says Professor Lyn Gilbert, infectious diseases physician and senior staff specialist at Westmead Hospital.
“There’s been a tendency in the past to assume that antibiotics are terribly safe, and just start antibiotics ‘on spec’ on the grounds that if you’re wrong it’s not going to be a big problem,” says Gilbert.
“But now we realise of course that it is potentially a problem, because it’s been happening for so many years, so frequently, that resistance is starting to develop.”
What we now know, says Gilbert, is that resistance is generally proportional to the total amount of antibiotics being used in a population.
“The more antibiotics are used in a community or in a hospital, the more likely you are to develop resistance,” she says.
So someone continuing to take antibiotics after their infection has resolved, when there is no medical need for them to do so, is contributing far more to this overall problem than someone stopping a course of antibiotics when they feel well enough to do so, even if they haven’t finished the full course.
Australia has one of the highest rates of per capita antibiotic use in the world, says Dr Andrew Boyden, clinical advisory at the NPS MedicineWise, so while we’re getting better at cutting down on inappropriate prescribing, we’ve still got a long way to go.
“It’s raising awareness about when antibiotics are not needed at all,” says Boyden, pointing out that many in the community still expect to be prescribed antibiotics for a cold or flu.
However he also stresses that the decision about how long to continue a course of antibiotics should always be on the advice of your doctor.
“It’s not to take into your own hands and say ‘I’m feeling better, I should stop’… unless the doctor has given you guidance around that.”
Antibiotics – while generally very safe – also have side effects.
“Antibiotics not only kill off the organisms causing infection but will also affect all the bacteria in the gut and all the other places where [you find] normal, important bacteria that are important for health,” Gilbert says.
Studies suggest that even extremely short courses of antibiotics have long-lasting effects on the bacterial make-up of our guts – called the microbiome – and it can take a long time for these to return to normal.
In some cases, antibiotic treatment can allow the flourishing of a species of gut bacteria called Clostridium difficile that is often resistant to antibiotics and is responsible for antibiotic-associated diarrhoea.
The challenge is finding the balance between too much and too little therapy. It’s virtually impossible to set down hard and fast rules about how long people should continue antibiotic therapy, and even clinical guidelines generally leave it up to the doctor to decide how long a course to prescribe for difference conditions.
“It’s still quite a lot of an art, it’s that sort of clinical judgement that’s required,” Gilbert says.
“What you’re hoping to do is to kill enough of the bacteria so that the patient’s normal immune response and defences will be able to kick in and they’ll really clean up the last few on their own if the antibiotics haven’t killed them all.”
For some conditions, that might only be a few days of treatment, even in the case of infections as feared as meningococcal sepsis.
However there are a few notable cases where it’s essential to complete a full course, such as bacterial infection of the heart valves (called endocarditis) or a throat infection with streptococcus A bacteria, which can lead to a more serious condition called rheumatic fever if the bacteria aren’t eradicated.
Issue of fixed sizes
Boyden says another complication is the fact that antibiotics generally come in fixed pack sizes, so patients will often be given more antibiotic tablets than they need.
“Part of the confusion lies in that we don’t necessarily have a correlation between, for instance, the pack size of an antibiotic that is dispensed, and what might actually be recommended on the prescription in terms of the number of doses taken,” says Boyden.
Some people might therefore take a whole pack, rather than only taking the number of doses prescribed by their doctor.