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Should Fighting Antibiotic

Resistance Always Include
Finishing a Prescribed
A group of experts takes a controversial stance on how to control superbugs

By Dina Fine Maron on July 26, 2017



Superbug Explosion Triggers

U.N. General Assembly

Antibiotic Resistance Is Now

Rife across the Globe

Microscopic view of staphylococcus, a group of bacteria that can become resistant to certain
antibiotics and cause serious or fatal infections. Credit: Stocktrek Getty Images

If there were a battle hymn against antibiotic resistance, it would have one Supercharged Tuberculosis,
Made in India
common refrain: Every inappropriate prescription or insufficient dose
strengthens the enemy. It may kill weak bacteria but it wont eliminate
stronger, drug-resistant ones that can move in and multiply. Eventually
those robust microbes can outsmart available drugs, and even pass on The viruses that spread
survival instructions to other bacterial strains.Thats why most doctors antibiotic resistance

along with the World Health Organization and the U.S. Centers for
Disease Control and Preventionurge patients to always complete
prescribed drug courses, even after they feel better. Taking too small a
dose or stopping early, they reason, could fuel surges in drug resistance.

But a group of U.K. infectious disease experts is urging physicians and

public health experts to change their tune. In a commentary published
Wednesday in the British Medical Journal, they wrote, The complete the
course message has persisted despite not being supported by evidence
and previous arguments that it should be replaced. ... Nevertheless, there
is evidence that, in many situations, stopping antibiotics sooner is a safe
and effective way to reduce antibiotic overuse.

The authorsMartin Llewelyn, a professor of infectious diseases at

Brighton and Sussex Medical School, and nine British colleaguespoint to
recent studies that have shown shorter courses of certain drug classes
such as quinolones are as effective as the longer courses that have been
recommended in the past.

Yet the authors are not just calling for more studies that might lead to
shorter standard treatment courses. They are saying that in the short-term
the always complete the course message should be dumped. Research
is needed to determine the most appropriate simple alternative messages,
such as stop when you feel better, they wrote. They assert that there is
also no evidence strong enough to support many of the current guidelines,
a situation that forces physicians to rely on assumptions or historical
practice to decide antibiotic treatment.

Drug resistance experts applauded the suggestions to reduce unnecessary

medication use and to improve standard treatment protocols when
possible. But they were skeptical about changing the finish your pills
messaging or significantly altering outpatient care. My thought is that
this is a radical stancealthough in some ways correct, says Lance Price,
a microbiologist and director of the Antibiotic Resistance Action Center at
The George Washington University. This [commentary] is a really good
thought piece, but I think they go too far in saying we need to stop this
messaging. We know antibiotics are not smart bombs or snipersthey do
not target only one desired body part like the bladder, as we would like.
But to say, Lets pull the plug on this messaging without providing a
reasonable, actionable countermessage is totally irresponsible.

Lauri Hicks, director of the Office of Antibiotic Stewardship at the CDC,

says she agrees that there are many unanswered questions about
appropriate drug treatment courses. But she cautions that patients should
not stop taking their prescribed antibiotics on their own. I recommend
that if a patient is feeling better while taking a course of antibiotics, that
the patient or the patients family should consult a physician to see if
those antibiotics can be safely stopped, she says. 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.

Bacteria have developed multiple tactics to boost their resistance,

depending on the infection and antibiotic involved. Some strains have
learned how to expel an antibiotic before it can do any damage. Others can
effectively neutralize an antibiotic by changing it in a way that makes it
harmless to them. In some cases bacteria have mutated to change their
outer structures so an antibiotic cannot recognize them or attach to them
rendering the drug useless.

Longer courses of antibiotics put selective pressure on bacteria in the

body, which can help the microbes resistance grow. As a result, infectious
disease experts currently try to find a balance between making sure drugs
are effective at knocking out harmful bacteria while keeping the treatment
duration to the bare minimum required to stamp out an infection. The
Infectious Diseases Society of America (IDSA) has changed some of its
guidelines for certain medications, based on recent studies that show
shorter courses suffice. But some studies indicate shortening treatment
courses would leave patients vulnerable to a resurgence of infection or, in
some cases, potentially result in selective growth of resistance organisms.

Existing recommendations are largely based on clinical trials, says Helen

Boucher, a professor of medicine and infectious diseases at Tufts Medical
Center and a spokesperson for the IDSA. I think the spirit of this paper is
very much in line with what IDSA advocates for, Boucher says. 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. The
incentive to study these shorter courses needs to come from funders like
the National Institutes of Health, she adds.

Llewelyn and his co-authors suggest some specific steps for the path
forward. They wrote that a common practice in hospitalsa daily review of
a patients continued need for antibioticsmust become more common in
primary care as well, because that is where some 85 percent of
prescriptions are written. (Many experts, including Hicks, say this
recommendation is probably unrealistic due to the need to pay for follow-
up visits and limitations on both doctors and patients time in an
outpatient setting.) The authors also call for fundamental changes in
public health and drug treatment messaging: Public education about
antibiotics should highlight the fact that antibiotic resistance is primarily
the result of antibiotic overuse and is not prevented by completing a
course, they wrote. Such big changes in messaging are not yet ready for
prime time, Price says.

No current guidelines suggest stopping drug treatment partway through a

recommended treatment course. For example, the CDC has often said in
its public materials and reports, Take antibiotics exactly as the doctor
prescribes. Do not skip doses. Complete the prescribed course of
treatment, even when you start feeling better. But the CDC and IDSA say
they are continually reviewing the literature and support guidelines based
on new information.

Changing standard prescribing practices will likely be challenging, the

commentarys authors acknowledge, pointing to the finish your drugs
education in U.K. schools. The idea is deeply embedded, and both
doctors and patients currently regard failure to complete a course of
antibiotics as irresponsible behavior, they wrote. Even designing
experiments to test reducing antibiotic courses remains difficult, they
added, because participants are often invited to consent to receive
shortened antibiotic treatment on the basis that this could reduce the risk
of antibiotic resistanceyet they are taught from school that it increases
this risk.

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Dina Fine Maron

Dina Fine Maron is an awardwinning journalist and an editor at Scientic

American covering medicine and health. She is based in Washington, D.C.

Credit: Nick Higgins

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