If there’s one thing that doctors can agree on, it’s that negligent prescription and use of antibiotics can give bacteria the edge. But some doctors are questioning the old dogma preached to all patients – that they must complete all of their antibiotics lest they grow more resistant bacteria. In a recent head-turning article, a group of doctors from the United Kingdom argue that the “complete the course” mantra is flawed, and that needlessly finishing your antibiotics could actually promote the resistance that everyone is trying to prevent.
The “complete the course” idea started in the 1940’s during the dawn of the antibiotic era. Doctors observed that an infection seemed to worsen, even leading to death, if it wasn’t thoroughly treated with antibiotics. In fact, in his 1945 Nobel Prize acceptance speech, Alexander Fleming, who discovered penicillin, painted a grim scenario where insufficient use of antibiotics contributed to a lethal bacteria-resistant infection. “If you use penicillin, use enough!” he famously cautioned.
The idea behind finishing your antibiotic prescription is quite compelling. Antibiotics kill bacteria, but if there’s not enough of the medicine, some bacteria will be left over. These survivors, having been strong enough to withstand the initial drug exposure, are likely to proliferate in the absence of antibiotics. The future generations derived from this population are sure to have picked up more mutations that, over time, can make them completely resistant to our current antibiotic arsenal.
But UK researchers say there’s a big flaw behind this long-standing wisdom. They argue that there’s poor scientific evidence to support antibiotic resistance at the individual level; rather the phenomenon is at the population level. “For common bacterial infections no evidence exists that stopping antibiotic treatment early increases a patient’s risk of resistant infection,” the authors stated as one of the key messages in the opinion piece.
"'Complete the course' is taught very widely, but it's been known to be wrong for quite a while," said Dr. Martin Llewelyn, a professor of infectious diseases at Brighton and Sussex Medical School in the U.K. and the paper’s lead author.
"We're not at all saying that patients should stop when they feel like it or that patients should ignore their doctor's advice," said Dr. Tim Peto, professor of medicine at the University of Oxford and the paper’s co-author. Instead of “complete the course,” the group is encouraging a shift towards “exactly as prescribed.”
"'Exactly as prescribed' is OK and at least it gives flexibility in the discussion between doctor and patient about when to stop — perhaps when [the patients] have been reviewed, or have a certain test result, or have been better for a certain period of time," said Llewelyn.
But herein lies a catch-22: how do doctors determine what is “exact”? Currently, the length of an antibiotic regimen is guided by clinical trial data. But if Llewelyn and colleagues argue this guidance is too broad, what can doctors rely on instead when they first write the prescription? Furthermore, the follow-up tests under the “exactly as prescribed” model can put significant stress on both patients and the healthcare system. In a society that’s already strapped for time and money, it’s not hard to imagine a patient neglecting a follow-up visit to determine whether they should continue antibiotics or stop. Are we equipped to handle the consequences? Perhaps not.
Understandably, the opinion article has drawn much criticism from the medical community. Some doctors argue that “exactly as prescribed” is confusing to patients, and that we need more evidence before such a drastic change in practice can be implemented.
In the meantime, don’t throw caution to the wind and stop your antibiotics on a whim. It’d be wise to consider your antibiotic use seriously, and to consult your doctor before you make any changes.