The shortest course is bad advice. When you do take antibiotics, you don't want to create antibiotic resistant bacteria.
That's why they tell you to always take the full course, even if you feel better.
this post was submitted on 22 Dec 2023
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tl;dr - Asking your doctor for the shortest reasonable course is a good thing that will both protect you as a patient as well as minimize your risk of antimicrobial resistance. But the key phrase is ask your doctor, do not take it upon yourself to decide when to stop them. Take whatever course you're prescribed.
Pharmacist and 4th year medical student with a passion for antimicrobial stewardship and infectious disease.
Historical treatment duration for most infections was truly quite arbitrary. Evidence for most infections, when it is actually tested, have pretty consistently demonstrated shorter treatment durations than were classically taught (10-14 days for pneumonia now generally 5-7, 14 days for Gram Negative Bacteremia now 7, etc). There is a subset of infectious disease doctors that are bucking the trend of historical "you have to complete your course advice" for some infections. In general, what I have seen is recommendations to discontinue antibiotics with significant clinical improvement AND a non-life-threatening infection in a non-sterile body cavity. So nobody is shortening course durations for empyemas or endocarditis.
The issue becomes expecting patients to know what constitutes clinically meaningful recovery and whether or not their infection is one of the "safe" ones to stop antibiotics earlier.
At the end of the day, I totally disagree with your premise, as we should always strive for the minimum safe antimicrobial exposure. However I do agree that telling patients "shorter is better" is bad advice because I don't want laypeople making these decisions when usually no-ID physicians don't make them.
NYT undoing years of “finish your fucking course”
Yup, it's hard to have a good discussion about the changing tides in ID without feeling like you're causing a bunch of backsliding and non-compliance. I think being honest with people that the data is generally poor about how we select durations is the moral thing to do. But I do want you to just take your damn antibiotics as prescribed instead of going rouge because you heard "shorter is better" and your pneumonia recurring.
NYT undoing years of “finish your fucking course”
WITH CITATIONS.
“finish your fucking course” is wrong, and pigheaded people that refuse to review scientific evidence and reshape their opinions accordingly do a lot of harm and make it impossible for the scientific method to work and for the scientific community to update the public when the evidence and consensus changes.
Look man, I gave the link a good and thorough read. Leave the hate at the door. I already said it’s good research, it’s just kind of all over the place.
What that link is saying is already in practice. If it’s a viral infection you won’t get antibiotics, if it’s a clean procedure you probably won’t get antibiotics for more than a day.
That’s already in practice. Because studies show antibiotics are probably not the most important in those select very few cases. Those are good practice methods and are part of IDSA guidelines.
What is not in practice, and what I feel is the main point of confusion here, is that everyone should take shorter courses.
Nope absolutely not. If your doctor says take it for x days then you do it because they already went through the protocol and have deemed X days to be the best course of action. Your doctors will let you know if you are a prime candidate for a shorter duration of therapy, they’ll do all the research for you because they will not risk your death by having your disease state possibly recur and in a more aggressive manner.
Telling everyone that everything should be shorter will only confuse patients. I promise that if you are a prime candidate for a shorter duration, your doctor will know, and will give you the appropriate course of treatment.
Another thing is this quote from the link you provided
“Antifungals also do collateral damage: Disruption of Intestinal Fungi Leads to Increased Severity of Inflammatory Disease https://news.weill.cornell.edu/news/2016/06/disruption-of-intestinal-fungi-leads-to-increased-severity-of-inflammatory-disease. Immunological Consequences of Intestinal Fungal Dysbiosis (2016).
Long-term impact of oral vancomycin, ciprofloxacin and metronidazole on the gut microbiota in healthy humans (Nov 2018)”
It goes on to mention antifungals and then talks about different drugs not related to antifungals but that are instead used as additional therapy for when the exact cause is unknown. I was thinking it would mention AmphotericinB, Voriconazole, Itraconazole, Micafungin etc.
It just seems to be all over the place and is not a great source to base medical decisions off of. I’m sorry.
I'm not as confident as you are in the evidence-based nature/abilities of doctors. See https://forum.humanmicrobiome.info/threads/doctors-are-not-systematically-updated-on-the-latest-literature-what-t.27/
Well.. here’s my advice. Bring it up to them if you feel they didn’t remember.
I guarantee the pharmacy is also tearing a new one into the doctor for not following guidelines. (If that’s the case) Some pharmacists will outright deny the prescription until either the doctor changes it to what is needed, or another pharmacist is pressured into doing as the doctor says. This has a paper trail. All decisions do.
Medicine is so complicated because there are soooo many things that can be wrong. Usually we get over that by creating specialty care:
Usually, doctors at hospitals are dedicated to a single specific thing. ICU-Trauma, infectious disease, dialysis, diabetes. And they have a team that is also part of that specialty care, pharmacists, nurses, technicians that are all familiar with the specialty.
If an ICU doctor realizes that there is an infection going on, the Infectious Disease team will work on it alongside with the doctor that will treat the trauma as 2+ heads are always better than one.
At the end of the day, your doctor will have to go with what’s better because he has a team dedicated to knowing the exact specifics of all antibiotics and therapies.
As for outpatient treatment, the pharmacy will not fill anything that looks out of the norm before getting some sort of reasoning from the doctor.
Please don’t hesitate to ask any questions when you’re under someone’s care. I’m sure you’ll get an eye roll but shorter durations ARE important, sometimes.
Infectious Disease takes years of mastery, I am nowhere near that, just the basics. The doctors and pharmacists in charge of infectious disease have been buried in literature for years/decades which is why I can only paint a picture and not necessarily describe all the intricacies.
Edit: also brother, sue for malpractice if that was the case for you. It’s not all bad, but you’re right to say that some doctors are meatheaded. That’s why there is a paper trail and guidelines to follow. It’s important that there is trust in our medical pros. I hope that one day you can feel safe again in the hands of doctors.
You're citing forum posts to discussions (with some evidence mentioned within) to support this supposition that doctors are horribly informed and out of date. But I'd like to point out that this is being vastly overblown, and even a 5-10 year out-of-date medical professional has immensely more knowledge and safe ability to recommend therapy than a layperson. I can't pretend to know the credentials of the individual you're responding to, but they're clearly well versed in clinical infectious disease based on their comments, and you're not supporting your position by citing a forum instead of the actual primary literature that supports your position.
even a 5-10 year out-of-date medical professional has immensely more knowledge and safe ability to recommend therapy than a layperson
I know from a plethora of experience that this is wrong. It's also way too broad of a claim. Laypeople knowledge varies a lot. I know first-hand of some laypeople who are actually top experts in scientific/medical fields and I know of people with medical degrees who promote themselves as experts in their field yet they spread harmful misinformation that severely harmed patients and nearly got them killed.
you’re not supporting your position by citing a forum instead of the actual primary literature that supports your position
I think this is poorly worded, but I think I still understand what you were trying to say. There is no reason for me to duplicate the forum post here. There are citations there. Copying them here doesn't make them more legitimate.
That's wrong. Stop confidently spreading harmful misinformation. I already provided citations that you should have checked before making that statement: https://humanmicrobiome.info/antibiotics/
EDIT: And to all the people who upvoted the person I’m responding to, you should not be upvoting people who make medical/scientific claims without a citation, especially when they’re contradicting a highly reputable news source (NYT) that contains scientific citations and expert commentary.
The real information is to ask your doctor and be careful with advice from social media.
That is not a website doctors look at. Medical procedures are formed and approved through NIH articles with vast testing pools across many geographical areas.
If you would like more info, please look up the IDSA guidelines
That is not a website doctors look at.
Wrong. Also irrelevant. It contains a plethora of scientific citations, which is all that matters.
Medical procedures are formed and approved through NIH articles with vast testing pools across many geographical areas.
Gibberish that tells me you don't know what you're talking about, but want to sound authoritative.
I’m letting you know that those links are all to small journals. Good luck getting huge corporations to follow that advice versus tried and true advice. I rather a patient live than risk the infection returning and killing them.
It’s not invalid but until IDSA adopts any of that… it’s not medical advice for anyone, just research.
The IDSA guidelines are all based on huge clinical trials. I don’t know what you’re talking about because it’s what everyone has to follow to treat infectious diseases. There is variations between hospitals and providers but it is all based off of that.
I would like to point out, the NYT is a reputable news site but cannot even remotely be trusted with medical information/recommendations. I can't tell you the last time I read a medical news piece from any source (and the NYT is the primary place I get my news) that I couldn't read it and say "well that's a gross oversimplification" or worse "this is blatantly misrepresenting the scientific author's conclusions". Holding up the NYT as a source of medical/scientific truth is just demonstrating how scientifically illiterate you really are.
Wow, projecting hard with that comment. This is a fantastic and well-cited article, and your comment does nothing to debunk anything in it, and you end with a baseless "you're scientifically illiterate" comment. Amazing.
Hello all, I'm a pharmacist and 4th year medical student with a passion for antimicrobial stewardship and infectious disease. Just wanted to share my overall thoughts on the article.
The author's point of "finding out if you really need an antibiotic" is honestly one of the central issues in modern antimicrobial resistance coming from two fronts: patients who demand an antimicrobial for a non-indicated reason, and doctors who for various reasons excessively prescribe antibiotics. I could wax on this for hours, but at its core, the single most important thing we can do to decrease antimicrobial resistance is decreasing total antimicrobial exposure. That means fewer prescriptions for shorter courses of narrow-spectrum antibiotics. Unfortunately every bit of this requires more buy-in from patients and more work from clinicians.
To go along with my point above, asking your doctor to make sure you're getting the shortest possible duration is the single best thing you as a patient can do to help with these issues (other than just not demanding antibiotics if your doctor says no, but that's a low bar). The key word here is ask though. There's a huge amount of clinical experience and evidence that is used to determine when it is safe to stop antibiotics. And as much as I believe in patient autonomy and educating my patients, frankly antibiotic selection/course duration is not something the general public is capable of independently making decision on. Ask your doctor, and take what they prescribe for how long they're prescribed for, and if you have issues then call them to discuss it.
With regards to probiotics, it's an interesting topic that we don't have a ton of great data for and physicians are fervently behind or against them in my experience. The fact is we just don't know enough about them, and most aren't regulated well enough to give good information about them. Interestingly, there was a recent study which suggested higher rates of central line infections with the organisms in the probiotics in individuals given probiotics while they had a line in place.
Lastly, I think I have to disagree with Dr. Blaser. Medicine doesn't overvalue antibiotics. We certainly underestimate their risks, but antibiotics are some of the most effective and life-saving medications we as a species have ever developed. Countless lives have been saved solely from their development, and very very few therapies have a NNT as low as appropriate antimicrobial therapy. They truly are astonishingly good medications when they are indicated. The issue is simply prescribing them when they aren't indicated, which is a big part of why we're in the mess we're in, and is in large part driven by underestimating the risks they pose.
I’m considering this to be harmful information.
When you wipe out all of your microbiome, chances are it returns to normal in the following months after antibiotic treatment.
Your doctor will know if you need antibiotics because there is a positive test for a bacterial infection.
You have to take the full course to prevent resistance from forming. Resistance will form, no matter what, if you don’t fully eradicate the foreign organism. Studies are conducted to find out what the best course duration is in order to completely eradicate the organism. (STOP-IT trial for Intra Abdominal Infections suggest 4/5 days vs 10 day norm to be effective)
That is something you don’t want to happen because then you have to use stronger antibiotics which will absolutely do more than make your tummy hurt. (Ouch my kidneys)
The only medical indication for a FMT is a C.diff infection that is recurring. This means your microbiome has been wiped and replaced with C. Difficile. A bug that causes severe diarrhea.
If you let resistance flourish, then every single time someone needs to take an antibiotic it will be even more likely they develop a C. Diff infection due to the microbiota being wiped even harder. Resistance will become even more common due to the least harmful antibiotics not being available for use.
If you prevent resistance you prevent the use of harder antibiotics which prevents microbiome damage which prevents c. diff.
When you wipe out all of your microbiome, chances are it returns to normal in the following months after antibiotic treatment.
Harmful misinformation. A plethora of citations were already provided that debunk that claim.
You have to take the full course to prevent resistance from forming.
Harmful misinformation that is contradicted by the citation in the article and numerous other citations that I provided in the OP and my introductory comment.
If you let resistance flourish, then every single time someone needs to take an antibiotic it will be even more likely they develop a C. Diff infection due to the microbiota being wiped even harder.
This makes no sense. I'll rephrase it to make it sensical and accurate:
If you overuse antibiotics, every time someone needs to take an antibiotic it will be even more likely they develop a C. Diff infection due to their microbiota being wiped out previously.
https://www.idsociety.org/practice-guideline/practice-guidelines/#/+/0/date_na_dt/desc/
I’ll play your game. Everything in here refutes and proves all your claims wrong, with clinical trials and sources for your enjoyment.
Everything in here refutes and proves all your claims wrong
Not even close. You seem to be the only one playing games.
Some relevant info I shared yesterday:
Resistance can be solved by restoring lost microbes with FMT: https://humanmicrobiome.info/antibiotics/
That's not exactly true. FMT isn't going to fix your MRSA colonization, and it doesn't inherently remove resistance genes from the population of bacteria in your gut. If those genes produce a survival disadvantage, they may be selected against and become a minor serotype in your GI tract, but that doesn't mean that it is eradicated.
Also, you seem to be sharing a lot of links from humanmicrobiome.info, which I would advise against. While I can appreciate the primary author's dedication to the topic and willingness to cite his sources, his website is not peer reviewed, and he explicitly states he is a proponent of FMT, introducing bias which is not being balanced by a peer review process. Not to mention he admits he is a layperson with no formal medical training/experience. I would direct you to IDSociety.org which is the home of the Infectious Disease Society of America, who publishes the actual guidelines used by infectious disease physicians in North America.
MRSA is actually covered in the cited links. Here's one for example https://academic.oup.com/ofid/article/6/7/ofz288/5522275.
The gut microbiome regulates the entire body, including the immune system and other body site's microbiomes https://humanmicrobiome.info/systemic. You can see what a great resource it is -- very handy to provide categorized citations.
his website is not peer reviewed
Anyone is welcome to contribute and peer review it.
Yes, it covers intestinal colonization with MRSA. Unfortunately Staph aureus is an uncommon GI pathogen, and the majority of detrimental infections secondary to MRSA come from skin-flora translocation to produce surgical site infections/blood stream infections, as well as translocation from the nares into the lungs to produce pneumonia. We thankfully have another method of nares decolonization. While metallobetalactamase producing Pseudomonas is mentioned as well, I have a very low suspicion that FMT would be useful for resistant Pseudomonal pneumonia or diabetic foot infections/osteomyelitis. FMT certainly has a role to play in ID, particularly for enteric gram negatives and VRE within the alimentary canal, but is not a cure-all for antimicrobial resistance.
For anyone wondering, FMT = Fecal Microbiota Transplants.
It's exactly what it sounds like; through oral or rectal.
I imagine burping after taking it through the oral route would be a special kind of horrible
I tried to find other studies going into this in more detail, especially in regards to targetted antibiotics.
Am I correct in assuming that the future hence lies in getting antibiotics far more target-specific? I don't know how it is in other parts of the world, but over here broad-spectrum antibiotics are already used as a last-ditch effort, usually when there's no time to truly figure out what a patient is suffering from because of their extremely bad overall state. But I assume broader antibiotics are more common around the world?
The trouble is that, as a whole, antibiotics that work against resistant organisms are inherently more broad. Bacteria develop resistance by either mutating the target site of an antibiotic, decreasing/removing the expression of a target site, increasing removal of the drug from the bacterial cell, or preventing entrance to the cell.
These changes are relatively antibiotic agnostic (in the sense that they do not target one specific antibiotic, they target a general chemical structure which is shared among a class of antibiotics), and in most cases, if you develop a drug which is able to circumvent one of these problems, it will continue to work on the wild-type bacteria of that species (by definition making it broader). I am unaware of any antimicrobial which is effective against drug-resistant organism which has no efficacy against the wild-type of that organism.
I agree with the other poster that phage therapy likely represents a future avenue for antimicrobial resistance. Unfortunately antibiotics will (at least for the foreseeable future) be required as to effectively use phage therapy you must identify the organism and then select appropriate phages which will kill the bacteria, which takes time that a sick patient may not have without antibiotics. We also haven't quite figured out how to keep our immune system from eradicating the bacteriophages, particularly for infections requiring longer treatment such as endocarditis.
There is a currently existing technology which allows for genetic identification of bacteria and fungi in positive blood cultures approximately 1 day faster than classical methods of culture and biochemical testing. There is active research into changing these tests slightly to be able to function on other body fluids (pus, pulmonary secretions, urine, etc) as well as to be able to function on fresh blood samples instead of waiting 1-2 days for the culture to become positive from bacterial growth, but these technologies are not ready for clinical use, and until they are, broad spectrum antibiotics will be a necessity.
as to effectively use phage therapy you must identify the organism and then select appropriate phages which will kill the bacteria, which takes time that a sick patient may not have without antibiotics
Phage cocktails, FMT, etc... Also, we should get better at speeding that process up if we fund research for it, but we've been instead continuing to rely on antibiotics.
We also haven’t quite figured out how to keep our immune system from eradicating the bacteriophages
Citation? I don't recall that being a thing... phages are ubiquitous in the human body. As much or more so than bacteria. They are the natural way bacteria are kept in check.
Section 2, first paragraph. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6956183/
At their core phages are viruses, there is no reason to expect the host immune system to not recognize them as foreign and attempt to eradicate them outside the GI tract, where most serious infections occur. The GI tract, skin, and to some extent the lower UG tract will likely tolerate these through mechanisms we tolerate colonizing bacterial flora, but colonization, even with antibiotic resistant organisms, is not a primary indication for empiric treatment for eradication. In fact there are some studies that attempting to sterilize the UG tract in colonized asymptomatic women promote symptomatic UTI.
These colonizations become problematic when growth becomes unchecked and infection develops, or they seed infection into another compartment. There is no reason to think something as foreign as a bacteriophage wouldn't be recognized as foreign in a sterile space (kidneys for pyelonephritis, liver abscess from migrated gut flora, endocarditis, etc) where these serious infections occur.
This ties in nicely with your suggestion of phage cocktail therapy. Yes, that can expedite the delivery of phages, however excessive use of phages could result in anti-phage antibodies, limiting future treatment in a method similar to the development of anti-drug antibodies in epoeitin analogues, insulin therapy, antivenin, and anti-inflammatory antibody therapies like adalimumab (Humira)
IMO the future lies in replacing antibiotics with adding instead of subtracting: phages/phage cocktails, FMT, etc. There's also a massive amount of antibiotic overuse for a variety of reasons, including public ignorance about their necessity (lack of) and harms, and emotional thinking and lack of consequences for people in the medical system.
Phages were given up on because antibiotics were an easier solution and the consequences aren't always immediately obvious. But that decision has likely played a major role in getting to the current chronic disease crisis.
Sounds interesting.
I will say that having had two eye infections, one resulting in a surgery and the other being solved with antibiotics before it got to bad, give me all the antibiotics, I don't care, before you make me get that surgery again. Straight outta Saw, that shit. But that's an edge case of course.
Probiotics are basically a meme. Fiber is the new hot thing as unsurprisingly your gut biome wants to eat not new neighbours to compete with.
Fiber won't re-add the microbes that antibiotics killed off. Neither will probiotic supplements, but some of them are proven to be beneficial. https://humanmicrobiome.info/probiotic-guide
Thanks for sharing!
Other relevant communities
Yep, I crossposted to two of those already. Feel free to x-post to the medicine one if you want.
Thanks :) I'll try to get to it next time I'm on desktop