
Taking a full course of antibiotics doesn’t help prevent spread of resistance - raldi
http://www.slate.com/articles/health_and_science/medical_examiner/2017/08/stop_taking_antibiotics_once_you_feel_better.html#lf_comment=720520299
======
neohaven
The problem with stopping early is that you may have to start again. A whole
course, since feeling better doesn't mean you have a low enough population of
the bacteria to not reinfect you.

Surely, repeated/massive bottlenecks in a viral population aren't a good thing
for antibiotic resistance.

Of course, the absolute best scenario to avoid resistance is to treat exactly
as needed (say, kill 95% of the bacterial population, let the immune system
clear the last 5%, done) but really, you can't realistically do that right
now.

So you have two choices : Either you tell patients "Take it until the end even
if you feel better!" which leads to _some_ antibiotic resistance, or you tell
them "Take them until you feel better!" which probably leads to reinfection
and use of a _second course_ of the same antibiotic.

Taking exactly enough > Taking more to make sure it's dead > Stopping too
early, requiring the process to be done again.

~~~
ddlatham
However, this doesn't mean that the current courses that are being prescribed
are in the sweet spot, and the article cites evidence showing that courses of
certain shorter durations are _just as effective_ as the currently prescribed
longer courses at curing the infection, with the added gains of being less
likely to produce resistence, more likely to be completed, fewer side effects,
and cheaper.

It's unfortunate that the Slate article reprinting the The Conversation
article discussing the British Medical Journal article used a title of "Stop
taking antibiotics once you feel better" which is not what the underlying
article is claiming.

~~~
13of40
I just had a round of antibiotics for an infected spider bite (no super
powers) and the prescription amount and duration was extremely arbitrary -
2000mg/day of something for 10 days. I'm guessing not only are they not
hitting the sweet spot, but they're prescribing multiple times more than
someone would need, just to be safe, considering they don't know the strain of
bacteria or anything relevant about me besides my weight.

------
lprubin
If you're worried about antibiotic resistance, consider cutting back or
eliminating animal agriculture products from your diet.

According to the FDA, 80% of antibiotics used in the US are given to farm
animals. This is because it is cheaper to give antibiotics to every farm
animal just in case rather than giving the medical care needed to properly
diagnose and treat. Bird flu or swine flu has a decent probability of being
the next epidemic because of this practice.

[http://www.sustainabletable.org/257/antibiotics](http://www.sustainabletable.org/257/antibiotics)

EDIT: My mistake, bird and swine flu are caused by viruses not bacteria and
are therefore not affected by the antibiotic stuffing of farm animals. But the
crowding and conditions of factory farms do contribute to potential bird and
swine flu outbreaks. See my comment below.

~~~
lidlin
> 80% of antibiotics used in the US are given to farm animals

These antibiotics are not the same ones used to treat human infections, and
the correlation between the rise in antibiotic resistant infections and
antibiotic use in livestock does not indicate causation.

> Bird flu or swine flu has a decent probability of being the next epidemic
> because of this practice.

Influenza is caused by a virus, and is unaffected by antibiotics.

~~~
DennisP
It's simply not the case that we use totally different antibiotics for
agriculture.

Here's an article in Scientific American about the health risks of
agricultural antibiotics. One quote: "One study reported that more than 90
percent of E. coli in pigs raised on conventional farms are resistant to
tetracycline."

[https://www.scientificamerican.com/article/how-drug-
resistan...](https://www.scientificamerican.com/article/how-drug-resistant-
bacteria-travel-from-the-farm-to-your-table/)

I guess it's possible that the rise of both antibiotic use in livestock and
antibiotic resistance in their bacteria is completely coincidental, but given
the well-understood causal connection it seems quite unlikely.

------
dzdt
There is a systematic property of the modern medical system to overtreat.

At the first level, if a patient goes to a doctor the expectation is the
doctor should do something to help. If the doctor says, "sorry there is
nothing I can do" the patient will likely leave unhappy and try a different
doctor. This leads to things like prescription of antibiotics for viral
infections. There is no effective treatment, but patients leave happier with a
useless treatment than with a denial.

One thing ignored in the article is that, in this role as a placebo
prescription, a longer course of antibiotics outperforms a short course. That
is because a longer course gives a viral infection a longer time to clear up
on its own.

~~~
yourkin
Secondary infection is a thing. Antibiotics may be prescribed to reduce the
risk of that.

~~~
StillBored
And as anyone with a child recently placed into daycare in a major city will
tell you, what happens is the kid gets the sniffles from a cold
virus/whatever, and it turns into a sore throat, then a bacterial sinus
infection, then a ear infection, and at this point the bacterial infections at
the daycare are resistant to antibiotics, so they end up gradually rolling
down the sickness hill until the doctor prescribes something strong enough to
knock it out.

And god forbid, mom/dad get it. I almost died from some crap my daughter
brought home because the doctor sent me home twice with a "suck it up"
attitude (after I had been "sucking it up" for nearly two months), until I
ended up in the emergency room at 1AM with pneumonia, a massively elevated
temp, and a pleural effusion that was so painful I could barely breath. The
doctor that sent me home called a couple days later (because they took blood
samples and some swabs) with a "we have to see you now" call, at which point I
was like, yah thanks a lot for nothing...

------
autokad
I'm not going to be able to explain my point clearly, but I will try.

you keep seeing rhetoric like this, 'we have antibiotic resistance because
doctors were prescribing it willy nilly' all the time, but it just doesn't
line up.

take a look at the list of diseases that formed / are forming resistance. they
are all diseases you absolutely should have been taking antibiotics for. they
werent diseases that gained super powers because someone was taking penicillin
for the flu.

then you have things like MRSA, which was discovered almost immediately after
antibiotics, however, it was probably discovered because people were
experimenting with antibiotics and that made it show its face. In other words,
it was always around. its documented that people died of such infections
before, we just dont look too much past it because they didnt have antibiotics
at the time.

~~~
devmunchies
85% of all antibiotics sold are for livestock. The volume of antibiotic given
to animals, and the cramped and dirty living conditions of many farms results
in a damn good engine for creating antibiotic resistant bacteria

~~~
autokad
not just livestock, one of our most powerful antibiotics (tetracycline), was
used en-mase to wash down produce such as grapes.

still, things like antibiotic resistant gonorrhea, syphilis, and tuberculosis
scare me the most, and they have nothing to do with livestock.

we are in a bit of a catch 22, we want to treat these diseases, but in doing
so the diseases are getting stronger in an arms race against our technology.
meanwhile our bodies de-evolve due to its dependence on our technology to
defend it.

~~~
devmunchies
> _meanwhile our bodies de-evolve due to its dependence on our technology to
> defend it_

I saw in a documentary a couple years ago that skulls of our ancient hunter-
gatherer ancestors had little to no dental cavities—their teeth were intact.
It was attributed to their very diverse bacteria exposure (being hunter
gatherers) and no sterilization. This changed with farming.

I'm a bigger fan of probiotic research rather than this antibacterial "arms
race".

~~~
shagie
This has more to do with sugar (corn in the americas). For example, in
Wisconsin it is possible to use dental information to identify if there was a
diet of wild rice or corn. [https://www.wpr.org/shows/wisconsins-mound-
builders](https://www.wpr.org/shows/wisconsins-mound-builders)

Farming is in part responsible for the concentration of sugars that bacteria
use.

------
robbiep
This has been well established in medical circles for at least 5 years now,
the difficulty is in ensuring that people in the community cease at an
appropriate time (i.e. Not before it is fully cleared) because that is
potentially worse than taking a 'whole' un-needed course

~~~
danmaz74
Is there any reliable self-managed way to determine what is the appropriate
time?

------
danmaz74
The message could be right, but the unnecessarily condescending and derisive
tone of this article undermines its effectiveness. I for one don't feel any
more informed about the data showing that longer courses of antibiotics create
enhance the chances of creating resistant bacteria, nor about why this
happens.

~~~
mikk14
I think the mechanism might work like this (disclaimer, I'm not a doctor, I'm
just making a theoretical guess):

What can an antibiotic do? Kill bacteria that are not resistant to it. If a
bacterium is resistant to it, it will be unaffected. Now, if you stop taking
it "early" the antibiotic didn't have the time to kill 100% of non-resistant
bacteria. You leave your body in a mixed environment where non-resistant and
resistant bacteria have to compete. If you keep taking it once you feel better
maybe you killed all the non-resistant bacteria. So you leave your body in an
homogeneous environment where only resistant bacteria live, don't have to
compete, and can prosper undisturbed.

~~~
danmaz74
Makes sense; in the end, only experimental data could show how this works
compared to the other mechanism, ie, that strains that aren't yet fully
resistant, but have some genes that help resistance, are favored by a partial
course, and thus have "time" to develop full resistance (especially if the
patient then uses the same antibiotic again).

------
triplesec
Please, after reading this, don't take this as advice not to finish your
prescribed antibiotic courses. You personally do not know if a shorter course
would work for you.

------
Benjamin_Dobell
> If you feel completely well before you finish that course, you should be
> encouraged to call your physician to discuss if it is safe to stop early.

Not suggesting this is bad advice in general, but man, elsewhere in the world
do doctors still speak to patients on the phone?

I remember it being possible as a child, but living as an adult in Australia
I'm yet to find a doctor who takes phone calls. They won't speak to you at all
unless you book an appointment.

~~~
maneesh
I email my doctor or call them whenever I have an issue. I'm in Boston.

~~~
mikeash
My insurance company has a phone number set up just for medical advice. You
initially talk to a nurse, but they'll send me to my doctor if it's necessary.
It's much cheaper for them to take a phone call than have me visit in person.

------
gnicholas
> _That’s why your doctor gives you seven or 14 days’ worth of antibiotics!_

This makes it seem like courses of antibiotics are always 7 or 14 days, but
they're not. I just filled a prescription for a 5-day course. It may have been
more uniform at 7/14 in the past, but it isn't now.

------
kusmi
The antibiotic problem has nothing to do with young people. It's old people
that are always in the hospital and will die if infection is not treated
immediatly with antibiotics. That's where resistance incubates, not in a bunch
of 30 something's with cold.

------
joveian
Maybe gut bacteria are quite a bit different from bacteria elsewhere in the
body, but I had an experience that makes me wonder about antibiotic
effectiveness in general. My sister gave me a couple of ubiome gut bacteria
kits and I took one a few weeks before my first course of antibiotics (that I
can recall - possibly I had to take them at some point decades ago) and one
after two weeks on Amoxicillin/clavulanic acid, which was sampled right at the
point where I would have taken the next pill if I wasn't stopping.

In the "microbiome diversity" score, I was at 7th percentile before the
antibiotics and 15th percentile after (inverse Simpson's Diversity Index
normalized to 10 score went from 6.05 to 6.69). I did a couple of times notice
ubiome presenting obviously incorrect information (and they never made a
substantial response to reporting the first one) so one possible explanation
that I could believe is that ubiome simply presents incorrect data. Another is
that gut motility changes and/or somehow due to the diarrhea I got earlier in
the treatment there was a larger collection of dead bacteria from meals in my
gut the second time. I guess a third is that when alive some bacteria are not
only killing others that arrive from meals but destroying them beyond
recognition. Still, this makes me wonder a tiny bit if even two weeks of
antibiotics doesn't fully kill non-antibiotic resistant bacteria in the gut. I
was taking the antibiotics to try to calm down overactive gut bacteria (it
helped for a few months), so even if this is the case for me it might not be
generally true, but if it is true for anyone than we could be the ones
breeding antibiotic resistant bacteria in our gut.

------
monochromatic
> If you are sick and your doctor mentions antibiotics to you, the first thing
> you should say is, “Hey, doc, do I really need the antibiotic?”

This will of course never happen. Tragedy of the commons and all that.

~~~
zzz95
Anecdata, but I always ask if I really need them, and 100% of the cases the
doc says: we can probably wait a few days. In my life of 30years, never had to
take antibiotics...not even once! My case might be special, but at least shows
that most of the time (in our times at least) we can easily do without them.

~~~
AnkhMorporkian
I think you probably are fairly special. Most people I know have had some
pretty intense infections that could have been fatal, though only two of them
would have certainly been fatal. As for myself, I've had a jaw infection that
actually got into the bone, meningitis, lyme disease, and walking pneumonia
twice. Compared to some of my peers, I actually consider myself pretty
healthy.

That being said, I have definitely been prescribed antibiotics a few times
that it wasn't necessary.

------
gforge
I'm a little late to the game but I would like to point out that this doesn't
apply to infected implants and some other special orthopaedic infections where
you just as with TB need to treat for a long subclinical period. Otherwise I
think it is an excellent article that many of my colleagues should read. I've
actually also always wondered where this myth comes from.

------
graycat
Warning: A scientific result that a _treatment_ "doesn't help" is always
suspicious: (A) The study may have neglected to measure all the ways the
treatment might help. (B) Getting a result of "doesn't help" is always easy --
just use a silly means, e.g., insensitive or nearly irrelevant, of evaluation.

------
alkonaut
> Doctors may otherwise prescribe an antibiotic even when you don’t need one,
> out of fear that you will be unhappy without the prescription.

This is the argument for single provider right there. Patients are not
customers and a doctors job is not to make the customer "happy" \- the job is
to make them well.

~~~
Dove
I think this idea is a lot more appealing if we imagine someone else being
unhappy with their doctor and wanting to go elsewhere, than if we imagine
ourselves in that position. I think we have all had doctors who we did not
like, who we thought missed something, whose philosophy of care we didn't
share, and been grateful for the opportunity to go somewhere else.

------
chewbacha
Actual article (the BMJ peer reviewed analysis) is behind a paywall. But my
thoughts as a microbiologist are that this is more a situation when the
"course" that's been prescribed is generally wrong or the diagnosis is wrong.

In either case, the risk for increased resistance is high, while the value for
treatment low. Without a positive biochemical assay to assert a bacterial
agent, antibiotics should not be prescribed, but likely are. Knowing how long
a course to prescribe takes empirical evidence, which seems to indicate
shorter courses are needed.

Since I don't have access to the actual research, I'm guessing that it's more
like "old, long antibiotic prescriptions were generally over prescribed,
doctors should prescribe shorter doses and confirm with lab that bacterial
agent present"

It's been a decade since I've need antibiotics, but the last time I took a
z-pak which is only 3 doses. Since initial immune response normally takes
longer to ramp up and normally is a few days, this seems reasonable.

~~~
exikyut
> _Actual article (the BMJ peer reviewed analysis) is behind a paywall._

I might be barking up the wrong tree here but if you're referring to
[http://www.bmj.com/content/358/bmj.j3418](http://www.bmj.com/content/358/bmj.j3418)
then that page has an open(-access) link to
[http://www.bmj.com/content/358/bmj.j3418.full.pdf](http://www.bmj.com/content/358/bmj.j3418.full.pdf).

~~~
chewbacha
Still paid wall, you only get the abstract.

------
TorKlingberg
The author here clearly has an axe to grind. Is this an established fact now,
or an exaggeration of one study?

~~~
DennisP
From the article: "in the last two decades, we actually have had dozens of
clinical trials published demonstrating that shorter courses of antibiotics
are just as effective as longer courses."

And from the linked WHO page: "There has been a lot of research into how long
antibiotic courses should be, to determine the shortest possible length of
course needed to completely kill all bacteria....Evidence is emerging that
shorter courses of antibiotics may be just as effective as longer courses for
some infections....They also reduce the exposure of bacteria to antibiotics,
thereby reducing the speed by which the pathogen develops resistance."

[http://www.who.int/features/qa/stopping-antibiotic-
treatment...](http://www.who.int/features/qa/stopping-antibiotic-
treatment/en/)

~~~
Retric
'Reducing the speed' Is this being measured or just an assumption?

Because resistance shows up extremely quickly with short dosage. But, it seems
like a dangerous experiment.

------
deskamess
Meta comment: The HN headline is difficult to parse. The original headline is
a lot better.

~~~
raldi
The first half of the original headline is clickbait; the second is too long
for an HN title. What text would you suggest?

------
kusmi
What? It's to prevent reinfection not resistance.

------
YSFEJ4SWJUVU6
He sure can't help calling himself an expert.

------
dhimes
This is a shit article that provides no insight into what we learned that
changed our mind about how antibiotic resistance arises. He simple derides as
silly and stupid the idea that we ever thought that resistance could possibly
arise if we quit taking antibiotics before the bacteria were all dead, leaving
a population with better survival characteristics to rebuild the population.

Interesting finding if true, but don't waste your time with this article.

~~~
bitexploder
Experts, such as the author should be listened to. Because they are experts.
And you should listen to them /s

I dislike when someone needs to inflate the worth of their ideas by repeatedly
reminding us they are experts. Show me facts. Briefly, and I mean briefly,
introduce your background up front and let your evidence and ideas talk, not
"I am an expert, trust me". Especially on issues such as this one.

This is not to say credible people should always be challenged constantly for
facts, but said credible don't need to make such a deal out of it.

~~~
yborg
I dislike the general feeling among some in the HN community to conflate tone
with message and, generally within one paragraph of a linked article,
determine that the style of delivery is not within the community standard of
humorlessness and pedantry and thus requires a metaphorical (or literal)
downvote.

Actually reading this article, we discover that the author refers to himself
exactly once as an 'expert'. He cites a number of other professionals, mostly
in order to provide linked journal references supporting his position. It's
generally difficult to get published in a peer-reviewed journal without some
kind of credentials in a field, so if the presence of opinions by
professionals in an area is offensive, it's going to be hard to find anything
of substance to read.

~~~
dhimes
I read the entire article before I posted. Despite the downvotes, I stand by
my original claim. This article sheds no insight on the mechanism, and takes a
supercilious tone towards those who believed in the "old" ideas.

This is akin to someone announcing a paper that shows evidence of a "fifth
force" (baryonic) after all (30 years or so later) and dismisses everybody who
believed in the old law of mass attraction (gravity only) as being silly.

IMHO, it's a shitty way to be, _especially_ when you don't even _bother_ to
present the new insight.

~~~
jwilk
From the HN guidelines:

 _Please don 't comment about the voting on comments. It never does any good,
and it makes boring reading._

~~~
dhimes
The downvote comment was ancillary to my message. I'm new here, y'know.

