Taking a full course of antibiotics doesn’t help prevent spread of resistance
slate.com
slate.com
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.
The goal of the antibiotics is to prevent the infection from killing you while buying time for your immune system to kick in and handle things.
Secondly, why would a second course be more harmful if the duration of the two courses combined is less total time than the initial prescribed amount?
If you feel better after 4 days of antibiotics, stop, get sick again and take 4 more days of antibiotics, you're still only dosing for 8 days. That's far better than a default of 2 weeks (14 days), and only barely worse than a 7 day course.
Now factor in the number of people who would have been just fine after 4 days, with no re-occurrence, and I'm really struggling to see why your advice is any better than: Treat when sick, stop when well. Even if you get sick again: treat when sick, stop when well.
First, bacteria multiply very quickly. In the days between the first and second course, the bacteria could recolonize to the same number you had before. So it's not just as simple as taking the remainder of the course of antibiotics or even a slightly shortened one. You may need to take another full course. Additionally, those bacteria have had time to evolve and possibly become resistant.
Second, when you take antibiotics, it doesn't just kill the bad bacteria. Sometimes good bacteria dies as well. This can be disastrous to your health if done too many times.
Sure, but where's the data collection that states taking it for a standard longer period is better than a repeated dose? Even if you have to bump the second dose to something like "Take until well plus 2 days, since you got sick again last time"? Not even mentioning that in most cases, your body actively gets better at handling the infection...
>>Second, when you take antibiotics, it doesn't just kill the bad bacteria. Sometimes good bacteria dies as well. This can be disastrous to your health if done too many times.
I agree, my issue is with the idea that taking it more times is ANY different than taking it longer. Why would two doses of seven days with a 3 day break between be any different than one 14 day dose?
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Edit: I want to add, I'm aware that the idea with a longer dose is to lower total levels of the bacteria below the amount the immune system can handle. And if we don't hit that target re-infection can occur. My issue is that we're assuming here that longer is always better, and I simply don't think we actually have data to back that up.
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.
I wonder if that counts as medical advice under the law...
"which probably leads to reinfection"
Probably? More than 50% chance? Which studies do you have to back this up or did you just make that up?
They also taught us that vaccines are a good thing, yet plenty of people seem to be questioning that as well these days. Reading the replies here feels very like some of the smart sounding yet ignorant comments that some antivaccers make. :/
Incredibly weak article, IMO, regardless of the merits of what he's saying.
We know that moment. At least, I do. When you're not really sick anymore but you're still recovering from the weakness left in the wake.
I have a group of doctors for an advanced immune system issue and this has been there advice for about four years. When I need antibiotics, we have top use the minimum dosage possible. So they tell me to stop when I feel better. And I do. I have bottles of half-full antibiotics in the bathroom drawer because of it.
My experience is only anecdotal, but I've never had to start over.
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
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.
Eg this http://webarchive.nationalarchives.gov.uk/20130107105354/htt...
"Honeysuckle-encoded atypical microRNA2911 directly targets influenza A viruses"
Cell Research (2015) 25:39–49. dx.doi.org/10.1038/cr.2014.130; published online 7 October 2014
> The conditions on these farms greatly contribute to the creation of deadly pathogens, including influenza viruses. Here’s how it works: Wild aquatic birds are the primordial source of all influenza A viruses — the ones that have the potential to cause pandemics. However, people rarely become infected directly from aquatic birds. Usually, an intermediate host must be involved. This intermediate host provides the right biological setting for the virus to transform into something that can easily infect a human. And that’s where chickens and other farmed animals come in.
Most avian influenzas are mild, low-pathogenic (i.e., not very lethal) viruses. However, once they enter poultry factory farms (through insects or workers carrying the virus, for example), they can rapidly mutate into highly-pathogenic (very lethal) viruses, even over very short periods of time. Since 1990, outbreaks of highly-pathogenic virus subtypes have increased substantially among farmed birds compared with the years prior to 1990 (3, 4). The intensive confinement of birds has been found to facilitate both the increasing frequency and scale of these outbreaks (3, 5).
http://www.huffingtonpost.com/aysha-akhtar/bird-flu_b_279813...
New subtypes / serotypes that are highly pathogenic to humans usually develop when multiple different subtypes co-infect and replicate in the same cell of an infected host. This can lead to "reassortment" of the genes in pool of replicating viral genomes. Most of the time when this happens the resulting hybrid genomes are probably too screwed up to be viable, but sometimes it leads to new genomic assortments that are viable and remix the pathogenic genes of one donor subtype with the surface coat proteins of a different subtype, resulting in a new subtype that is both pathogenic and antigenically novel to the host species. This is why we need to constantly make new influenza vaccines as fast as possible.
This page explains it better than I did:
"Influenza A viruses have eight separate gene segments. The segmented genome allows influenza A viruses from different species to mix and create a new virus if influenza A viruses from two different species infect the same person or animal. For example, if a pig were infected with a human influenza A virus and an avian influenza A virus at the same time, the new replicating viruses could mix existing genetic information (reassortment) and produce a new influenza A virus that had most of the genes from the human virus, but a hemagglutinin gene and/or neuraminidase gene and other genes from the avian virus. The resulting new virus might then be able to infect humans and spread easily from person to person, but it would have surface proteins (hemagglutinin and/or neuraminidase) different than those currently found in influenza viruses that infect humans.
This type of major change in the influenza A viruses is known as “antigenic shift.” Antigenic shift results when a new influenza A virus subtype to which most people have little or no immune protection infects humans. If this new influenza A virus causes illness in people and is transmitted easily from person to person in a sustained manner, an influenza pandemic can occur." - https://www.cdc.gov/flu/avianflu/virus-transmission.htm
Unless serious action is taken around the world to reduce or eliminate this practice, the disturbing predictions on untreatable epidemics may come true within the next couple of decades (there are already thousands of people dying every year because their infections cannot be treated with the antibiotic arsenal we have).
Also, consider the following:
> In 2010, the U.S. Food and Drug Administration, U.S. Department of Agriculture, and the CDC all testified before Congress that there is a connection between the routine use of antibiotics for meat production and the declining effectiveness of antibiotics for people.
Dr. Thomas R. Frieden, Director of the CDC, noted that “there is strong scientific evidence of a link between antibiotic use in food animals and antibiotic resistance in humans.”
http://www.livablefutureblog.com/wp-content/uploads/2010/11/...
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.
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...
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.
This is not true. There are multiple antibiotics that are used in both livestock and humans. It is only true that there are some antibiotics used in livestock and not in humans.
My guess is not, but if you have evidence to the contrary I'd like to hear about it.
E. coli, Salmonella, C. difficile (though resistance in C. difficile is...funny), Listeria, Shigella and Staphylococcus all come to mind off the top of my head.
CDC even has a nice little infographic on it. https://www.cdc.gov/foodsafety/challenges/from-farm-to-table...
However, one of the big things that is changing antibiotic use in agriculture is market forces.
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.
I had a seven week bout with bronchitis recently because the first three doctors I went to insisted "it's viral, there's nothing we can do" without doing a sputum test. When I finally found someone who would give me a Z-pak it cleared up in three days after weeks of misery.
It's also a problem when the system has swung so far the other direction that you can't get medication you actually need.
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...
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.
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.
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".
It'd probably be more prevalent if we didn't cook food and needed our teeth more.
Farming is in part responsible for the concentration of sugars that bacteria use.
PS: Horizontal DNA transfer is wacky in single cell organisms. http://amrls.cvm.msu.edu/microbiology/molecular-basis-for-an...
The concern is that we generate resistance in your ordinary gut flora, and then via horizontal gene transfer that resistance gets into a pathogen that's actively dangerous.
It seems like the best thing to do to prevent human over-use of antibiotics would be to convince developing countries to impose stricter food handling regulations and assist them in upgrading their water and sewer infrastructure so that the water that comes from a faucet is safe to drink. If people don't get sick in the first place, they don't need antibiotics.
Based on his cv he probably really is an expert, but still, it's bad writing.
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.
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.
It's a rarity for sure, but keep looking until you find one that isn't solely working for their "career" -- they do exist, though they're hard to find and commonly are not taking new patients (diamonds in the rough).
You can also look into finding a "concierge doctor", I believe its a somewhat newer business model but is one I had been looking towards for a while until I found my current doctor. I'm in the southwestern U.S. FWIW.
I've been called a couple times by one of my doctors after I sent a message when she wanted additional information or wanted to verify something before adjusting my meds.
From what I can tell the big problem is doctors don't get paid for phone calls, at least in the US. A doctor who spent too much time on the phone would go broke.
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.
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.
This will of course never happen. Tragedy of the commons and all that.
Of course there are already lots of people that would rather not take antibiotics in cases where they aren't needed and especially in cases where they won't do any good.
But antibiotics have some individual costs too. They are bad for your gut flora, and I think you can't drink alcohol while you are on antibiotics.
Maybe these individual costs should be raised. Perhaps via a special tax on antibiotics for people who don't have a positive test for a specific bacteria.
That being said, I have definitely been prescribed antibiotics a few times that it wasn't necessary.
"Well is that the treatment you recommend?"
I mean, the NHS are spending millions and having hundreds of doctors and researchers look at these questions ... why am I, completely uninformed, being asked to make a judgment??
Beggars belief.
The doctor presumably considers that you need the treatment otherwise they wouldn't recommend it. If they would recommend a treatment they know you don't need then they should have their license revoked. The only answer a doctor should be able to give is "only if you want to get better".
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.
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.
I might be barking up the wrong tree here but if you're referring to 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.
If we've been creating resistant bacteria because we've been following this "take it all" mentality, then I don't really blame the author for getting a little worked up over this.
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...
Because resistance shows up extremely quickly with short dosage. But, it seems like a dangerous experiment.
Interesting finding if true, but don't waste your time with this article.
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.
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.
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.
Please don't comment about the voting on comments. It never does any good, and it makes boring reading.
But in the media, on Facebook... anywhere, people say they are an expert at some random bullshit or non-bullshit thing, state some stuff, and if it fits within someone's world view it is then accepted as fact. If it doesn't fit within their world view it is rejected for any number of reasons.
To reach the people who will be the hardest convince, the people who run to the doctor and ask for antibiotics every time their head gets stuffy linking to studies is pointless. Saying you are an expert is pointless. Using any sort of logical reasoning is pointless. Because those people KNOW they feel better when they take antibiotics. You literally have to market your value to them and probably lie or cast things in an extreme way to be heard these days.
Yet on HN and among the technologists, though we are susceptible to the same things, as a broad group, we are one of the few that still respects facts and experts. If Richard Feynmann tells me this is how magnets work, I believe the guy.
My default approach is that someone claiming to be an expert is just a big giant red flag these days. It is a real problem of how to figure out who we can trust. I am just trigger happy and jumpy about people who claim to be experts because in modern media that usually means the opposite. Anyhow, I don't know what the right answer is, but I should definitely overlook writing style a little more and focus on what facts, if any, an author is providing.