For decades, we’ve been taught that we must always complete a prescribed antibiotic course. The World Health Organization and promotional literature on antibiotic resistance have reinforced the principle that patients must always complete an antibiotic course prescribed by their doctors. However, a recent BMJ article titled “The antibiotic course has had its day” argues that currently prescribed antibiotic courses are overextended, and that there’s clear evidence linking antibiotic exposure with drug resistance. The article suggests that prescribed antibiotic courses ought to be shortened, and that the longstanding notion that requires completion of a course of medication should be abandoned altogether. Naturally, the publication of this article generated much controversy and debate in the industry.

Regardless, the article still presents a convincing enough argument to make us revisit the merits of antibiotic courses. First, let’s look at the origins of the course of medication. When Howard Florey, one of the discoverers of penicillin, was using penicillin to treat patients with septicemia, or blood poisoning, he had used up his supply of penicillin before his patients were able to make a full recovery. Subsequently, the patients’ conditions  began to revert and worsen. This event gave rise to the concept that patients must take antibiotics over a certain period of time.

Recurrence of diseases was observed in medical treatments where antibiotics were taken within insufficiently short periods of time, which often resulted in inefficacy. In some observations, inadequate treatment periods actually led to other diseases. For instance, Group A Streptococcus could lead to tonsillitis. If the treatment period was too short and the Streptococcus bacteria were not fully cleared, the patient could have ended up contracting acute glomerulonephritis, rheumatoid arthritis, or rheumatic heart disease. Thus, implementing a “course of medication” gradually developed out of attempts to effectively remove bacteria. In a time where drug resistance was not as serious an issue as it is today, extending the course of medication seemed to be beneficial and harmless. During the rise of the “evidence-based medicine” approach to medical research, large scale clinical studies on infectious diseases were conducted, which showed that antibiotics courses could be further refined. For example, the antibiotic course for community-acquired pneumonia was 3 – 5 days or even up to 10 – 21 days after symptoms disappeared; for complicated urinary tract infections, the antibiotic course lasted 10 – 14 days.

With an increase in data quality and evidence-based research, an efficacious course of medication for removing pathogens and preventing relapses became shorter. The course of medication for community-acquired pneumonia was shortened to 5 – 7 days, or even 3 days according to some literature. It is clear that the course of medication is not set and apt to change. The courses of medication for a single disease could differ according to circumstances. In the case of complicated urinary tract infection, an antibiotic course can be 10 days or 14 days depending on clinical examinations.

We should be pushing for larger scale clinical experiments using evidence-based approaches to reevaluate the merits and validity of current antibiotic courses and prescriptions, and improve scientific precision in developing treatments for infections. As medical treatments gradually become more personalized and precise, antibiotic courses of treatment should follow suit. Every patient is different and requires individualized evidence-based treatments that are developed and determined by observations made by experienced clinical scientists.

References

The antibiotic course has had its day. BMJ 2017;358:j3418. doi: https://doi.org/10.1136/bmj.j3418