A single analysis piece published in the The BMJ journal has done more harm than good to antibiotics stewardship. Though the article makes a strong case for carrying out research in shorter antibiotic courses, it is very misleading. The headline, “ The antibiotic course has had its day ” (July 26), seems to suggest that completing the antibiotic course is no longer necessary. Worse, the authors say that patients who are not admitted in hospitals “might be best advised to stop treatment when they feel better”.
The media’s coverage of this too was unquestioning. An article in The Guardian , “ Rule that patients must finish antibiotics course is wrong, study says ”, read: “Experts suggest patients should stop taking the drugs when they feel better rather than completing their prescription”. It was shared 25,000 times.
The WHO’s advice
The bone of contention is the WHO’s advice to patients to “always complete the full prescription, even if you feel better, because stopping treatment early promotes the growth of drug-resistant bacteria”. According to the authors of The BMJ article, this advice is not evidence-based and is incorrect.
“The WHO statement is oversimplified and partially incorrect. Stopping antibiotics early will not promote resistance in the case of common bacterial infections though stopping them halfway when the patient feels better may not guarantee cure,” says Dr. Abdul Ghafur, Consultant in Infectious Diseases at Apollo Hospital, Chennai, and co-ordinator of the Chennai declaration on antibiotic resistance. “ The BMJ article, instead of clarifying this confusion, gives an erroneous impression that it’s safe to stop antibiotics when patients feel better.”
It is to address this confusion that the Centres for Disease Control and Prevention slightly changed the WHO’s advice and asked patients to take antibiotics “exactly as prescribed”. It does not ask patients to decide when to stop medication.
As per the available evidence, patients cannot stop antibiotics when they feel better. Antibiotics misuse such as inappropriate use (for viral infections), over medication, self-medication, and stopping treatment midway are already leading to problems. Asking patients to stop medication when they feel better can be dangerous, especially in the case of TB. One of the main reasons why drug-resistant TB strains have emerged is because patients discontinue medication mid-course when they feel better, much like what the authors are advocating. The BMJ article has failed to clarify upfront that its suggestion is restricted to common bacterial infections.
Asking patients to stop antibiotics when they feel better is a new concept and there is no evidence to support it in clinical practice. There are several patients groups such as adults, children, the elderly, and immuno-compromised patients. “We need data on all these groups for each indication before advocating it,” Dr. Ghafur says. As the authors have argued, there is evidence that a longer rather than shorter course of antibiotics promotes bacterial resistance. Shorter courses based on evidence are already available for certain bacterial infections. “Whether a short/long-course, patients should not decide to stop taking antibiotics when they feel better,” Dr. Ghafur says.
