Stopping antibiotics half way through the course, when a patient feels better, may not guarantee cure of the infection.

A single analysis piece published on July 26, 2017 in the journal BMJ (British Medical Journal) has done more harm than good to the field of antimicrobial stewardship. Though the article makes a strong case for carrying out research into shorter antibiotic courses, it is completely misleading and the advice, if faithfully followed, will have dangerous consequences.

“The antibiotic course has had its day” heading seems to suggest that completing the antibiotic course is no longer necessary. To make it 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 coverage was on expected lines with very misleading articles. Even The Guardian wrote a misleading article saying that according to experts “patients should stop taking the drugs when they feel better rather than completing their prescription”.  The article “Rule that patients must finish antibiotics course is wrong, study says” had 25,000 shares on social media.

The WHO’s advice

The bone of contention is the World Health Organisation’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, this advice that not completing the course will lead to resistance is not evidence-based and is incorrect.

“It is true that the WHO statement is oversimplified and partially incorrect. Stopping antibiotic early will not promote resistance in the case of common bacterial infections. But stopping an antibiotic half way through, when patient feels better, may not guarantee cure of the infection. The BMJ article, instead of clarifying this confusion, has provided an erroneous impression to the readers that it is safe to stop antibiotics when patients feel better,” says Dr. Abdul Ghafur, Consultant in Infectious Diseases at Apollo Hospital, Chennai and the Co-ordinator of the Chennai declaration on antibiotic resistance.

Most patients would start feeling better midway through the course even before the bacteria causing the infection have been cleared. Discontinuing antibiotics midway might lead to relapse.

It is to address this confusion that the Centres for Disease Control and Prevention (CDC) had slightly changed the WHO advice asking 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.

This is especially true for infections such as 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 advocate patients to do. The BMJ article has failed to upfront clarify that its suggestion is restricted to common bacterial infections.

A new concept lacking evidence

“Asking patients to stop antibiotics when they feel better is a new concept and there is absolutely no evidence so far to support it in clinical practice. There are several patients groups such as adults, children, elderly, immunocompromised patients. We need data on all these groups for each indication before advocating it,” says Dr. Ghafur.

As the authors have argued, there is evidence that longer rather than shorter course of antibiotics promote bacterial resistance. There is ongoing research to establish effectiveness of shorter courses of antibiotics. Shorter courses based on evidence are already available for certain bacterial infections such as intra-abdominal sepsis, nosocomial pneumonia, and community acquired pneumonia. But evidence on emergence of resistance as a result of reducing the duration is not known for most of these infections.

“Wherever and whenever evidence for shorter courses for infections such as pneumonia, urinary tract infection and throat infection are available doctors will definitely prescribe shorter courses. Whether it is short-course or long-course, patients should not decide to stop taking antibiotics when they feel better,” he stresses.

The spread of wrong message

As on August 14, 2017, how far and wide this wrong message has spread becomes clear by looking at the Altmetric score of this paper. Altmetric collects and collates information regarding a published paper from multiple websites and platforms to provide a “single visually engaging and informative view of the online activity surrounding a scholarly content”.

With a Altmetric score of 3,244, it falls in the top 5% of all research outputs scored by Altmetric. From The BMJ, it is the second highest scoring paper. The number of newspapers that have covered this paper stands at 187; the actual number would be much higher as not all newspapers get counted by Altmetric. The reason: “To track a news source we need to index it in our database. To track blog posts they need to have a working RSS feed,” Altmetric says. There have been nearly 3,000 tweets and 92 Facebook pages about this paper. It has been shared the most in the UK with a score of 300, closely followed by the U.S. with 271.

Published in The Hindu on August 14, 2017