The truth about antibiotics

James Sutton battled doctors for six weeks to get a ten-day course of amoxicillin for his severe bronchitic chest infection. When he got the antibiotics, they didn’t really work and, what’s more, he had a major allergic reaction which caused a huge outbreak of hives all over his torso, adding to his misery.

“No one seems to know any more what’s the right thing to do,” says Sutton, a 43-year-old fit and healthy publisher who cycles 18 miles to and from his office every day.

“For the past 50 years or more, doctors have been giving us antibiotics and telling us we must make sure we complete the course, then they started rationing them because of antibiotic resistance in the bacteria. Now we’re being told that doctors don’t really know how to use them either because there hasn’t been enough research, and that taking them for too long might be fuelling the rise of infection resistant superbugs.”

Ten senior scientists trawled medical literature and found that no studies have ever been done to support the ‘complete the course’ mantra

He was referring to last week’s report in the British Medical Journal declaring there is absolutely no evidence for the arbitrary lengths of time people are told to take antibiotics, which can range from two to ten days or even longer, and that it might be better for them to stop as soon as they feel better to reduce the global growth of antibiotic resistance in bacteria.

The report has left many people baffled, and GPs have reported a stream of anxious inquiries from patients who are now unsure whose advice to believe.

The report came from a group of 10 senior scientists led by Martin Llewelyn, professor of infectious diseases at Brighton and Sussex Medical School, who have trawled the literature and found no studies have ever been done to support the “complete the course” mantra, which his group says goes against all common sense to stop taking medicines when you’re g no longer ill, and probably assists the selective development of antibiotic resistant bugs by freeing up space in the body for them to colonise.

“There is evidence that in many situations stopping antibiotics sooner is a safe and effective way to reduce antibiotic overuse,” the report said. “There are reasons to believe the public will accept that completing the course to prevent resistance is wrong, if the medical profession openly acknowledges that this is so.”

The BMJ paper repeats a similar publication by Professor Harold Lambert in The Lancet in 1999. “Antibiotic resistance is more likely to be encouraged by longer than by shorter courses,” he wrote.

It is not clear why the message has taken almost two decades to get through, but it could be that from being a relatively low-level concern, antibiotic resistance and our growing inability to overcome infection, has now become a source of major anxiety.

Chief medical officer Dame Sally Davies has warned the golden age of effective antibiotics is over

Sadly, Professsor Lambert an emeritus professor at St George’s hospital medical school, did not live long enough to see his warnings taken seriously. He died in April this year.

Only last week, however, a joint report from the European Medicines Agency, Food Safety Authority and Centre for Disease Prevention and Control, showed a worrying increase in resistant superbugs both in humans and in animals destined for meat consumption.

Our own chief medical officer Dame Sally Davies has also warned the golden age of effective antibiotics is over. In a speech to the Institute of Actuaries earlier this Spring, she warned that 50,000 deaths a year are already being caused by superbugs in Europe and America. According to a government review published last year, at least 700,000 deaths globally are now caused by treatment-resistant infections, and that number is rising.

So what should patients do? James Sutton was so ill he could hardly manage a flight of stairs and had been to the doctors twice before they agreed to give him antibiotics, and it was more than a week after he finished the course before he began to feel any better.

“Now I’m left wondering if I would have got better on my own anyway, and taking this course of co-amoxiclav (amoxicillin) has just fuelled global antibiotic resistance and triggered an allergy, which means I might not be able to take antibiotics again,” he said.

 While he and other patients may argue that maintaining the status quo without evidence does not make sense, the Royal College of General Practitioners (RCGP), which represents Britain’s 51,000 family doctors, is sticking firmly to the line that practice should not change until there is evidence.

“We cannot advocate widespread behaviour change on the results of just one study,” said the RCGP chair Professore Helen Stokes-Lampard. “Recommended courses of antibiotics are not random. They are tailored to individual conditions. The mantra to always take the full course of antibiotics is well-known. Changing this will simply confuse people.”

She insisted, however, that long courses of antibiotics have been replaced anyway as knowledge has evolved: “Nowadays if a fit, well person comes in with a nasty urinary tract infection, they get a three-day course of antibiotics. That is the standard guidance. Guidance has changed, and it does change quite regularly.”

In the past few days, however, worried patients have begun queuing up at GP surgeries.

“I was very surprised about this publication which goes against everything we have always been told,” said Dr Martin Godfrey, a GP in south London. “It has indeed caused a lot of confusion, and we need more definitive guidance about what to say to people.

“Lots of patients are now coming in and asking if they should stop taking the tablets because they think they’re not doing anything. But the effects of antibiotics do sometimes take a while to kick in, and if people stop taking them too soon, there’s a risk of the infection coming back with a vengeance.”

Dr Godfrey says there is indeed an increase in numbers of people claiming allergies to antibiotics in the same way more of us seem to be allergic to different elements of modern environment, but he warned against making a fuss about minor conditions such as hives. “If you have an antibiotic allergy recorded on your notes, you may not get them when you need them and in general it’s worth putting up with something minor to get the benefit of antibiotics.”

Tim Peto, professor of infectious diseases at Oxford and one of the co-authors of the BMJ study, is also anxious to spell out the position. “We want people to do exactly what their GP tells them, but we want to encourage GPs to give people short courses of antibiotics if they think that’s sensible. They might not have done this in the past because of a genuine fear of promoting antibiotic resistance by doing so, but they shouldn’t feel pressurised to continue giving people longer courses. Our main message is that.”

Personalised medicine for everyone may be the answer. “At the moment, we are using antibiotics indiscriminately and hoping they might work,” said Professor Colin Garner, a senior pharmacologist who is chief executive of the Antibiotic Research UK network of commercial and university scientists.

“We can’t even tell if someone has a bacterial infection or a viral one which antibiotics wont work on anyway,” he said. “We need DNA fingerprinting so we can analyse infections in one or two hours in the same way we already analyse cancer tumours. That way, we can get the right antibiotic to the right person for the right bug, and do another test afterwards to check its been eliminated.”

Prof Garner says such technology is expected to become routinely available soon. Whether it can still tackle the new generation of superbugs however, remains to be seen.