Pretty sure the point of the article is that the idea that we need to take the full round of antibiotics is itself an exaggeration of one study that's now known to be wrong, and dangerously so.
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.
If by "grinding an axe" you mean "trying to ensure that humanity preserves some of its best weapons against disease instead of squandering them". Seems fine to be emphatic about that.
From the article: "in the last two decades, we actually have had dozens of clinical trials published demonstrating that shorter courses of antibiotics are just as effective as longer courses."
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."
This is a shit article that provides no insight into what we learned that changed our mind about how antibiotic resistance arises. He simple derides as silly and stupid the idea that we ever thought that resistance could possibly arise if we quit taking antibiotics before the bacteria were all dead, leaving a population with better survival characteristics to rebuild the population.
Interesting finding if true, but don't waste your time with this article.
Experts, such as the author should be listened to. Because they are experts. And you should listen to them /s
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.
I dislike the general feeling among some in the HN community to conflate tone with message and, generally within one paragraph of a linked article, determine that the style of delivery is not within the community standard of humorlessness and pedantry and thus requires a metaphorical (or literal) downvote.
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.
I read the entire article before I posted. Despite the downvotes, I stand by my original claim. This article sheds no insight on the mechanism, and takes a supercilious tone towards those who believed in the "old" ideas.
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.
You know, you are right in a way. It was just a knee jerk reaction, and the author has an extremely important message. How to present factual information so that most people will accept it as fact is an issue that is raging in our lives right now. Facts have died in the minds of many, with FB, the US president, and the media constantly just completely making shit up. That is why I have such a strong reaction to the word expert. And I fall victim to this myself, being, gulp, an "expert" at something that at times really needs people to listen to my advice and findings without spending 3 hours convincing them.
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.
There is a systematic property of the modern medical system to overtreat.
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 understand that is the expectation for some, but I personally am happy when the doctor tells me I'll be better on my own. It keeps me form worrying that I have something more serious.
I'd be more accepting of that if they actually tested before saying "there's nothing we can do".
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.
Unless you got a positive bacterial cultural you still don't know if it was the z Pak that cleared up your bronchitis or your immune system. The vast majority of illnesses are self limiting and bronchitis is one of those things that can really linger, every time I get it it takes more than a month to clear up (on its own).
In most cases a secondary infection is going to be more of an annoyance than a danger, so for otherwise healthy people it probably makes sense to treat a secondary infection when it appears.
I heard that even from a veterinarian who prescribed antibiotic to my cat with acute viral infection, in a course of complex treatment. Now I wonder was antibiotic really necessary.
And as anyone with a child recently placed into daycare in a major city will tell you, what happens is the kid gets the sniffles from a cold virus/whatever, and it turns into a sore throat, then a bacterial sinus infection, then a ear infection, and at this point the bacterial infections at the daycare are resistant to antibiotics, so they end up gradually rolling down the sickness hill until the doctor prescribes something strong enough to knock it out.
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...
AFAIK, antibiotics are usually only prescribed prophylactically to sensitive populations or for apparent viral infections with a particularly elevated risk (with frequency or severity) from secondary infection.
This has been well established in medical circles for at least 5 years now, the difficulty is in ensuring that people in the community cease at an appropriate time (i.e. Not before it is fully cleared) because that is potentially worse than taking a 'whole' un-needed course
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.
What is the benefit of taking an antibiotic you don't need? Even if people are perfectly selfish, they should want to not bother with useless medicine.
I see. Benefits for the individual and costs for the collective is a recipe for a tragedy of the commons.
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.
I used to get those all the freaking time. And it really sucks, because you start to feel a bit better, and then it drags on and on and on and you don't want to take antibiotics, but you don't want to feel shitty and drained and not do anything either.
Anecdata, but I always ask if I really need them, and 100% of the cases the doc says: we can probably wait a few days.
In my life of 30years, never had to take antibiotics...not even once! My case might be special, but at least shows that most of the time (in our times at least) we can easily do without them.
I think you probably are fairly special. Most people I know have had some pretty intense infections that could have been fatal, though only two of them would have certainly been fatal. As for myself, I've had a jaw infection that actually got into the bone, meningitis, lyme disease, and walking pneumonia twice. Compared to some of my peers, I actually consider myself pretty healthy.
That being said, I have definitely been prescribed antibiotics a few times that it wasn't necessary.
I rarely take antibiotics (can think of once in the last 25 years), and it's at least partly because I always push back. I do this partly because I know they're overprescribed, and partly because in my youth I had a bad reaction to one.
I've been asked (UK) do I "want antibiotics" (scratched cornea IIRC), a question I didn't understand.
"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".
It's not that simple. In most cases, you'll be fine without antibiotics, it will just take longer to get rid of the disease. But as avoiding antibiotics in general is a good thing, the question is basically about how much you value getting better sooner. If you actually needed antibiotics they would not ask you that.
The problem with stopping early is that you may have to start again. A whole course, since feeling better doesn't mean you have a low enough population of the bacteria to not reinfect you.
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.
Last time I needed to take them, they lasted about a day and a half before I felt truly 100%.
Haven't been sick (at all, not even the sniffles) in almost a decade. Just an anecdote and definitely doesn't consider other illnesses I never fell to, but it's all I've got.
Doesn't adaptive immunity come into play here, though?
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.
> 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.
>>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.
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?
----
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.
I don't know other than saying "likely enough that doctors don't recommend not finishing the full course." Seriously, I find it hilarious that on HN that questioning a doctor's, no an entire field of science's, opinion on the matter goes nearly unfettered, but question the science behind climate change research and you'd better duck.
However, this doesn't mean that the current courses that are being prescribed are in the sweet spot, and the article cites evidence showing that courses of certain shorter durations are just as effective as the currently prescribed longer courses at curing the infection, with the added gains of being less likely to produce resistence, more likely to be completed, fewer side effects, and cheaper.
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 just had a round of antibiotics for an infected spider bite (no super powers) and the prescription amount and duration was extremely arbitrary - 2000mg/day of something for 10 days. I'm guessing not only are they not hitting the sweet spot, but they're prescribing multiple times more than someone would need, just to be safe, considering they don't know the strain of bacteria or anything relevant about me besides my weight.
You say this is necessary, the author says it's not. Why should I believe you (and same question for him)? Has the argument about the risk of reinfection been evaluated in the medical field?
I studied microbiology at university (over 20 years ago admittedly), but that was pretty much what they taught us. People often don't take the full course because they feel better, then the infection reestablishes itself.
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.
:/
This guy says the conventional wisdom in the medical profession is wrong. I don't know if he's right, but just repeating the conventional wisdom seems like an unenlightening response.
Problem is, that's all the columnist does as well. He states, over and over, that the conventional wisdom is wrong, but he never seems to get around to explaining why.
Incredibly weak article, IMO, regardless of the merits of what he's saying.
There's more than one medical authority and article cited (the 2007 piece, the more recent one, the WHO). It could be more detailed, I agree, but it's not like there's nothing there.
Unrelated. There's a growing body of science backing up the idea that antibiotics are very often way over-prescribed, and that over-prescribing does NOT prevent bacterial resistance.
You might, but the research is starting to become more and more clear that the "magic moment" is when you feel better.
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.
Actual article (the BMJ peer reviewed analysis) is behind a paywall. But my thoughts as a microbiologist are that this is more a situation when the "course" that's been prescribed is generally wrong or the diagnosis is wrong.
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.
The message could be right, but the unnecessarily condescending and derisive tone of this article undermines its effectiveness. I for one don't feel any more informed about the data showing that longer courses of antibiotics create enhance the chances of creating resistant bacteria, nor about why this happens.
He describes himself as an expert two or three times in the short article. When I see that it makes me wonder if it's really true. It's like when people repeatedly describe themselves as strong or independent - who are they trying to convince?
Based on his cv he probably really is an expert, but still, it's bad writing.
I think the mechanism might work like this (disclaimer, I'm not a doctor, I'm just making a theoretical guess):
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.
Makes sense; in the end, only experimental data could show how this works compared to the other mechanism, ie, that strains that aren't yet fully resistant, but have some genes that help resistance, are favored by a partial course, and thus have "time" to develop full resistance (especially if the patient then uses the same antibiotic again).
I'm not going to be able to explain my point clearly, but I will try.
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.
85% of all antibiotics sold are for livestock. The volume of antibiotic given to animals, and the cramped and dirty living conditions of many farms results in a damn good engine for creating antibiotic resistant bacteria
not just livestock, one of our most powerful antibiotics (tetracycline), was used en-mase to wash down produce such as grapes.
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.
> 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".
This has more to do with sugar (corn in the americas). For example, in Wisconsin it is possible to use dental information to identify if there was a diet of wild rice or corn. https://www.wpr.org/shows/wisconsins-mound-builders
Farming is in part responsible for the concentration of sugars that bacteria use.
Antibiotic resistance jumps across disease types. You often don't notice resistance for less serious diseases because people get better even if the pills did nothing.
I think you're assuming everywhere in the world is like where you are. I remember reading "The Coming Plague" as a kid and being freaked out when the author predicted this given how antibiotics are consumed in poorer economies: some are available on the black market, so you take what's available, not necessarily what kills the thing you have which is how germs build up and then pass on resistance (assuming my 25 year-old memory of the book is accurate).
You only notice that because they're the ones that get you sick.
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.
Something I realized by travelling to Indonesia is that people in developing countries take antibiotics a lot (you can buy Cipro as easily as buying Tylenol in the U.S.) and that they really do need them because they get bacterial infections from bad food or water a lot.
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.
Please, after reading this, don't take this as advice not to finish your prescribed antibiotic courses. You personally do not know if a shorter course would work for you.
If you're worried about antibiotic resistance, consider cutting back or eliminating animal agriculture products from your diet.
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.
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.
My mistake. Animals are stuffed with antibiotics but you're right that swine and bird flu are caused by viruses. This article explains why factory farming is dangerous with regards to bird flu:
> 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).
"Mutation" in the sense of a single subtype stochastically accumulating mutations to its own genome is not what causes the emergence of most new pathogenic subtypes - its antigenic drift via genomic reassortment in co-infected hosts.
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
It's not only cheaper to feed animals antibiotics, but it also makes the animals put on more weight quicker, which is monetarily beneficial for the farmers/companies in the industry. From whatever I have read (over time), this is a routine practice in most places around the world.
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).
While what you are saying is true, one of the antibiotics that is used in farm animals is penicillin.
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.”
> 80% of antibiotics used in the US are given to farm animals
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.
It's simply not the case that we use totally different antibiotics for agriculture.
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."
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.
But aren't influenza infections often associated with secondary bacterial infections, eg https://academic.oup.com/jac/article/64/5/889/716264/Swine-f..., where to treat the patient "with flu" prescription of antibiotics is a normal and beneficial course of action?
> 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.
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.
Sorry, I'm just not seeing the connection here. How much overlap is there between the set of zoonotic diseases (those transmitted from animals to humans), and diseases where antibiotic resistance is a concern?
A tremendous amount. Just to name a few potentially found in food:
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.
I study antimicrobial resistance for a living, and I will note that the "Animal Antibiotics" ---> "Resistance Relevant to Human Health" pathway is not nearly that clear cut.
However, one of the big things that is changing antibiotic use in agriculture is market forces.
> If you feel completely well before you finish that course, you should be encouraged to call your physician to discuss if it is safe to stop early.
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.
My insurance company has a phone number set up just for medical advice. You initially talk to a nurse, but they'll send me to my doctor if it's necessary. It's much cheaper for them to take a phone call than have me visit in person.
I email or even text my doctor, depending on the urgency.
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.
When I call my doctor's office, I speak with a nurse, or I leave a message and a nurse calls me back. After talking to me, the nurse may consult with the doctor and call me back, or if necessary, the doctor might call me. I can also email, and I have no idea if emails are directly answered by the doctor or if there is some kind of delegation going on there too.
My medical group has a website which allows you to send text messages to your doctor. It all gets filtered through staff, of course, but you usually get a response from the doctor. Sometimes the response is "you need to make an appointment", but it's really handy for conditions you can monitor at home like hypertension and diabetes.
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.
The antibiotic problem has nothing to do with young people. It's old people that are always in the hospital and will die if infection is not treated immediatly with antibiotics. That's where resistance incubates, not in a bunch of 30 something's with cold.
> That’s why your doctor gives you seven or 14 days’ worth of antibiotics!
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.
> Doctors may otherwise prescribe an antibiotic even when you don’t need one, out of fear that you will be unhappy without the prescription.
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.
I think this idea is a lot more appealing if we imagine someone else being unhappy with their doctor and wanting to go elsewhere, than if we imagine ourselves in that position. I think we have all had doctors who we did not like, who we thought missed something, whose philosophy of care we didn't share, and been grateful for the opportunity to go somewhere else.
Warning: A scientific result that a treatment "doesn't help" is always suspicious: (A) The study may have neglected to measure all the ways the treatment might help. (B) Getting a result of "doesn't help" is always easy -- just use a silly means, e.g., insensitive or nearly irrelevant, of evaluation.
Maybe gut bacteria are quite a bit different from bacteria elsewhere in the body, but I had an experience that makes me wonder about antibiotic effectiveness in general. My sister gave me a couple of ubiome gut bacteria kits and I took one a few weeks before my first course of antibiotics (that I can recall - possibly I had to take them at some point decades ago) and one after two weeks on Amoxicillin/clavulanic acid, which was sampled right at the point where I would have taken the next pill if I wasn't stopping.
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.
I'm a little late to the game but I would like to point out that this doesn't apply to infected implants and some other special orthopaedic infections where you just as with TB need to treat for a long subclinical period. Otherwise I think it is an excellent article that many of my colleagues should read. I've actually also always wondered where this myth comes from.
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[ 2.4 ms ] story [ 202 ms ] threadIf 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.
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...
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".
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.
Haven't been sick (at all, not even the sniffles) in almost a decade. Just an anecdote and definitely doesn't consider other illnesses I never fell to, but it's all I've got.
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.
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.
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.
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.
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.
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.
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 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.