Straight ahead

The main advice of doctors about antibiotics is harmful, according to British scientists

Olga Dobrovidova, "The Attic"

Anyone who has been prescribed antibiotics by a doctor knows that they should never be "underdone" – stop treatment earlier than recommended, even if you feel better. Proper use of antibiotics is your personal contribution to the fight against bacterial resistance to them. Or not? Are your irresponsible friends, who drop medications as soon as the temperature has subsided, actually doing everything right? This is exactly what the article is about British scientists write for the journal BMJ (The antibiotic course has had its day).

The authors of the article, Martin Llewelyn from the Medical School of Brighton and Sussex and his colleagues, emphasize that antibiotic resistance is a global problem and a threat to human health. They note that among the recommendations of doctors on the proper use of antibiotics, the need is often mentioned to always finish the course of antibiotics prescribed by the doctor and in no case interrupt it earlier, as soon as the state of health has improved. This point is in the recommendations of the World Health Organization (WHO), as well as in national campaigns to combat antibiotic resistance in Australia, Canada, the USA and Europe. In the UK, where the authors of the article work, this prescription is taught as a scientific fact in secondary school.

"However, the idea that early discontinuation of antibiotic treatment contributes to the emergence of resistance is not supported by evidence, whereas taking medications longer than necessary increases the risk of its occurrence… We urge decision–makers, teachers and doctors to stop talking about the importance of finishing the course of antibiotics and, moreover, to publicly and actively declare that this recommendation is not based on facts and is not true," the scientists write.

They note that the erroneous idea of the need to "drink the whole course" of antibiotics arose at the dawn of their use. In his Nobel speech in 1945, Alexander Fleming described a dangerous scenario, in his opinion, when an imaginary patient with a streptococcal infection does not take enough penicillin, as a result of which streptococcus develops resistance to an antibiotic, and then infects his wife with it, who then dies of an incurable disease and his imprudence. That's why, according to Fleming, "if you use penicillin, use it in sufficient quantities."

However, the authors of the article write, the drug resistance that Fleming had in mind in this harsh scenario occurs, for example, in HIV or tuberculosis, but almost does not occur in bacteria that cause particular concern to scientists. These are, for example, Escherichia coli and the so-called ESKAPE bacteria: enterococci, Staphylococci, Friedlander's bacillus, Acinetobacteria, Pseudomonas and Enterobacteria. These opportunistic bacteria live in our bodies and the environment, usually without causing any problems. But they can cause opportunistic infections in patients with weakened immunity and – in the case of antibiotic resistance – dangerous nosocomial infections.

"When a patient takes antibiotics for any reason, the species and strains sensitive to them on the skin, in the intestine and the environment are replaced by resistant ones and capable of further causing infection. Such concomitant selection is the main driver of the formation of important and dangerous forms of antibiotic resistance for patients. The longer these opportunistic bacteria are exposed to antibiotics, the stronger the selection in favor of resistant species and strains," the scientists explain (it is this resistance to methicillin that has developed in Staphylococcus aureus, MRSA).

Moreover, according to them, the very idea of a course of antibiotics implicitly assumes that if you "undertreat", that is, do not complete the entire course, then the results of treatment will be bad. Meanwhile, we have very little evidence that the recommended courses of antibiotics (formed in practice and out of fear of short-term treatment) – this is actually the minimum required time for their admission. There are almost no studies that would help determine the minimum necessary course of antibiotics. One of the exceptions that we know something about is otitis media in children under two years of age, where in five days of treatment symptoms passed in significantly fewer children than in 10 days.

At the same time, for example, for hospital pneumonia, where the risk of drug resistance is high, available studies show that short treatment strategies work just as well as long ones, but resistance and repeated cases of the disease occur less often.

"The very idea of an antibiotic course does not take into account that different patients may react differently to the same antibiotic. Now we ignore this fact and give universal recommendations on the duration of antibiotic use based on poor data," the authors of the article emphasize.

In their opinion, the simplicity and unambiguity of the advice about completing a full course of antibiotics may be the reason for the survivability of this myth. To understand how long it is worth taking antibiotics, we need research and careful monitoring of the condition of patients.

"In the meantime, educational materials about antibiotics should emphasize the fact that antibiotic resistance is a consequence of their overuse and cannot be prevented by taking a course of medication. Society needs to be reminded that antibiotics are a valuable and exhaustible resource that needs to be preserved," the scientists conclude.

Pavel Volchkov, head of the Laboratory of Genomic Engineering at MIPT, commenting on the article, told the Attic that the controversial thesis of Levelin and his colleagues, in principle, has the right to life.

"However, here we must understand that antibiotics are different. Here it is necessary to turn to specific data, not so much even to clinical, as to experimental, in the case of antibiotics and resistance, such experiments can be carried out in vitro. I would go through each antibiotic here in detail, so it would probably be wrong to talk about everything indiscriminately," Volchkov said.

At the same time, the interlocutor of the "Attic" stressed that the problem raised by the authors of the article concerns primarily the United States, Great Britain and other developed countries where the sale of antibiotics is strictly regulated.

"In Russia, there is an excessive use of antibiotics all around – not even on a doctor's prescription, but people prescribe themselves. They are already following the course here, they are not following the course – such chaos is actually happening. It seems to me that it would not hurt us to follow the prescriptions for taking antibiotics. If we give even more indulgences, it will be wrong," the scientist said.

He noted that the latest developments in the field of antibiotics are not broad–spectrum drugs, but "targeted" ones that destroy only a specific pathogenic organism. In combination with rapid diagnostic systems like SHERLOCK, presented by scientists this year, such drugs will allow for pinpoint strikes. "This thing, new antibiotics with a rapid diagnosis system, will work more efficiently and will remove the problems that we are discussing with you," Volchkov said.

"Indeed, we use data on recommended course durations and antibiotic dosages, many of which originate from the 1960s, suggesting that these courses were selected using evidence-based medicine methods, but in fact this may not be the case and is largely determined by habit and practical experience," he said.Konstantin Severinov, Professor at Skoltech and Rutgers University (USA), Head of Laboratories at the Institute of Molecular Genetics and the Institute of Gene Biology of the Russian Academy of Sciences.

Severinov stressed that there is no statement in the article that it is necessary to "undertreat" with antibiotics: if you want to be cured of an infectious disease, you will have to use an antibiotic until the pathogen dies or weakens so much that your immune system can cope with it. "If you don't do this, nothing good will happen, the disease will return and you really risk bringing out antibiotic–resistant microbes inside yourself," the scientist said.

"You know, they say that one bad commander is better than several good ones. From the point of view of medical practice, doctors in general know a little more about diseases, about the human body, than patients, even those patients who read the Internet. Therefore, it would still be better for patients to follow some instructions, even if they are not optimal, than not to follow any instructions and self-medicate," Severinov concluded.

Portal "Eternal youth" http://vechnayamolodost.ru  28.07.2017