Antibiotic Therapy: Shorter = Better, Especially For Sicker Patients

A core issue in antibiotic therapy these past few years is duration; namely, should patients complete every dose of antibiotics prescribed, even after they feel better? The emerging consensus is no, and one of the leading proponents of this school of thought is the impeccably qualified Brad Spellberg, MD, Chief Medical Officer of the Los Angeles County-University of Southern California Medical Center, who says:

Every randomized clinical trial that has ever compared short-course therapy with longer-course therapy … has found that shorter-course therapies are just as effective.… Patients should be told that if they feel substantially better, with resolution of symptoms of infection, they should call the clinician to determine whether antibiotics can be stopped early. Clinicians should be receptive to this concept, and not fear customizing the duration of therapy.

That was in 2016 – and now we have an update. Just last week Dr. Spellberg added to the shorter is better mantra by saying that with sicker patients, those on 5-day courses of antibiotics have better treatment outcomes than those on 10-day courses. And that’s because the shorter duration group experience less antibiotic-driven superinfections, less drug resistance, and less antibiotic side effects.

The following are Dr. Spellberg’s remarks given at a webinar last week hosted by the Health Services Advisory Group in the United States. He addresses the antibiotic duration question beginning at the 41-minute mark. If you haven’t heard Spellberg in action, you want to. The written word cannot capture his passionate, sometimes sardonic, quick-witted way of speaking:

Since then, studies have come out on the sicker type of patients…. And the trials with the sicker patients found the same thing – not only are the antibiotics just as safe & effective [but] [t]here was one subpopulation in which there was a statistically significant difference found. That was the Port 4 & 5 population [people who should be hospitalized].

The sicker patient was the only population that found a difference in outcome between the short course therapy and the long course therapy group. And here’s the fascinating thing: The patients who were sicker did better with short course therapy. They actually had better clinical outcomes when they got 5 days than 10.

And so somebody commented to me at one point, Well that doesn’t make any sense. That would only be true if antibiotics were harmful. YEAH! That’s what it’s telling you. Antibiotics are harmful. They’re not this thing that magically cures disease and has no unfortunate side effects – that’s not real. Antibiotics have lots of problems associated with them: They breed out resistance. They breed out superinfections like C. diff [an antibiotic-driven bacterial infection] and Candida [a fungal infection]. They cause side effects.

Right? Who gets the resistance, the superinfections and the side effects? The sickest patients in the ICU. This makes perfect sense. Not only was there no improved outcome with longer therapy, patients who were sicker did better … with short course therapy.

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