THE MYTH OF ANTIBIOTICS: ‘COMPLETE THE COURSE’

WON’T STOP RESISTANCE, RESEARCHERS SAY

http:www.newsweek.com.myth-antibiotics-complete-course-wont-stop-resistance

Doctors have long urged patients to adhere strictly to antibiotic prescriptions, asserting that the
entire course should be completed regardless of whether their symptoms have been resolved. Not doing
so, conventional wisdom has held, brings the risk of increasing bacterial resistance to antibiotics.
Antibiotic resistance is one of the most serious global threats to both human health and
agriculture, and finding ways to avoid it is a priority. When it comes to treatment for our bacterial
infections, it has long been thought that cutting a course short eradicates most but not all of the bacteria
behind the illness, thus leaving the door open for the pathogens to develop the ability to evade attack by
the drugs.
Recently, that approach has been called into question. Most notably, Louise Rice, who chairs the
department of medicine at the Warren Alpert Medical School at Brown University, has led the movement
to re-examine this directive. Now, this paradigm shift has taken yet another step. In a newly published
issue of BMJ, a major medical journal, researchers argue that telling patients to complete a full course of
antibiotics to avoid resistance is not backed by evidence.
In fact, Martin Llewelyn and his colleagues at Brighton and Sussex Medical School in the United
Kingdom say in the paper there is evidence that, in many situations, stopping antibiotics sooner is a safe
and effective way to reduce overuse, while taking antibiotics for longer than necessary increases the risk
of resistance.

Amoxicillin penicillin antibiotics are seen in a pharmacy at a free medical and dental health clinic in Los Angeles on April 27,
2016. Researchers in a new study urge doctors, educators and policy makers to drop the deeply embedded “complete the course”
message.

“We found that the common advice that it is ‘important for patients to finish their course of
antibiotics in order to avoid the emergence of antibiotic resistance’ appears to be a modern myth, deeply
embedded in our culture but based on no sound scientific evidence,” Tim Peto, professor of infectious
diseases at the NIHR Biomedical Research Center, Oxford University the medical school,
tells Newsweek.
Their main argument for changing how doctors discuss antibiotic courses with patients is that
shorter treatment can be better for individual patients. Not only does an individual patient’s risk of
resistant infection depend on his/her previous antibiotic exposure, but reducing that exposure via shorter
treatment is associated with reduced risk of resistant infection and better clinical outcome, they say.
 As the authors note, antibiotics are vital to modern medicine and resistance is a global, urgent
threat to human health. But completing a course, they add, defies one of the most fundamental and
widespread medication beliefs: that we should take as little medication as necessary.

Traditionally, antibiotics are prescribed for recommended durations or courses. Fundamental to

the concept of an antibiotic course is the notion that shorter treatment will be inferior.

Concern that giving too little antibiotic treatment could select for resistance can be traced back to
1941, when Howard Florey’s team treated Albert Alexander’s staphylococcal sepsis with penicillin. They
stretched out all the penicillin they had over four days by repeatedly recovering the drug from the
patient’s urine. When the drug ran out, the clinical improvement they had noted reversed, and he
subsequently succumbed to his infection. As the researchers note in their new study, there was no
evidence that this was because of resistance, but the experience may have planted the idea that prolonged
therapy was needed to avoid treatment failure.

More recently, in materials supporting Antibiotic Awareness Week 2016, the World Health
Organization advised patients to “always complete the full prescription, even if you feel better, because
stopping treatment early promotes the growth of drug-resistant bacteria.” Similar advice appears in
national campaigns in Australia, Canada, the United States and throughout Europe. In the U.K., it’s
included as fact in the curriculum for secondary school children, the authors note.
They also note there are exceptions for some types of antibiotics, including those used to treat
tuberculosis.

They call for research to determine the most appropriate, simple alternative messages, such as
stop when you feel better, and advise policy makers to publicly and actively state that the old message
was not evidence-based and is incorrect. Clinical trials are required to determine the most effective
strategies for optimizing duration of antibiotic treatment.

“The public,” they add, “should also be encouraged to recognize that antibiotics are a precious and
finite natural resource that should be conserved by tailoring treatment duration for individual patients.”
 Pros & Cons of Antibiotics
https://medshadow.org/features/pros-cons-of-antibiotics/

By Debra Witt
Published: May 28, 2015
Last updated: June 15, 2016

The news is certainly scary — each year in the US more than 2 million people become infected with
bacteria that are resistant to antibiotics (aka superbugs), 23,000 of them will die as a result, and new
alternatives are slow in coming. But what really troubles many medical experts is the fact that too many
individuals — patients and physicians alike — aren’t taking the messages seriously.

“Antibiotic resistance is still an epic problem,” says Belinda E. Ostrowsky, MD, director of the Albert
Einstein College of Medicine-Montefiore Medical Center Antibiotic Stewardship Program in New York
City. The reasons are many and complicated and include the following realities:

 Population upticks mean more people are getting sick and need treatment
 The first line of defense in hospital emergency rooms is often a dose of antibiotics
 Antibiotic use in animals is widespread and largely unnecessary
 There aren’t enough incentives for pharmaceutical companies to make developing new, safer
antibiotics a top priority
 Many patients cling to the mistaken belief that antibiotics will help them get over their cold and
flu symptoms and pressure doctors to give them antibiotics for themselves or for their loved ones
 Some patients fail to take the full dose of the antibiotic recommended to them
 Many physicians continue to prescribe antibiotics for conditions that don’t warrant their use

Antibiotic Pros & Cons

Antibiotics are miracle drugs, for sure. When introduced in the 1940s, they dramatically reduced the
numbers and severity of illness and death from bacterial infections such as pneumonia. There are more
than 100 types of antibiotics — you’re likely most familiar with penicillins such as amoxicillin,
erythromycin, tetracycline, ciproflaxin, and azithromycin, or Z-pack — and each is designed to target
certain types of infections. They either kill bacteria or keep them from reproducing. What antibiotics can’t
do is fight viral infections like colds, flu, upper respiratory infections, allergies, many earaches, and most
sore throats (those not due to strep).

What’s often cast aside is the fact that antibiotics kill good bacteria along with the bad. They also carry
the potential of setting off harmful adverse reactions (more on that below). In other words, they’re serious
medicine that shouldn’t be taken casually. Yet many people “continue to cling to the notion of ‘why not
take something if there’s even a chance that it will make me better?,’ when in reality there are big risks,”
says Jason G. Newland, MD, medical director in charge of patient safety at Children’s Mercy Hospital in
Kansas City, Missouri. “Risks that can land you in the hospital.”

The risk isn’t just to you, such as when the antibiotic causes side effects. There’s also a risk to society in
general when these drugs aren’t prescribed properly, or aren’t taken as prescribed. That’s because over
time the harmful bacteria have adapted to the antibiotics currently in circulation, rendering this remedy
less effective or, in some cases, useless. Part of that is simply the nature of how bacteria work, but the
widespread overuse of these drugs has fast-tracked the consequences.

“In the pediatric community alone we have recent data showing an excess of 11 million prescriptions a
year for antibiotics that are likely unnecessary,” says Dr. Newland, who is also co-chair for the Pediatric
Committee on Antimicrobial Stewardship within the Pediatric Infectious Diseases Society. Studies cited
by the CDC show that up to 50% of all antibiotic prescriptions written each year in the US are not
needed, or are not prescribed appropriately.

Side Effects of Antibiotics

The side effects associated with antibiotics aren’t trivial. They range from merely annoying (mild rashes,
minor skin irritations, or a short bout of diarrhea) to potentially life-threatening reactions (anaphylactic
shock, for example).

In between are a host of serious reactions that lead to time missed from work or school; one or more trips
to the doctor to treat the new symptoms and find a new way to treat the original infection; or worse,
hospitalization and/or long-term debilitating complications.

These side effects include, but aren’t limited to:

 Bad rash
 Bad sore throat
 Respiratory difficulties
 Nausea and vomiting
 Diarrhea
 Stomach pain
 Swelling of joints
 Stevens-Johnson Syndrome (a rare skin disorder most associated with sulfonamides such as
bactrum)

This last side effect is of unique concern because of the important role gut bacteria play in one’s overall
health. The facts aren’t entirely known, but a growing body of research links beneficial gut-dwelling
bacteria to an active metabolism, improved heart health, better stress hormone levels, fewer allergies,
and certain immune system responses.

The FDA has put a black-box warning on fluoroquinolones because of the link to tendinitis and the drugs’
ability to block neuromuscular activity. Some types of fluoroquinolones were even pulled from the market
by the FDA because of “unjustifiable risks of adverse effects.”

“I think it’s natural for people tend to underestimate the downside of things,” says Dr. Ostrowsky. “That
includes taking antibiotics until something like a C. difficile infection strikes you hard and quickly
travels.”

“The thing to be aware of with side effects is that you don’t know if or how your body will react until it’s
too late,” adds Dr. Newland. “I’m not suggesting that antibiotics aren’t necessary or aren’t important, but
they need to be prescribed and taken wisely.”

Striking a Balance

Doctors are on the front line of the problem of antibiotic resistance, working with hospitals and colleagues
to reinforce or even re-write prescribing guidelines. In particular, there’s a strong movement to reduce
the use of antibiotics in emergency rooms, where lack of patient information and history often makes
antibiotics the default first-line drug of choice. Says Dr. Ostrowsky, “Research shows that over 50% of ER
patients are prescribed inappropriate antibiotics for viral upper respiratory infections,” like the flu. One
issue may be that too many people use emergency rooms for routine illnesses. That’s why many
healthcare professionals are hopeful that the ongoing roll-out of the Affordable Care Act, which means
more Americans will have insurance, will translate into fewer people using ER departments for non-
emergency treatment.

And there’s promising, albeit slow-moving, work among chemists to create new antibiotics. (More
research funding would greatly help speed up the process, but the economics involved mean there’s less
incentive for pharmaceutical companies to bump antibiotic development up on the priority list.
How do bacteria become resistant to antibiotics?
Why are antibiotics so vital for the developing world?
Why is resistance on the rise?
Why can't industry just produce more(antibiotics)?

Antibiotics are miracle drugs, for sure.

However, the side effects associated with
antibiotics can potentially be life-threatening

ANTIBIOTICS QUIZ

1. Antibiotics can kill viruses

2. You don’t need to finish a course of antibiotics

if you are feeling better

3. You should not share antibiotics

4. Taking antibiotics weakens your immune system

5. Healthy people carry antibiotic resistant bacteria

ANSWER KEY
Antibiotics can kill viruses – False
Antibiotics can only be used to treat bacterial infections due to the different structures of bacteria and
viruses. Antibiotics work by targeting specific parts of the bacteria, e.g. the cell wall, or only parts of the
ribosome that are found in bacteria, and therefore are only effective against bacterial infections.

You don’t need to finish a course of antibiotics if you are feeling better – False
Taking an antibiotic incorrectly increases the risk of the bacteria in your body developing antibiotic
resistance. If you do not complete the course the infection may also not be completely killed. You should
always take antibiotics as instructed by the nurse or doctor and ensure you complete the course.
Not taking the correct dose (one or two capsules a day instead of three) means you get less antibiotic in the
area of the infection. These lower concentrations can encourage the multiplication of resistant strains.
You should not share antibiotics – True
Each antibiotic that is prescribed is personal to you and specific to your type of infection. Therefore
antibiotics taken for one infection, will probably not work for another.

Taking antibiotics weakens your immune system – False

Most antibiotics do not negatively affect your immune system, so do not reduce your ability to fight off
future infections. Antibiotics are designed to target bacteria, by directly killing them or slowing their
growth.
The body does not become resistant to antibiotics. It is the bacteria that become resistant through genetic
mutations.

Healthy people carry antibiotic resistant bacteria – True

Antibiotic resistant bacteria can be carried by healthy or ill people. Antibiotic resistant bacteria can be
passed on easily to others through contact (sneezes and coughs), everything we touch or even our poo!
It is everyone’s responsibility to help control antibiotic resistance.
 Antibiotic resistance: Frequently asked questions
26/03/08
https://www.scidev.net/global/health/feature/antibiotic-resistance-frequently-asked-questions.html
Priya Shetty answers some common questions surrounding antibiotic resistance, and
the dangers for the developing world.

Since the development of the first antibiotics 50 years ago (see Box 1) the world has come to
rely on these drugs to vanquish the many varieties of disease-causing bacteria. Their absence
would have grave implications for the health of all populations, but particularly those of
developing countries.

Unfortunately, the effectiveness of antibiotics is under threat. Around the world, bacteria are
mutating to defend themselves against drugs that would once have killed them. This is not
unexpected — organisms constantly evolve to find ways to adapt to new circumstances. What
is threatening global health is the speed with which some strains are developing resistance.

Because of the enormous worldwide use of antibiotics — for example, in pills to treat human
illness or as growth promoters for food animals — bacteria are adapting to modern antibiotics
faster than we can create new ones.

How do bacteria become resistant to antibiotics?

Bacteria develop resistance in different ways but they all involve either a change in their
existing genetic material (known as spontaneous mutation) or the acquisition of new genetic
material. The addition of new material can happen when bacteria-specific viruses (called
bacteriophages) transfer DNA between two closely related bacteria. Bacteria can also absorb
the DNA of bacteria in its vicinity. The most common way in which DNA can be exchanged
is when small pieces of DNA called plasmids are moved between bacteria in direct contact.

These are some of the ways bacteria develop resistance:

 Altering membrane pumps. Some antibiotics collect inside the bacteria to kill it. The bacteria
in turn have pumps on their cell membrane to get rid of the drug. Usually, the bacteria can't
pump the drug out fast enough. But if a mutation enables the bacteria to produce more pumps
than normal, the drug can be ejected from the cell before it takes effect.

 Destroying the antibiotic with enzymes. A bacterial enzyme can destroy a key component
of the antibiotic, rendering it useless. Lactamase, for example, can target the core of penicillin.
Scientists are now adding 'enzyme-silencers' — such as clavulanic acid for penicillin — to
make sure the antibiotic continues to work.

 Moving the target. The bacteria can change the molecules that the drug targets. The antibiotic
would normally attach to this, so altering it stops the antibiotic from taking hold.
Figure 1. Mechanisms of antibiotic resistance
Credit: The Science Creative Quarterly (http://www.scq.ubc.ca/)/Fan Sozzi

Why are antibiotics so vital for the developing world?

Unlike developed countries, where people have easy access to antibiotics, many people in
developing nations — which tend to have poor healthcare systems, poor infrastructure and
few resources — die from diseases that are easily treatable. Illnesses such as tuberculosis (TB)
can be fatal if left untreated and, by weakening immune systems, they can make people
vulnerable to severe infectious diseases, such as HIV/AIDS and malaria.

TB alone kills 1.6 million people every year — 98 per cent of whom live in developing
countries (see figure 2). [1–3] Data on resistance to TB drugs indicates that 3.2 per cent of all
new cases are multidrug resistant. [4] Around 70 million people could be infected with latent
(i.e. not active) multidrug-resistant TB. [5]

Bacterial sexual diseases are still major health concerns in the developing world. Between
three and 18 per cent of pregnant women attending antenatal centres in Africa have syphilis.
Even in low-risk populations in Africa, 40 per cent have infections like gonorrhoea and
chlamydia. Penicillin resistance in Neisseria gonorrhoeae — the bacteria causing gonorrhoea
— can be as high as 90 per cent in Asia, and is higher than 35 per cent in Sub-Saharan Africa
and the Caribbean. Women who have antibiotic-resistant gonorrhoea are at risk of pelvic
inflammatory disease and infertility, which can increase the chance of HIV transmission.
[5,6]

In many developed countries, antibiotic-resistant infections such as MRSA transmitted in

hospitals have grabbed headlines. In developing countries, resource constraints, overcrowding
and inadequate medical supplies can increase the risk of patients being infected with resistant
bacteria. Estimates from South Africa suggest that hospital infection rates in developing
countries are about 15 per cent, making it a key cause of death. [5]

Why is resistance on the rise?

Some of the reasons for the growth of antibiotic resistance — such as overuse or misuse —
are common to all countries, but developing countries have unique factors that tend to be
absent in developed nations.

For example, prescribing the right antibiotics for a bacterial illness requires accurate diagnosis.
In many poor countries, such diagnostics are simply non-existent. Faced with a sick patient
but no way of finding out exactly what they are infected with, doctors will often make an
educated guess at the cause of illness or prescribe an antibiotic that targets several bacteria.

Patients are also often not educated about why they should complete their course of antibiotics
(although this is by no means unique to developing countries). A Mexican study found that 60
per cent of patients did not adhere to their prescribed regimens. [7]

Developing countries often have limited access to drugs, and poor infrastructure can mean
supplies are erratic. Even when drugs are available, people might not be able to afford them,
and so resort to buying them from untrained vendors or street hawkers. A Vietnamese study
reported that 72 per cent of drug purchases were made without prescription. [8]

Antibiotics sold illegally can be counterfeit and contain no active ingredient; worse still, they
can sometimes contain a small amount of the active ingredient, which is not enough to kill the
bacteria but is enough for them to develop an immunity to it, thus increasing resistance.
Counterfeit drugs account for 6–20 per cent of all drug sales, most of which are antibiotics.
[9]

Causes of antibiotic resistance in developed countries — the growing use of antibacterial

detergents, and pressures on doctors from patients who want to be prescribed antibiotics
regardless of whether they are necessary — are also relevant to developing countries. Global
travel means that antibiotic-resistant bacteria are not confined to the country in which they
originate.

Why can't industry just make more (antibiotics)?

An obvious question is why drug companies can't simply produce more antibiotics. Firstly,
developing new drugs is enormously expensive. It costs about US$900 million to bring a drug
from research to market. The investment needed to research and produce these drugs can
sometimes cost far more than the companies are ever likely to see from drug sales.

Experts estimate that research and development into antibiotics has fallen by about 60 per cent
in the past decade. Given a choice between focusing on antibiotics or other drugs that are
likely to yield a better return, pharmaceutical companies understandably often choose the
latter.

Even if drug companies were given more incentive to research new antibiotics, one barrier is
the growing difficulty of discovering new drug classes. In the early days of antibiotic
development, new classes were identified every few years, but inevitably this has slowed
down.
ROTEIRO – AULA CONVERSAÇÃO - VIP LUCAS PESSÔA 08/06 10:00
PARTE 1
1. Introduzir o tema ao aluno (So today let´s talk about...)
2. Apresentar os SLIDES p/ iniciar a discussão sobre o tema (aluno respondendo as questões)
3. Após finalizar c/ os SLIDES, fazer a transição p/ o texto “THE MYTH OF ANTIBIOTICS”
3.1 Entregar o texto ao aluno p/ leitura silenciosa (4 primeiros parágrafos) e checagem de
vocabulário (sublinhar)
3.2 Fazer a checagem de vocabulário novo c/ aluno (tirar dúvidas) por parágrafo;
3.3 Iniciar as perguntas p/ aluno, de acordo com os parágrafos;
3.4. Após concluir a 1ª parte (4 primeiros parágrafos), instruir o aluno p/ prosseguir c/ leitura
silenciosa dos demais parágrafos c/ checagem de vocabulário (sublinhar)

4. Fazer a checagem de vocabulário novo c/ aluno (tirar dúvidas) por parágrafo;

4. 1 Iniciar as perguntas (prof. lê cada 1 por vez) referentes ao parags. 6, 9, 11, 12.

5. Após finalizar as perguntas, usar as 4 perguntas extras, já preparadas e cortadas em tirinhas de

papel (EXTRA PRACTICE) – o prof. estira todas viradas na mão e o aluno vai retirando 1 por vez e
respondendo.

PARTE 2
6. Finalizadas as 4 extras, fazer a transição p/ o próximo texto “PROS AND CONS OF ANTIBIOTICS”, c/ a
pergunta “Antibiotics are miracle drugs, for sure. However, the side effects
associated with antibiotics can potentially be life-threatening” já cortada na tirinha
de papel p/ entregar ao aluno.

7. Entregar o texto ao aluno p/ leitura silenciosa (1ª parte até as razões p/ resistência de antibiótiocos)
e checagem de vocabulário se houver (sublinhar)
7.1 Prof. faz a checagem de vocabulário novo c/ aluno (tirar dúvidas)
7.2 Instruir o aluno p/ prosseguir c/ leitura silenciosa da próxima parte “Antibiotic Pros &
Cons” c/ checagem de vocabulário (sublinhar).
7.3 Prof. faz a checagem de vocabulário novo c/ aluno (tirar dúvidas) por parágrafo
7.4 Iniciar as perguntas (prof. lê cada 1 por vez) referentes ao parags. 1, 2, 3;
8. Instruir o aluno p/ prosseguir c/ leitura silenciosa da próxima parte “Side Effects” c/ checagem de
vocabulário (sublinhar)
8.1 Prof. faz a checagem de vocabulário novo c/ aluno (tirar dúvidas)
8.2 Iniciar as perguntas.

9. Instruir o aluno p/ prosseguir c/ leitura silenciosa da parte final “Striking Balance” c/ checagem de
vocabulário se houver (sublinhar)
9.2 Prof. faz a checagem de vocabulário novo c/ aluno (tirar dúvidas)
9.3 Iniciar as perguntas