YSK: Do You Really Need That Antibiotic? It’s antibiotic season. Brush up on how you should use them — and when to avoid them. (NYT, Dec 2023)

Submitted ⁨⁨10⁩ ⁨months⁩ ago⁩ by ⁨MaximilianKohler@lemmy.world⁩ to ⁨youshouldknow@lemmy.world⁩

https://www.nytimes.com/2023/12/21/well/antibiotic-resistance-infection.html

It’s refreshing to see a major news outlet discussing collateral damage and not just resistance. Over the past decade, 99% of the time antibiotic overuse is covered and warned about it’s always only in regards to resistance.

It’s a good article that also doesn’t spread the common misinformation of “just take some probiotics and fermented foods after antibiotics and you’re good to go”.

Swallowing an antibiotic is like carpet-bombing the trillions of microorganisms that live in the gut, killing not just the bad but the good too, said Dr. Martin Blaser, author of the book “Missing Microbes” and director of the Center for Advanced Biotechnology and Medicine at Rutgers University.

“I think the health profession in general has systematically overestimated the value of antibiotics and underestimated the cost,” Dr. Blaser said.

No shit. And it has spread like a virus to the general populace as well. The majority of people seem mentally addicted to antibiotics and think they’re going to die if they don’t get an antibiotic for every minor issue.

Find out if you really need an antibiotic.

Ask for the shortest course.

Rethink probiotics.

I appreciate the NYTs for finally helping spread this.

Just yesterday people on Lemmy were cheering about AI discovering new antibiotics. When I shared info about the concerns of collateral damage, the responses were more unintelligent and close-minded than on reddit. Extremely depressing.

For more info on this subject there’s a wiki and forum at humanmicrobiome.info.

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Serinus@lemmy.world ⁨10⁩ ⁨months⁩ ago
The shortest course is bad advice. When you do take antibiotics, you don’t want to create antibiotic resistant bacteria.

That’s why they tell you to always take the full course, even if you feel better.

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- godzillabacter@lemmy.world ⁨10⁩ ⁨months⁩ ago
  tl;dr - Asking your doctor for the shortest reasonable course is a good thing that will both protect you as a patient as well as minimize your risk of antimicrobial resistance. But the key phrase is ask your doctor, do not take it upon yourself to decide when to stop them. Take whatever course you’re prescribed.
  
  Pharmacist and 4th year medical student with a passion for antimicrobial stewardship and infectious disease.
  
  Historical treatment duration for most infections was truly quite arbitrary. Evidence for most infections, when it is actually tested, have pretty consistently demonstrated shorter treatment durations than were classically taught (10-14 days for pneumonia now generally 5-7, 14 days for Gram Negative Bacteremia now 7, etc). There is a subset of infectious disease doctors that are bucking the trend of historical “you have to complete your course advice” for some infections. In general, what I have seen is recommendations to discontinue antibiotics with significant clinical improvement AND a non-life-threatening infection in a non-sterile body cavity. So nobody is shortening course durations for empyemas or endocarditis.
  
  The issue becomes expecting patients to know what constitutes clinically meaningful recovery and whether or not their infection is one of the “safe” ones to stop antibiotics earlier.
  
  At the end of the day, I totally disagree with your premise, as we should always strive for the minimum safe antimicrobial exposure. However I do agree that telling patients “shorter is better” is bad advice because I don’t want laypeople making these decisions when usually no-ID physicians don’t make them.
  
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  - flooppoolf@lemmy.world ⁨10⁩ ⁨months⁩ ago
    NYT undoing years of “finish your fucking course”
    
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- MaximilianKohler@lemmy.world ⁨10⁩ ⁨months⁩ ago
  That’s wrong. Stop confidently spreading harmful misinformation. I already provided citations that you should have checked before making that statement: humanmicrobiome.info/antibiotics/
  
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  - flooppoolf@lemmy.world ⁨10⁩ ⁨months⁩ ago
    That is not a website doctors look at. Medical procedures are formed and approved through NIH articles with vast testing pools across many geographical areas.
    
    If you would like more info, please look up the IDSA guidelines
    
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  - Serinus@lemmy.world ⁨10⁩ ⁨months⁩ ago
    The real information is to ask your doctor and be careful with advice from social media.
    
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  - godzillabacter@lemmy.world ⁨10⁩ ⁨months⁩ ago
    I would like to point out, the NYT is a reputable news site but cannot even remotely be trusted with medical information/recommendations. I can’t tell you the last time I read a medical news piece from any source (and the NYT is the primary place I get my news) that I couldn’t read it and say “well that’s a gross oversimplification” or worse “this is blatantly misrepresenting the scientific author’s conclusions”. Holding up the NYT as a source of medical/scientific truth is just demonstrating how scientifically illiterate you really are.
    
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godzillabacter@lemmy.world ⁨10⁩ ⁨months⁩ ago
Hello all, I’m a pharmacist and 4th year medical student with a passion for antimicrobial stewardship and infectious disease. Just wanted to share my overall thoughts on the article.

The author’s point of “finding out if you really need an antibiotic” is honestly one of the central issues in modern antimicrobial resistance coming from two fronts: patients who demand an antimicrobial for a non-indicated reason, and doctors who for various reasons excessively prescribe antibiotics. I could wax on this for hours, but at its core, the single most important thing we can do to decrease antimicrobial resistance is decreasing total antimicrobial exposure. That means fewer prescriptions for shorter courses of narrow-spectrum antibiotics. Unfortunately every bit of this requires more buy-in from patients and more work from clinicians.

To go along with my point above, asking your doctor to make sure you’re getting the shortest possible duration is the single best thing you as a patient can do to help with these issues (other than just not demanding antibiotics if your doctor says no, but that’s a low bar). The key word here is ask though. There’s a huge amount of clinical experience and evidence that is used to determine when it is safe to stop antibiotics. And as much as I believe in patient autonomy and educating my patients, frankly antibiotic selection/course duration is not something the general public is capable of independently making decision on. Ask your doctor, and take what they prescribe for how long they’re prescribed for, and if you have issues then call them to discuss it.

With regards to probiotics, it’s an interesting topic that we don’t have a ton of great data for and physicians are fervently behind or against them in my experience. The fact is we just don’t know enough about them, and most aren’t regulated well enough to give good information about them. Interestingly, there was a recent study which suggested higher rates of central line infections with the organisms in the probiotics in individuals given probiotics while they had a line in place.

Lastly, I think I have to disagree with Dr. Blaser. Medicine doesn’t overvalue antibiotics. We certainly underestimate their risks, but antibiotics are some of the most effective and life-saving medications we as a species have ever developed. Countless lives have been saved solely from their development, and very very few therapies have a NNT as low as appropriate antimicrobial therapy. They truly are astonishingly good medications when they are indicated. The issue is simply prescribing them when they aren’t indicated, which is a big part of why we’re in the mess we’re in, and is in large part driven by underestimating the risks they pose.

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MaximilianKohler@lemmy.world ⁨10⁩ ⁨months⁩ ago
Some relevant info I shared yesterday:

While antibiotic resistance gets all the attention, the damage being done to our host-native microbiomes is arguably as big a threat as climate change, as the damage compounds over generations, and once it’s gone you can’t get it back. (Apr 2019).

Resistance can be solved by restoring lost microbes with FMT: humanmicrobiome.info/antibiotics/

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- godzillabacter@lemmy.world ⁨10⁩ ⁨months⁩ ago
  That’s not exactly true. FMT isn’t going to fix your MRSA colonization, and it doesn’t inherently remove resistance genes from the population of bacteria in your gut. If those genes produce a survival disadvantage, they may be selected against and become a minor serotype in your GI tract, but that doesn’t mean that it is eradicated.
  
  Also, you seem to be sharing a lot of links from humanmicrobiome.info, which I would advise against. While I can appreciate the primary author’s dedication to the topic and willingness to cite his sources, his website is not peer reviewed, and he explicitly states he is a proponent of FMT, introducing bias which is not being balanced by a peer review process. Not to mention he admits he is a layperson with no formal medical training/experience. I would direct you to IDSociety.org which is the home of the Infectious Disease Society of America, who publishes the actual guidelines used by infectious disease physicians in North America.
  
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  - MaximilianKohler@lemmy.world ⁨10⁩ ⁨months⁩ ago
    MRSA is actually covered in the cited links. Here’s one for example academic.oup.com/ofid/article/6/7/ofz288/5522275.
    
    The gut microbiome regulates the entire body, including the immune system and other body site’s microbiomes humanmicrobiome.info/systemic. You can see what a great resource it is – very handy to provide categorized citations.
    
    his website is not peer reviewed
    
    Anyone is welcome to contribute and peer review it.
    
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- gonta@mander.xyz ⁨10⁩ ⁨months⁩ ago
  For anyone wondering, FMT = Fecal Microbiota Transplants.
  
  It’s exactly what it sounds like; through oral or rectal.
  
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  - Nurse_Robot@lemmy.world ⁨10⁩ ⁨months⁩ ago
    I imagine burping after taking it through the oral route would be a special kind of horrible
    
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flooppoolf@lemmy.world ⁨10⁩ ⁨months⁩ ago
I’m considering this to be harmful information.

When you wipe out all of your microbiome, chances are it returns to normal in the following months after antibiotic treatment.

Your doctor will know if you need antibiotics because there is a positive test for a bacterial infection.

You have to take the full course to prevent resistance from forming. Resistance will form, no matter what, if you don’t fully eradicate the foreign organism. Studies are conducted to find out what the best course duration is in order to completely eradicate the organism. (STOP-IT trial for Intra Abdominal Infections suggest 4/5 days vs 10 day norm to be effective)

That is something you don’t want to happen because then you have to use stronger antibiotics which will absolutely do more than make your tummy hurt. (Ouch my kidneys)

The only medical indication for a FMT is a C.diff infection that is recurring. This means your microbiome has been wiped and replaced with C. Difficile. A bug that causes severe diarrhea.

If you let resistance flourish, then every single time someone needs to take an antibiotic it will be even more likely they develop a C. Diff infection due to the microbiota being wiped even harder. Resistance will become even more common due to the least harmful antibiotics not being available for use.

If you prevent resistance you prevent the use of harder antibiotics which prevents microbiome damage which prevents c. diff.

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- MaximilianKohler@lemmy.world ⁨10⁩ ⁨months⁩ ago
  
  When you wipe out all of your microbiome, chances are it returns to normal in the following months after antibiotic treatment.
  
  Harmful misinformation. A plethora of citations were already provided that debunk that claim.
  
  You have to take the full course to prevent resistance from forming.
  
  Harmful misinformation that is contradicted by the citation in the article and numerous other citations that I provided in the OP.
  
  If you let resistance flourish, then every single time someone needs to take an antibiotic it will be even more likely they develop a C. Diff infection due to the microbiota being wiped even harder.
  
  This makes no sense. I’ll rephrase it to make it sensical and accurate:
  
  If you overuse antibiotics, every time someone needs to take an antibiotic it will be even more likely they develop a C. Diff infection due to their microbiota being wiped out previously.
  
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  - flooppoolf@lemmy.world ⁨10⁩ ⁨months⁩ ago
    www.idsociety.org/…/practice-guidelines/#/+/0/dat…
    
    I’ll play your game. Everything in here refutes and proves all your claims wrong, with clinical trials and sources for your enjoyment.
    
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Carighan@lemmy.world ⁨10⁩ ⁨months⁩ ago
I tried to find other studies going into this in more detail, especially in regards to targetted antibiotics.

Am I correct in assuming that the future hence lies in getting antibiotics far more target-specific? I don’t know how it is in other parts of the world, but over here broad-spectrum antibiotics are already used as a last-ditch effort, usually when there’s no time to truly figure out what a patient is suffering from because of their extremely bad overall state. But I assume broader antibiotics are more common around the world?

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- godzillabacter@lemmy.world ⁨10⁩ ⁨months⁩ ago
  The trouble is that, as a whole, antibiotics that work against resistant organisms are inherently more broad. Bacteria develop resistance by either mutating the target site of an antibiotic, decreasing/removing the expression of a target site, increasing removal of the drug from the bacterial cell, or preventing entrance to the cell.
  
  These changes are relatively antibiotic agnostic (in the sense that they do not target one specific antibiotic, they target a general chemical structure which is shared among a class of antibiotics), and in most cases, if you develop a drug which is able to circumvent one of these problems, it will continue to work on the wild-type bacteria of that species (by definition making it broader). I am unaware of any antimicrobial which is effective against drug-resistant organism which has no efficacy against the wild-type of that organism.
  
  I agree with the other poster that phage therapy likely represents a future avenue for antimicrobial resistance. Unfortunately antibiotics will (at least for the foreseeable future) be required as to effectively use phage therapy you must identify the organism and then select appropriate phages which will kill the bacteria, which takes time that a sick patient may not have without antibiotics. We also haven’t quite figured out how to keep our immune system from eradicating the bacteriophages, particularly for infections requiring longer treatment such as endocarditis.
  
  There is a currently existing technology which allows for genetic identification of bacteria and fungi in positive blood cultures approximately 1 day faster than classical methods of culture and biochemical testing. There is active research into changing these tests slightly to be able to function on other body fluids (pus, pulmonary secretions, urine, etc) as well as to be able to function on fresh blood samples instead of waiting 1-2 days for the culture to become positive from bacterial growth, but these technologies are not ready for clinical use, and until they are, broad spectrum antibiotics will be a necessity.
  
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  - MaximilianKohler@lemmy.world ⁨10⁩ ⁨months⁩ ago
    
    as to effectively use phage therapy you must identify the organism and then select appropriate phages which will kill the bacteria, which takes time that a sick patient may not have without antibiotics
    
    Phage cocktails, FMT, etc… Also, we should get better at speeding that process up if we fund research for it, but we’ve been instead continuing to rely on antibiotics.
    
    We also haven’t quite figured out how to keep our immune system from eradicating the bacteriophages
    
    Citation? I don’t recall that being a thing… phages are ubiquitous in the human body. As much or more so than bacteria. They are the natural way bacteria are kept in check.
    
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- MaximilianKohler@lemmy.world ⁨10⁩ ⁨months⁩ ago
  IMO the future lies in replacing antibiotics with adding instead of subtracting: phages/phage cocktails, FMT, etc. There’s also a massive amount of antibiotic overuse for a variety of reasons, including public ignorance about their necessity (lack of) and harms, and emotional thinking and lack of consequences for people in the medical system.
  
  Phages were given up on because antibiotics were an easier solution and the consequences aren’t always immediately obvious. But that decision has likely played a major role in getting to the current chronic disease crisis.
  
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  - Carighan@lemmy.world ⁨10⁩ ⁨months⁩ ago
    Sounds interesting.
    
    I will say that having had two eye infections, one resulting in a surgery and the other being solved with antibiotics before it got to bad, give me all the antibiotics, I don’t care, before you make me get that surgery again. Straight outta Saw, that shit. But that’s an edge case of course.
    
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otter@lemmy.ca ⁨10⁩ ⁨months⁩ ago
Thanks for sharing!

Other relevant communities

!medicine@mander.xyz

!health@lemmy.world

!publichealth@mander.xyz

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- MaximilianKohler@lemmy.world ⁨10⁩ ⁨months⁩ ago
  Yep, I crossposted to two of those already. Feel free to x-post to the medicine one if you want.
  
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  - otter@lemmy.ca ⁨10⁩ ⁨months⁩ ago
    Thanks :) I’ll try to get to it next time I’m on desktop
    
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