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Bacteria Can’t Read Calendars

November 16, 2010

Physicians should stop a course of antibiotics once the infection has cleared, instead of using an arbitrary number of days.

I am constantly amazed at the standard practice of giving antibiotics for a predetermined number of days.  We often prescribe a 7-day course or a 10-day course or a 14-day course.  Sometimes, it’s just a 3-day course.  Whatever it is, it seems that it has to be a relatively standard football score; an 8-day course simply won’t do.

Over the years, I’ve tried to find out where these numbers come from.  The best I can determine is that it comes from the process of antibiotic approval by the Food and Drug Administration.  A prospective controlled study must be done to compare a new drug for a particular infection with a drug that already has FDA approval.  However, instead of comparing which drug cures patients faster or more effectively, cure rates are sought after a predetermined number of days of treatment.  I suspect that is because it would be almost impossible for the pharmaceutical company to determine study costs with an uncertain duration of treatment.  So when the study is completed and the drug is approved, its publication becomes the reference for physicians to use.

Unfortunately, the duration of treatment — that predefined and arbitrary number of days — is taken to be gospel, and physicians start using for their patient management, even though it was cooked up by some bean-counter in the pharmaceutical company.

We have data to suggest a better way.  In a study analyzing 11 prospective controlled trials of antibiotic alternatives for the treatment of intra-abdominal infections, Dr. Harlan Stone demonstrated that the inflammatory signs (fever, elevated white blood cell count, presence of immature neutrophils) often used to identify the presence of an infection can also be used to identify its eradication.

It is amazing to realize that it would be a paradigm shift in medicine for doctors to act like doctors and not obey the therapeutic recommendations of accountants.

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