Virologist: 'You don't always have to finish your antibiotics course'

You don’t always have to finish your course of antibiotics: Just one of the controversial suggestions in a myth-busting new book by a leading virologist

Some of the most common medical treatments we rely on are out of date and may even be bad for us, says Dr Paul Offit, a leading U.S. paediatrician and expert in immunology and virology, who developed the vaccine against rotavirus, an infection that can cause life-threatening diarrhoea in children and babies.

Here, Dr Offit examines various treatments to help YOU ask your doctor the right questions about your care…

Full course of tablets is often unnecessary

This is the advice in the UK school curriculum: ‘Always complete the full prescription, even if you feel better, because stopping antibiotics early promotes the growth of drug-resistant bacteria.’

But the opposite is true. The longer the course of antibiotics, the greater the chance bacteria will learn to become resistant.

The misconception about how long to give antibiotics began with one of the first patients to receive them. In 1941, Albert Alexander was given penicillin to cure a rampaging Staphylococcus aureus infection that had initially invaded a sore in his mouth.

The new drug worked, but the doctors only had four days’ worth — not enough to eradicate the infection.

After the drug ran out, the resurgent infection killed Alexander. When the drug’s discoverer, Alexander Fleming, received his Nobel Prize in Medicine in 1945, he said: ‘If you use penicillin, use enough.’

The longer the course of antibiotics, the greater the chance bacteria will learn to become resistant

Clinicians interpreted this to mean that they should continue antibiotics until well after the patient appeared to be getting better, to avoid a relapse.

But in their quest to survive, bacteria have a variety of strategies. They make antibiotic-destroying chemicals. They change proteins on their surface so antibiotics can no longer attach. They create an internal pump that spits out antibiotics.

Perhaps worst, these resistant bacteria teach neighbouring bacteria to become resistant. This sparks the central horror of antibiotic resistance.

It’s often not the bacteria doctors are treating that become resistant; it is others that live on the surface of the skin, nose, throat and intestine. These bacteria (such as E. coli, Klebsiella and Proteus) are common causes of urinary tract, abdominal and blood infections.

Perhaps the best strategy to reduce antibiotic resistance is to abandon the archaic notion of the ‘antibiotic course’ and give antibiotics only for as long as necessary, says Dr Paul Offit

And often it’s not the bacteria that cause the symptoms; it is our immune response that triggers inflammation and fever. When these abate, it means the bacteria are no longer breeding. Therefore antibiotics are no longer necessary and all they are doing now is creating resistant strains and increasing the risk of side-effects.

Perhaps the best strategy to reduce antibiotic resistance is to abandon the archaic notion of the ‘antibiotic course’ and give antibiotics only for as long as necessary.

One of the first experts to decry the old approach was Dr Martin Llewelyn, a professor of infectious diseases at Brighton and Sussex Medical School. In 2017, in the British Medical Journal, Llewelyn wrote that the length of treatments should be determined by how quickly the patient recovers, and should not be an arbitrary length determined at the start of the illness.

With cystitis, for example, in 2007 a study in the journal Archives of Internal Medicine, based on 340 women with the infection, concluded that three days of antibiotics was enough to cure it.

More recently, in 2018, a multinational research team studied 500 women with cystitis and concluded that five days’ treatment was adequate. Now advisory groups, including the European Society of Microbiology and Infectious Diseases, recommend either three or five days of antibiotics for cystitis, depending on the antibiotic used.

There are now specific numbers of days of antibiotic treatment recommended by advisory groups for other common bacterial conditions — for example, sinusitis (five to seven days), skin infection (five days) and school-aged children’s ear infection (three days).

The best advice for cystitis, pneumonia, sinusitis, cellulitis and ear infections is to stop antibiotics when symptoms begin to improve.

Don’t depend on high SPF creams

Given that sunscreen reduces the body’s exposure to the ultraviolet radiation that causes skin cancer, medics have assumed that studies would clearly show sunscreens prevent cancer.

But in 1999, a Harvard Medical School review of the research found two studies that showed sunscreen prevented the most dangerous type of skin cancer — melanoma; three showed it made no difference, and six showed that sunscreen actually increased melanoma risk.

Subsequently, Philippe Autier, a Belgian epidemiologist, compared sunbathers given lower-factor SPF10 sunscreen with a group who used higher-protection SPF30.

He found that those who used SPF30 stayed longer in the sun than those who used SPF10, presumably because they felt less likely to get sunburnt.

SPF30 users were also more likely to sunbathe around midday, when solar radiation is greatest. SPF10 wearers were more likely to sunbathe later in the afternoon, when it is less intense, Autier reported in the British Journal of Cancer in 2000.

But although all the bathers avoided sunburn, that doesn’t mean they were below the levels of solar radiation that cause melanoma.

Dermatologists had assumed that sunburn led to melanoma, so the more times someone was sunburnt over the course of their life, the greater the risk of this cancer.

But lab studies by researchers at Cancer Research UK’s Manchester Institute, in 2014, showed that even SPF50 sunscreens don’t prevent melanoma, they only slow the process by which UV light causes it. Sunscreens had provided a false sense of security.

As Cancer Research UK has warned: ‘People tend to think they are invincible once they have put on [sunscreen] and end up spending longer out in the sun, increasing their overall exposure to UV rays.’

Aspirin isn’t a heart attack preventer

Should people with risk factors for heart attack or stroke — but who have had neither before — take daily low-dose (75mg) aspirin?

A burst of positive evidence has left many believing it will do more good than harm. Sadly, that is often wrong.

In 2009, researchers in Oxford reported that their meta-analysis of previous evidence indicated that people taking daily aspirin reduced their risk of a second stroke or second heart attack by about 20 per cent.

Thanks to such clear evidence, doctors began to recommend that people who had suffered a stroke or heart attack should receive daily low-dose (‘baby’) aspirin.

Evidence also appeared to back giving low-dose aspirin to people who hadn’t suffered a stroke or heart attack but were at high risk, such as those with diabetes, hypertension or high cholesterol.

For example, a 1989 Harvard Medical School study suggested daily aspirin would cut their risk by 44 per cent. But subsequent research failed to support this.

And while low-dose aspirin may sound harmless, it isn’t.

In 2016, a seven-year Oxford University study of 15,000 adults with diabetes warned that although the tablets cut heart attacks by a very modest amount, they raised the risk of potentially serious bleeding, such as intestinal haemorrhage, by nearly a third.

Aspirin benefits people who have already had a stroke or heart attack so much, this added protection outweighs the significant bleeding risks.

That is not true for people at risk of a stroke or heart attack but who haven’t had one. Therefore, only take daily low-dose aspirin if your doctor recommends it.

Mercury dental fillings are not dangerous

Tooth decay begins with bacteria in plaque, a thick substance that sticks to teeth and gums. These bacteria interact with starches and sugars in food to erode the outer surface of the tooth, causing holes (cavities). If untreated, cavities can cause pain, inflammation and tooth loss.

To treat cavities, dentists drill out the decayed material and fill the hole with either a composite resin — which is the colour of teeth and made from the sap of fir and pine trees — or an amalgam, which is silver in colour and made by mixing powdered tin, copper and silver with liquid mercury.

Amalgams can be placed more quickly than resins and mercury also slows the growth of bacteria, making it less likely the tooth will erode further. But despite their advantages, mercury amalgams have always been controversial as, in some forms, mercury is toxic.

Mercury dental fillings can also be vaporised after brushing teeth or eating acidic foods.

So, the question is: does mercury vapour from amalgams cause harm? The World Health Organisation (WHO) has adopted a safety limit for mercury vapour of 25 micrograms (μg) per square metre of air per day.

Given that symptoms of mercury toxicity have never been observed below exposures of 100μg of mercury per square metre per day, the WHO guideline provides a margin of safety. The quantity of mercury found in the mouths of people who have at least eight mercury fillings is about 1μg per day, at least 100 times less than levels found to be harmful.

To put this in perspective, people typically eat or drink about 3.5μg of mercury every day (it is in our water supply and in fish such as swordfish and tuna, for example).

Therefore, the quantity we consume is more than three times greater than the quantity of mercury vapour we inhale from mercury fillings.

And both these sources of mercury are well within ranges shown to be safe.

Op won’t help arthritic knees

We outlive our knees. About one Briton in six suffers from knee pain, according to a 2013 report in the journal Osteoarthritis and Cartilage. Often this is caused by knee arthritis, which is characterised by chronic damage to cartilage that cushions the joint.

Desperate for help, people willingly pay privately to have arthroscopic keyhole surgery that removes tiny bone splinters and damaged cartilage, and smooths the remaining tissue — this is performed via a miniature fibre-optic ‘arthroscope’ camera under a local anaesthetic.

By 2002, 14 studies had shown that arthroscopic surgery offered substantial pain relief.

However, in that same year, a team of researchers from the Houston Veterans Affairs Medical Centre performed a ground-breaking (and to some, unethical) study.

They gave 120 patients knee arthroscopies and 60 patients sham ‘placebo’ surgery, where incisions were made in their knees. Those patients heard the surgeon at work and spent a night in hospital — but nothing had been done to them.

After two years, the researchers reported in the New England Journal of Medicine that the sham patients’ knee pain and function was the same as for patients who had received genuine surgery.

Further studies confirmed the results. Arthroscopic surgery is no longer recommended for knee arthritis. Yet on the internet, plenty of UK surgeons continue to offer it privately.

Current guidelines from the UK treatment watchdog, The National Institute for Health and Care Excellence (NICE), say knee arthroscopy should be given only to people who have a clear history of their knees locking up, even though this has been revealed as pointless by research.

Vitamin supplements could be harmful

We are born to die. One reason for this is inescapable: oxidation. This is an inevitable result of the way our cells turn food into energy. The process produces damaging substances called free radicals, which cause cancer, ageing and heart disease.

To fight free radicals, our bodies make antioxidants (such as glutathione). But that is not enough. We also benefit from supplementing our own antioxidants with those in food, such as vitamins A, C, E, lycopene and beta-carotene.

As you might expect, people who eat more fruit and vegetables containing antioxidants have lower rates of cancer and live longer.

By 1996, more than 200 human studies had shown that diets rich in fruit and vegetables protect against various cancers.

By the late 1990s, researchers could pinpoint exactly which produce was the most beneficial. In descending order of importance, the list included raw vegetables, allium vegetables (onions, garlic, leeks, chives and shallots), carrots, green vegetables, cruciferous vegetables (cauliflower, cabbage, broccoli, sprouts) and tomatoes.

It seemed logical that antioxidant supplements, which contained far greater quantities than could be found in foods, would have an even greater protective effect.

But in 1999, researchers from Finland found to their surprise that men who took beta-carotene supplements had an 18 per cent greater risk of lung cancer than those given a placebo.

In subsequent years, researchers across the globe attempted to find evidence that dietary supplements prevent cancer and heart disease. They found nothing conclusive.

It is said that, at worst, supplements make for a lot of expensive urine. But five large studies in the past 25 years have shown that not only do antioxidant supplements fail to prevent cancer and heart disease, they cause them.

In 1996, researchers from the Fred Hutchinson Cancer Research Centre in Seattle divided 18,000 people with a raised risk of lung cancer — smokers, former smokers and asbestos workers — into two groups.

One group received beta-carotene and vitamin A every day; the other, a placebo. To their surprise, the investigators found that the antioxidant group had a 46 per cent increased risk of dying from lung cancer and a 26 per cent increased risk of death from heart disease, compared with the placebo group.

Eleven years later, researchers found that the supplement group also had a 52 per cent increased risk of aggressive prostate cancer.

Worried researchers turned their attention to vitamin E. In 2005, scientists at Johns Hopkins School of Medicine in Baltimore reviewed 19 trials involving 140,000 people who had taken vitamin E supplements. They found they had a greater incidence of death from any cause.

The researchers urged: ‘Policy-making bodies… should caution the public against the use of high- dosage vitamin E supplementation.’

It remains a mystery why anti-oxidant supplements raise the risk of heart disease and cancer.

Scientists have suggested various possibilities, including that supplements provide far higher levels of vitamin than are found naturally, which may be dangerous.

For example, you would have to eat 2,000 almonds (a rich source of vitamin E) to obtain the equivalent of one lower-dose tablet.

Ice on a sprain delays healing

More than 300,000 Britons every year visit A&E with sprained ankles, according to a 2003 study in the Emergency Medicine Journal.

You can bet that one of the first things they tried at home was putting ice on the injured ankle. But this is the wrong response.

Ankle sprains injure three ligaments that stabilise the outside of the joint. If the ligaments don’t heal fully, it can cause long-term ankle instability. This affects up to a third of people with severe sprains. So the first few days of treatment are crucial.

The myth about icing gained official backing when Dr Gabe Mirkin, an American physician and athlete, published an instant bestseller entitled The Sports Medicine Book in 1978.

Ice became the go-to treatment. Unfortunately, Mirkin’s advice was based more on instinct than evidence.

Immune cells stronger at higher temperatures

Why is it that every warm-blooded and cold-blooded animal that has walked, flown, swum or crawled on the face of the Earth for the past 600 million years has the capacity to make fever?

Isn’t it possible that fever is an adaptive response to the environment, allowing us to survive?

And isn’t it then possible that reducing fever, with medicines such as aspirin or ibuprofen, might do more harm than good?

As early as 1975, researchers at the University of Illinois studied 45 young adults experimentally infected with a common cold virus. Half the subjects were treated with aspirin, half were not.

Those treated with aspirin shed virus from their noses for significantly longer than those who weren’t treated. And this result has been replicated with other infections.

In 2016, researchers in Hungary summarised the results of 42 studies that had examined the relationship between fever and survival in patients with severe bloodstream infections (sepsis).

They found that the death rate was 22 per cent in patients with fever, 31 per cent in patients with normal body temperature, and 47 per cent in patients with temp- eratures lower than normal.

So fever increased survival. Why? One thoery is that some bacteria are killed at higher temperatures. Also, our immune system seems to work better at higher temperatures, too.

Indeed, immune cells called neutrophils travel to the sites of infection faster and ingest and kill bacteria better at higher temperatures.

Similarly, B cells, which make antibodies that are specific for harmful invaders and help to neutralise them, also work better and faster at higher temperatures.

In fact, a growing number of studies have concluded that ice either doesn’t help or makes things worse. And in 2013, researchers from Taiwan discovered why.

When ligaments are damaged, they release substances that promote inflammation. In response, the body increases blood flow that brings immune cells to the damaged area. These help remove damaged ligament and muscle cells.

Increased blood flow also promotes the manufacture of collagen, which is necessary to build new, healthy ligament fibre.

Ice decreases inflammation. So does rest, compression and anti-inflammatory drugs. The current best recommendation is instead to keep the ankle moving a little.

Don’t put weight on it if this is painful, but pretend to write letters of the alphabet with your toes within a couple of days of sustaining the sprain. This gentle, continuous movement promotes healing blood flow.

Dr Paul Offit is director of the Vaccine Education Centre at the Children’s Hospital of Philadelphia, and holds professorships in vaccinology and paediatrics at Pennsylvania University.

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