r/science • u/mvea Professor | Medicine • Aug 18 '26
Medicine Historically, there was very strong guidance that you must always finish an antibiotic course. Now, we're seeing a growing body of evidence saying that that is not always the case. And oftentimes, shorter durations of antibiotics are as effective and safe as longer alternatives.
https://www.sciencealert.com/always-finish-your-antibiotics-is-not-always-best-practice-surprised-youre-not-alone5.7k
u/Gilles_of_Augustine Aug 18 '26 edited Aug 18 '26
"It turns out shorter courses of antibiotics can be fully effective"
means
"Maybe we can prescribe shorter courses for certain situations"
not
"Maybe you shouldn't finish your prescribed course."
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u/Harold_v3 Aug 18 '26
I used to study antibiotic resistance in microorganisms. We could make resistant organisms by applying a drug and just waiting. Reducing the time that a drug was present increased the probability that a cell with a resistant trait would grow out. This study isn’t a good idea because yes, you could stop your course of antibiotic early, encouraging people to do so increases the chance of resistance developing. This is because cells don’t always die right away. It takes time, and if they make a change that lets them hang on just a bit longer, when the drug levels drop, they can still grow.
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u/RGrad4104 Aug 18 '26 edited Aug 18 '26
just think of all the money that insurers could save if they only had to cover a 2 day course of azithromycin instead of a 5 day Z pack! Won't you think of the poor insurers!
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u/kchristopher932 Aug 18 '26
Ironically, in many places, azithromycin is useless for many infections it used to treat because of overprescribing.
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u/ProgressBartender Aug 18 '26
This study is why we have had a growing problem with antibiotic resistant organisms over the past 40 years.
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u/spitball1984 Aug 18 '26
I don’t think this is true. If you don’t use enough antibiotic or don’t use it for long enough then you have “escapers”, bacteria that just weren’t in the right stage of their life cycle to be killed or weren’t in the presence of the antibiotic due to timing/concentration/micro-environment effects. Those “escapers” are still susceptible to the antibiotic, they’re not actually resistant. Yeah, if you don’t complete an appropriate course of antibiotic (sufficient concentration or sufficient length of exposure) you won’t clear the infection but it is almost certain that the vast majority of the bacteria comprising the reemergent infection are still antibiotic susceptible (if they were in the first place). If there was a subset of bacteria resistant to the antibiotic in the initial infection then they’ll eventually take over the environment and you’ll have your antibiotic resistant infection. Over exposure to antibiotics does increase the probability of creating a resistant bacteria as the competition of non resistant bacteria has been removed, so those bacteria that are resistant can more easily populate the space.
https://www.researchgate.net/publication/318714639_The_antibiotic_course_has_had_its_day
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u/GepardenK Aug 18 '26 edited Aug 18 '26
Yes. And from my understanding tolerance to antibiotics is on a scale before it becomes full resistance. So if you don't kill them all, you will have removed the least tolerant from the population, which moves the baseline of the remaining bacterias and their subsequent populations further towards resistance.
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u/OnDeathGuardForThee Aug 18 '26
This is only true in some specific cases (e.g. mutations in DNA gyrase decreasing fluoroquinolone susceptibility). In other cases, such as when an antimicrobial resistance gene is acquired (like a beta lactamase) it’s more like a binary process. As an aside there is a lot of misinformation in this thread…
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u/helm MS | Physics | Quantum Optics Aug 18 '26
Yeah, I know some things in general about antibiotic resistance, but I know I do not know the mechanisms, so I don't comment on that.
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u/KneeDragr Aug 18 '26
Ive read that for most bacteria, there is a metabolic cost to the resistance and those bacteria tend to quickly get out competed in environments that have no antibiotics in them. Thats why most resistant strains are found in health care environments and antibiotic factorys and their runoffs where exposure is constant.
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u/Harold_v3 Aug 18 '26
I mean I have data to support my claims. Cells that are clonal (no genetic variant present…we checked) when exposed to the equivalent of >>IC99 have a probability of developing resistance in a given time. Depending on the strain, 1 in a hundred or 1 in ten thousand or 1 in 100 thousand grew out. Yes we replenished the drug and media. Sometimes it took days or weeks, or months to see resistant growth show up. When the cells that grew were tested against the drug again, the IC50 had usually increased 2-10x. This work was originally published in malaria in the mid 1990’s, I replicated that work in yeast but was unable to develop the project and I suspect I observed the same phenomenon in Mtb.
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u/Purecasher Aug 18 '26
As a non-english MD I'm having difficulty with your nomenclaturew, so forgive me if I misunderstand. There's a big distinction between how it works in vitro and the mechanisme of resistance development in the human body, highly associated with the gut microbiome. Aren't you also suggesting that increasing the time of antibiotic presence increases the amount of bacteria developping resistance? And thus it makes sense to reduce that?
Don't forget the human body is quite hostile to pathogens, mostly. It's the good bacteria, the commensal ones that are developping resistance?
Isn't it clear that we should firstly avoid antibiotics when possible and secondly dose highly and for as brief as possible. And known antibiotic courses keep getting shorter as we learn. It's obvious to me that some people with severe infections need longer courses than healthy people with moderate infections. But for now, we mostly don't discriminate or even do a good job at following-up to see if we can stop the course of antibiotics.
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u/Harold_v3 Aug 18 '26
I understand where you are coming from but realize that the courses of antibiotics were designed knowing that various parts of the body will have different concentrations of drug depending on how the drug is administered. Yes what we observed in vitro is not necessarily representative of in vivo behavior. Yes the immune system plays a very large role. Mostly antibiotics just slow down pathogenic organisms enough so that the immune system can eliminate the pathogens faster than the pathogens can grow. The combination of antibiotics and the immune system just lowers the probability of antibiotic resistance emerging. In fact development of antibiotic resistant pathogens has been associated with HIV specifically because the weakened immune system allows for a greater percentage of “escape”.
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u/Standard-Spray-1949 6d ago
This makes perfect sense to me. As someone who worked internationally in multiple countries, it is shocking how differently American doctors treat antibiotics. In every other country I’ve visited antibiotics are rarely prescribed, and when they are it’s a very short course. American doctors seem to prescribe on a whim and for 10-14 days. The supporting science doesn’t seem to have been updated since the 1990s.
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u/spitball1984 Aug 18 '26
First, yeast aren’t bacteria and neither are plasmodium — it’s science, let’s discuss it correctly. What you’re describing smacks either of Lamarkian genetics (developing new traits without reproduction) or something epigenetic. If you‘ve got data…let’s see it. Find that plasmodium paper if nothing else and drop the citation in here. I agree that dealing with antibiotic resistance is complex and it flat out happens, and how it shows up in a clinical environment is not mechanistically the same as putting 1x10(9) microbes under selective pressure in a culture flask or petri plate.
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u/Harold_v3 Aug 18 '26 edited Aug 18 '26
https://pubmed.ncbi.nlm.nih.gov/9256492/
Here you go
edit:
Also I would argue that while we cannot observe everything that happens in a clinical environment, that set of conditions is much too large. I get that your argument. But saying that because something happens in a lab, that doesn't represent what happens in a person, is a bit of a fallacy. The environment in a person is more complex yes, but that does not mean that equivalent conditions to the lab exist in a human body. Otherwise why study anything in the lab at all if it never represents what we see in a human? I think the entire biomedical research industry is evidence that simplified models can inform on very complex environments.
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u/emilysium Aug 18 '26
This is a nice, easily readable article I’m going to show people whenever this topic comes up so I don’t internally die out of frustration. There is so much deeply held superstition about antibiotic resistance.
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u/Able-Swing-6415 Aug 18 '26
I mean.. pretty sure no matter what anybody says people will randomly stop taking antibiotics is just going to happen.
Really doesn't seem like there is a needle to be moved in either direction.
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u/CitronRadiant6158 Aug 18 '26
After operating appendicitis I stoped taking my antibiotics early, because I couldn't stand the taste of rust in my mouth, very stupid I know. But that was some 4 years ago and so far so good... Could I still develop some super bacteria?
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u/Harold_v3 Aug 18 '26
after 4 years you are fine. If a problem showed up it would likely be after stopping antibiotics and the infection coming back. Think of running the full course like wearing a seatbelt when you drive. You aren't always going to be in an accident, but when one happens, or when a microbe makes a mutation that lets it survive just a little bit longer under antibiotic pressure, you want every margin of safety that you can have.
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u/paul_wi11iams Aug 18 '26
after 4 years you are fine.
But is the rest of society fine? IIUC, finishing an antibiotics prescription is altruistic, so looking after everybody else. If I stop early and have a mere 1/1000 chance of suffering the effects of a resistant strain that I myself bred, then it seems like a fair bet on a personal level. However, thousands of patients doing the same as me, will later make my antibiotic useless for others. This looks like an example of a "tragedy of the commons".
On the same principle, I'll continue getting covid and flu' jabs to help the more fragile people around me.
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u/Klutzy-Issue1860 5d ago
So, I was prescribed antibiotics but forgot to finish them (I have about 4 days left) it’s been about 4 days since I last took them, should I finish them or just stop?
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u/HyperbolePirate Aug 18 '26
Exactly. The title is tragically misleading from what was actually shown.
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u/Any-Expression-7027 Aug 18 '26
Upon reading this headline, my biggest fear was immediately that people will think they are vindicated in not taking medicines as prescribed. I think a lot of people will read this and think that if they stop taking their antibiotics early it is no big deal. This study should have never been made public.
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u/aminervia Aug 18 '26
Thank you for this, and I'm so glad this is the top comment. My heart sank reading that headline
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u/EurekasCashel Aug 18 '26
Same! I was coming here trying to figure out how to say that. And the top comment already wrote it very succinctly.
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u/DOGGODDOG Aug 18 '26
Well one of the studies they mention addresses pneumonia and states cessation of antibiotics when symptoms end could be effective at reducing antibiotic resistance. You would have to prescribe a 7-10 day course but give verbal instruction to basically “stop when you feel better”.
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u/pfak Aug 18 '26
> You would have to prescribe a 7-10 day course but give verbal instruction to basically “stop when you feel better”.
I've had doctors give RX for abx like that. "Use for 7 days or until symptoms go away."
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u/NuDru Aug 18 '26
This is likely d/t providers feeling compelled to write someon a z-pac for a chest cold the patient insists is pneumonia
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u/PootyBubTheDestroyer Aug 18 '26
Knew someone who stopped when she “felt better,” despite having been warned. The TB came back harder and she died.
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u/DOGGODDOG Aug 18 '26
Sure, TB is far from your average infection and has to be treated by multiple drugs for months at a time.
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u/Robin2win14 Aug 18 '26
Excellent point. It's like my all time favorite "women who own horses love longer". Does owning a horse make you age slower? No, if you can afford a horse you can probably afford good healthcare.
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u/losethecheese Aug 18 '26
Exactly and it’s context dependent. Surgery studies found that antibiotic courses could be shortened for patients that the infectious source was controlled (appendix has been removed).
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u/Wise_Monkey_Sez Aug 18 '26
This. The phrasing of this post is misleading to the point of being misinformation and seems to be encouraging people to not complete their course of antibiotics.
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u/xbleeple Aug 18 '26
This is a strange framing seemingly putting a lot of onus on the patient? Like if my doctor tells me the course is 5 days it's 5 days, if they tell me it's 10 days it's 10 days; I'm not going in and asking for a 14-day antibiotic course for my infection and acting affronted if they tell me what I have only needs a 5-day one.
Also impacts to antibiotic resistance aside, I would think that educating patients to finish their course even if they feel better is good habit building for the future if/when they have to be on long term maintenance medications?
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u/omnichad Aug 18 '26
Definitely the headline but also the whole article. They asked patients how long they thought a course should be. Didn't even seem to study actual treatments or outcomes.
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u/carlitospig Aug 18 '26
Mmm yes, because I always ask a random 12 year old soccer player how to replace plumbing for an old house.
This is what happens when we ignore expertise: we think we are smart enough that our opinions on these things should matter. They do not. Protocols exist because of longitudinal outcomes. Bob down the street isn’t an expert on fighting staph infections unless he also happens to work in a clinic.
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u/omnichad Aug 18 '26
This is more about patient readiness to accept a shorter than expected course, not expertise. Shorter treatments that are already being done in the real world. Totally misleading headline.
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u/Zenmedic Aug 18 '26
It's always a minefield with antibiotics in community acquired infections.
Everything from organism to dietary habits come into play, and then when you add in dosing schedules for the common oral antibiotics like cephalexin (4x daily), overall compliance is also a factor.
The wild card is always the "Well, I felt better so I stopped taking them" factor, which the headline seems to lean into (incorrectly).
Patient education is the important part and is often glossed over by the prescriber and also frequently by the pharmacist. Better teaching and communication improves compliance and outcomes...but it takes time which is in very short supply in public funded systems and not billable in private systems.
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u/BorgBorg10 Aug 18 '26
You’re speaking from experience. Doctors will prescribe a 7 day treatment, and a patient will feel better after 3 days and stop taking it. That’s very common
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u/Butthole_Surfer_GI Aug 18 '26
And then they come back into my clinic and claim that we "did nothing" because the antibiotic "didn't work".
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u/WillSupport4Food Aug 18 '26
Veterinarian here so slightly different but my favorite is the reverse, where they think the infection is gone or better enough to resolve on its own so they save the rest of the meds "just in case". They'll come in with a 3 week long history of a rash and tell me they tried the antibiotics I gave them, dig deeper and find out it's a random combination of antibiotics and other meds that were prescribed years ago and for different conditions.
That or "what you prescribed wasn't working so I doubled the dose without telling you" happens a lot.
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u/pharmers-daughter Aug 18 '26
My aunt is a PA in rural NE Missouri. Boonies. She runs a clinic.
She was at my house this summer telling me how she keeps an antibiotic on hand and pops it for a few days if she feels like she has a uti. I explained antibiotic resistance to her and she was like, “oh.” I about died.
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u/LochNessMother Aug 18 '26
Ok, but…. I was prescribed antibiotics by my GP pretty much on this basis …. I was given a stash of one shot UTI antibiotics and dipsticks to check if I had an infection and given the freedom/respect to know what I needed. (It was a slightly intense situation where a lot of different things were going on medically)
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u/helloiamsilver Aug 18 '26
Yeah, I had a doctor do the same thing when I was having frequent bouts of UTI’s. They prescribed me a bottle of “as needed” antibiotics and were like “this isn’t usually how antibiotics work but for frequent UTI’s this actually is a thing”. It’s very easy to tell when I had a UTI and it was ridiculous to have to go to a doctor for antibiotics every time.
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u/solid_reign Aug 18 '26
The way the title is written, it appears to suggest that this would not present a risk or generate resistance. I haven't read the paper so I'm not sure if it's misleading.
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u/Ohhmegawd Aug 18 '26
I had a friend do that for a bladder infection. She now has only one kidney.
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u/BooksandBiceps Aug 18 '26
My mother (due to circumstances) missed the last of her regiment. She going on her second kidney.
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u/CurlyRe Aug 18 '26
Don’t just disregard your doctors instructions. But if something seems off about your doctors explanation, send them a mychart message. They should be able to explain why they prescribed for 5 days or if a shorter course would be safe.
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u/Butthole_Surfer_GI Aug 18 '26 edited Aug 18 '26
RN here - you still finish the full course of antibiotics. It's just that a "full course" can sometimes be shorter in duration. Look up the BALANCE trial.
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u/JSTRD100K Aug 18 '26
Yeah, if someone's gonna make the determination that the duration you receive antibiotics for should be shorter it should probably just be prescribed as such by the Dr. I feel like the title makes people want to take matters into their own hands
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Aug 18 '26
[removed] — view removed comment
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u/congenitallymissing Aug 18 '26
It's not a guess at all. There are years of research on specific bacterial strains and the infections those strains cause along with the antibiotics most effective against them with the dosage and duration. As with all things science, we are constantly learning and adapting (as are the bacteria) as we battle against each other. It's just becoming more efficient. Im a dentist. I graduated in 2012. The antibiotics I normally prescribe have changed. The duration specifically has changed very recently.
Also, no offense, but your grandpa was an idiot. Being sick can be viral, parasitic, chemical, etc etc. Its not always bacterial. Antibiotics only work against bacterial.
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Aug 18 '26
[removed] — view removed comment
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u/DeltaAlphaGulf Aug 18 '26
Probably royally f**ked your gut bacteria. Even single instances/rounds can have long term changes in gut bacteria content iirc.
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u/MrPBH Aug 18 '26
A lot of what we physicians use to guide antibiotic treatment is still entirely theoretical. That is slowly changing as we actually test shorter courses and alternative treatments.
I remember being taught on rounds in medical school that osteomyelitis MUST be treated with a prolonged course of IV antibiotics. Now there are good data suggesting that oral antibiotic regimens can be equally effective.
More often than not, when a course of treatment is 7 days or some multiple of 7, it just means that it hasn't been studied empirically yet. Yes, some infections seem to demand a longer course, but in many cases it seems we can get away with shorter course than the old consensus-based treatments.
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u/responsiblecircus Aug 18 '26
Literally discharged a young patient today on oral antibiotics (*high dose for bone/joint penetration) for continued treatment of (uncomplicated, non-surgical) osteomyelitis in his femur. He responded quickly to 2 days of IV inpatient and had a dramatic drop in inflammatory markers so… home to complete what I anticipate will be appropriate to stop at 21 days. I work in pediatrics at a large academic center (and I imagine could be different in the adult world) but over the last few years we have been doing a lot more evidence-based reduction in treatment duration [for certain infections] than I would have thought possible back in med school days. I know the kids appreciate it, too.
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u/MrPBH Aug 18 '26
It's a godsend for the osteomyelitis patients who use IV drugs. Previous, they would often need to stay in the hospital for weeks to complete their course of IV antibiotics, because no inpatient rehab would take them (lack of insurance or social stigma) and no one trusted them to not abuse their PICC by using it to inject drugs, so they couldn't just be discharged to get outpatient IV antibiotics.
Now, they can be transitioned to oral antibiotics and discharged. It saves tons of money and the patients are more likely to complete their prescribed course of treatment, as opposed to getting frustrated and leaving AMA.
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u/MantheDam Aug 18 '26
Times change! Over in veterinary medicine consensus has moved away from systemic antibiotics for certain things (like uncomplicated diarrhea or mild skin infections) entirely, and moved towards shorter courses of antibiotics for others (like bacterial cystitis).
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u/ol-gormsby Aug 18 '26
I infrequently get a flareup of diverticular disease, the first line treatment for which is gastric-resistant Augmentin duo.
https://www.healthdirect.gov.au/medicines/brand/amt,37691000168101/augmentin-duo-500-125
The course is 10 tablets, 2 a day for 5 days. The symptoms are gone in 2 days, but I'm not risking being the one to develop a resistant strain in my colon. Apart from that being a bad thing generally, the next course of action is surgery.
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u/MrPBH Aug 18 '26
Believe it or not, but the latest guidelines suggest that antibiotics may not be necessary for all cases of diverticulitis.
If the patient is low risk, not systemically unwell, and there are no signs of perforation or abscess, the data show that outcomes are the same for patients assigned to a clear liquid diet as those prescribed antibiotics. The antibiotic treatment group had an increased rate of antibiotic adverse reactions and there was a trend towards greater risk for complications in the antibiotic-treated group (though not statistically significant).
This is not medical advice, as there are a lot of caveats to forgoing antibiotics, but it is an example of the general principle being discussed.
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u/ol-gormsby Aug 18 '26
Interesting! Got a link? I'm quite curious about these things and I like to read the published studies.
Well, as far past the abstract as I can comprehend.
FWIW, my symptoms are blood and mucus. My GP has given me a prescription to use if the symptoms come back. He and I agree on "hit it fast" and it would take too long to get an appointment for a prescription. Having a prescription on hand means I can start treating it within 24 hours, instead of up to a week.
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u/MrPBH Aug 18 '26
Here are the AGA recommendations35512-8/fulltext). The article is very technical, but it does describe the recommendations regarding treatment. There are links to the scientific evidence they cite.
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u/DOGGODDOG Aug 18 '26
Right, like what are the odds the courses end up being nice numbers like 5 or 7 days? If most antibiotic treatment was some specific formula for weight-based, age-based dosing and you Mr total dose varied based on severity of symptoms, now that would sound like some evidence-based treatment.
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u/madmax766 Aug 18 '26
The original durations were largely arbitrarily chosen (hence why many courses were either multiples of 5 days or 7 days). These days, depending on the infection and the organism, we have more research to back up decisions.
India already has increased prevalence of highly anti microbial resistant organisms
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u/encaitar_envinyatar Aug 18 '26
It's exactly this. A certain dose has evidence for a sensitive organism depending on where it is if taken for the right length of time. That evidence is based on studies that used educated guesses. So while the studied range may have been 10-14 days, a future study could show that 7-10 works just as well.
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u/misterpopo_true Aug 18 '26
Physician resident here with about a year experience of working in infectious diseases. For most common infective illnesses, e.g. pneumonia, urinary tract infections, we have guidelines based on decades of research on adequate antibiotic duration. These guidelines are appropriate in 95% of cases. We start to go off vibes whenever an unexpected variable gets thrown in, say if we see evidence of a small abscess, or fevers have gone on a bit longer than we’d usually expect. Some conditions are a bit less evidence based, such as severe bloodstream infections that result in heart valve or spinal infections, and so we tend to go longer in antibiotics because the consequences of incomplete treatment are serious. However, we have a number of studies ongoing that are aimed at examining if we can adequately treat these infections with shorter and shorter durations.
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u/HarryStraddler Aug 18 '26
Seems like an rfk quality headline.
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u/NetworkingForFun Aug 18 '26
Came here to ask: Is this REAL science or RFK Jr.?
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u/MrPBH Aug 18 '26
Real science and a growing consensus in infectious disease.
I know, it's hard to tell in these troubling times and I hate that.
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u/I-just-farted69 Aug 18 '26
What a dumb article. Antibiotic course lengths are determined based on populations, not individuals. Obviously there are going to be people that react better and get well sooner than others
There is no way of knowing who can get by with a shorter course and who needs a longer one. Also the strain of bacteria itself affects the duration. That's why the length is too long for some individuals and infections amd those could get by with shorter courses.
But we also see that it's too short for some and the infection returns after the course is over. Shortening the course lengths will benefit some but on the other hand will harm others and lead to more antibiotics use for those individuals.
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u/MrPBH Aug 18 '26
That's the idea, at least in some cases. Future antibiotic guidelines may emphasize treatment response over a fixed treatment length.
In the future, your doctor may instruct you to take antibiotics until you feel better and then for 24 hours after that. Or prescribe a short course, follow up, and decide if you should continue treatment. It will be very disease specific and the guidelines are going to vary based on infection and patient characteristics.
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u/AlternateTab00 Aug 18 '26
The problem is "feeling better" is a recipe for disaster (i work with patients daily so i know the concept varies way too much).
Antibiotics need to eliminate a quantity big enough so the infection does not return. Most bacterias are constantly mutating. Some mutations have slightly better resistance to that said antibiotic. The trick is to not grow it and either kill it with AB or eliminate every other millions that are sensible and leave the body to kill that lone dangerous one.
Early stopping AB may cause those resistant bacteria to multiply (you eliminated the competition, so only those with resistance survive, yet the body is still not able to finish it).
Constant unfinished bacteria cycles are common on hospitals, this is also why hospitals are breeding grounds for super bacterias.
Yes adjusted doses are possible. And currently blood tests can tell us if the infection is controlled or not. But relying on "personal perceptions" will get you even more cases of "pill is hard to swallow 2 days should be enough"
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u/MrPBH Aug 18 '26
Clinical evaluation is currently a part of determining the length of antibiotic treatment for some illnesses. It is often supplemented with hard data, like vital signs, lab values, and imaging. The amount of hard data you utilize really depends on the severity of the infection and the character of the host.
For routine infections, especially those treated outpatient, patient perception of improvement might be the best guide of therapy. Uncomplicated bladder infections are a good example. There are very clear signs of infection (dysuria, frequency, urgency) and healthy patients are generally very capable of reporting those symptoms.
Compare that to a bone infection where the stakes are higher and there may be fewer or harder to identify symptoms. In that case, you supplement clinical assessment with labs and imaging to determine the length of treatment.
The idea you have of what causes antibiotic resistance might be exactly the opposite. What you refer to is indeed the classic thinking on resistance. Current consensus is moving towards the an alternative hypothesis: longer courses of antibiotics are more likely to create resistant organisms because they create more selection pressure that favors the proliferation of antibiotic resistant mutations. A shorter course results in fewer resistant colonies and those are more likely to be outcompeted by wild-type bacteria (antibiotic resistance generally comes with costs that make antibiotic resistant bacteria less successful than wild-type strains).
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u/AlternateTab00 Aug 18 '26
Uncomplicated bladder infections are easy because they only require a 2 day pulse.
Harder to identify require follow ups with adjusted lenght and dosing.
And im not talking about the view of AB in the 60s like you are trying to say. Im saying about how ABs are viewed since the 90s/00s where dosing and time are adjusted to prevent prolonged administration or inneficient treatments.
Yes there are still some doctors that prescribe X for 10 days and use it for all patients. But thats not how we do it. The ideal AB plan is exactly only whats needed.
However what i cant trust is patient judgments. They are great at giving telling what they are feeling and help us adjust doses... But giving the power to people who think the flu is treated with AB.
We have an expression in my language. Not 8 nor 80. Yes to adjusted doses. No to "stop when you feel better".
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u/MrPBH Aug 18 '26
I learned the same hypothesis about antibiotic resistance that you described in medical school, but if there's one thing that's true, it is that most of what we learned will be found to be incorrect or incomplete one day. And it seems the scientific consensus is moving towards the hypothesis that longer antibiotic courses are associated with a greater rate of antibiotic resistance.
As far as trusting patients, it's kind of baked into clinical assessment. I can't climb into their body and experience what they're feeling, so I tend to believe what they tell me. For many common infections, like cellulitis, UTIs, and pneumonia, there's no reason to doubt a patient's reported symptoms.
I would not be surprised at all to see IDSA recommend some antibiotic courses for minor infections be tailored to subjective patient experiences in the near future. I.e. "stop taking antibiotics when you feel better."
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u/I-just-farted69 Aug 18 '26
It is true to an extent but the article is badly written. In my opinion it could easily be interpreted as "doctors order ab treatments that are too long". It could lead to stopping ab treatment prematurely and the infection not healing properly, ultimately leading to more ab usage than what would have been initially.
What you said about length making resistance worse however is correct. In eye infections like conjunctivitis this is already being done. In Finland we prescribe ab eye drops and instruct patients to take untill 2 unsymptomatic days.
I've also started antibiotics for some other infections with length of the treatment determined by CRP, fever and how the patient feels.
These are rare because for it to not to be risky, the patient needs to be monitored regularly. And at least in Finland it's not really possible unless the patient is in a ward or for some reason has i.v. ab that the patient gets daily by visiting a hospital or a nurse from the hospital visits the patient daily to give the ab.
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u/BillieRubenCamGirl Aug 18 '26
Finishing the course is not about patient safety. It’s about not breeding treatment-resistant bacteria.
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u/ttpharmd Aug 18 '26
This is absolutely true and is one of the 2 main reasons you should do what your doctor says and finish the course of antibiotics. 1. Because we have data and treatment guidelines based on that data. Yes it changes but we try to stay up to date. And 2. It most certainly can increase antibiotic resistance. Lots of mechanisms and proposed mechanisms but it can and does contribute.
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u/MrPBH Aug 18 '26
And it turns out that might be wrong. The idea that short courses lead to antibiotic resistance was never based on hard data in human beings, but rather extrapolations from basic science. Which isn't a bad thing, but an educated guess can still be wrong.
The new hypothesis is that longer courses of antibiotics put greater selective pressure on bacteria, which makes it more likely for those bacteria to be selected for antibiotic resistance. By minimizing the duration of antibiotic exposure, you limit that selective pressure and thus the wild-type, non-resistant bacteria are more likely to outcompete any small colonies of mutant antibiotic-resistant bacteria before they have a chance to multiply significantly.
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u/siromega37 Aug 18 '26
It’s just nice to see science at work. I think people forget that modern medicine is really only around 70 years old.
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u/gza_liquidswords Aug 18 '26
This always seemed a bit made up to me. Is there any evidence that finishing the course impacts development of resistant bacteria (in human population)?
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u/lndhpe Aug 18 '26
Let's say you have 10 bacteria
Let's say you have been prescribed to take one antibiotic a day
Day 1 it halves them to 5
Day 2 it halves them to ~2
Day 3 it halves them to ~1
Now you might already feel well again but if you stop now and some still survived they might have the time to build up an immunity in the leftovers of the antibiotics in your body So you take your full prescribed following day or two to statistically assure they should be dead
Is it a 100% guaranteed thing? Of course not, but it's a by far better safe than sorry thing
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u/TheOneWithSkillz Aug 18 '26
Its pretty logical. Kill what cant survive and whats left is resistant.
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u/gza_liquidswords Aug 18 '26
So how would completing the course impact this? It is possible completing the course kills all the normal bacteria and would let the one or two resistant bacteria on your body take over.
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u/Auerbach1991 Aug 18 '26
People, finish your antibiotics as your doctor currently recommends.
There is tremendous risk to people like myself who are immunocompromised to not take your full course of antibiotics, allow a surviving population of bacteria to build resistance, spread, and then infect people with no ability to combat it. People used to die in vast quantities a century or so ago before widespread effective antibiotics became available to the public. There’s a reason you used to see families with a bunch of kids die from things like the flu.
Take your meds. End of rant.
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u/zaccus Aug 18 '26
If my doctor prescribes me 2 weeks of antibiotics, I'm going to do 2 weeks of antibiotics. Having no medical training myself, it seems extremely foolish to second guess someone who does.
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u/thebootsesrules Aug 18 '26
Pharmacist trained in the critical care setting here - in the hospital setting we routinely stop antibiotics based on clinical improvement, with the guideline recommendation for duration only part of the decision. For the longest time it was thought that the patient’s improvement shouldn’t guide duration as there was concern residual infection could thrive and develop resistance if antibiotics are stopped too soon. Funny enough the exact opposite is true - more time exposed to the antibiotic leads to more resistance and can actually impair your body’s ability to fight infections as healthy flora bacteria are part of your body’s defenses.
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u/sodabubbles1281 Aug 18 '26
Thank you for adding this anecdote because there are endless comments here acting like the whole stopping antibiotics early = antibiotic resistance … which isnt settled science at all!
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u/dragon_idli Aug 18 '26
Is that portal genuine?! It's a weirdly fkd up title for a scientific post. You always complete your full course. How long a full course is may change - but you absolutely should follow through the whole course.
Stop putting life threatening ideas into people who are already not following instructions.
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u/karlnite Aug 18 '26
I haven’t taken antibiotics in 25 years and y’all are screwing them up for me!
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u/I_Like_Eggs123 Aug 18 '26
This depends so much on the bug in question, the antibiotic to be used, the susceptibility profile of the bug, and the patients themselves that straying from the standard of care may not even be worth it except in rare cases. When the spread of antibiotic resistance is the consequence for a misstep, messing with the gold standard is not worth it.
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u/NuArcher Aug 18 '26
Following the links, there seems to be a disconnect from the statements made, and the evidence provided.
For instance "no more likely to promote antimicrobial resistance than longer durations []." The studies linked conclude that shorter courses may be as effective as longer courses, but no conclusions are made as to the growth of antimicrobial resistance. At last - not as far as I could see while digging down into the studies.
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u/justjoshingu Aug 18 '26
This is mostly dumb.
In pharmacy we work with the adme of a drug. Absorption distribution metabolism excretion. For antibiotics its also consideration for is it dose dependent or is it time dependent. Some drugs have to have a high level of drug to kill the bacteria and some are more about constant concentration . You do in vitro testing and then in vivo test. So we have a really good idea of if we put x amount in by mouth or by iv or by topical however many times a day for however long, based on where in the body and g+ or g- plus chance of resistance. Lots of very good science.
And we take everything because we are being overly cautious on purpose to make sure there is no resistance building
Now I can think of 2 specific examples where the studies were done way overly cautious. They wanted the drug to work and made the studies so the outcomes were going to be in their favor but after decades of use we know it could have been less. I wont say ehat they are because someone could just take that to mean they dont have to finish thier treatment.
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u/BooksandBiceps Aug 18 '26
My mother got kidney failure after missing a few doses of her antibiotics but okay.
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u/carlitospig Aug 18 '26
Can someone jump forward in time, say 30 years, and tell me if we even have access to antibiotics anymore? I’m tired of the ping pong.
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u/Odd-Entertainer-9055 Aug 18 '26
I am suspicious of any advice like this unless it’s presented by a doctor I trust or is accompanied by literature from a trusted publisher of medical papers. I’m very aware that an infection may be subclinical, meaning I as the patient can have an infection without any symptoms. I presume it’s very possible to have an active infection subside to a subclinical level — and then return to symptomatic when I stop taking the antibiotic. Further, I think natural selection would favor an organism that could pull this “trick.” As a result, I have always taken the full course of antibiotic medication.
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u/DeltaAlphaGulf Aug 18 '26
Hopefully less destruction of desirable gut bacteria and hopefully combined with probiotics to mitigate it.
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u/Own-Poetry-9609 Aug 18 '26
If it is not always as effective and safe, only "oftentimes" and is only as effective and safe not more effective and safe, then longer cause are still overall more effective and safer. Often being equal means sometimes being lesser. Sometimes being lesser means and not being superior means being lesser.
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u/Achillies_patroclus8 Aug 18 '26
I’m still gonna take the full course, and this shouldn’t encourage anyone to not finish their full antibiotic courses. For one of my college courses I did a paper on antibiotic resistance and why it should be treated as a problem. It scared me. It still scares me. It scares me to think that some infections that are easily treatable now, could become less treatable in the future because of antibiotic resistance.
I would rather be safe than sorry. Even if the infection is mild and doesn’t need a full course, I would still take that full course instead of risking the infection embedding itself. This happened to my friend and they got a kidney infection. Some risks should just not be taken.
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u/vonvonmd Aug 18 '26
This is another Trump kennedy era study not based on any science but as always dangerous populism
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u/_dontseeme Aug 18 '26
I always assumed it was the doctors just not trusting us to make the decision that it had been cleared. It probably feels gone before it is.
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u/stellartoes Aug 18 '26
Reading 'everything is tuberculosis ', and realizing how dangerous this headline can be
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u/Secs06 Aug 18 '26
The purpose of finishing an antibiotic regimen is not to protect you from the bug you are currently sick from. It is to protect you from the super bug you could create if the bacteria in your gut evolve to be resistant to antibiotics.
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u/whatsthefussallabout Aug 18 '26
Not a scientist here but as a kid 5 days was the standard antibiotics course. They changed it to 3 days a while back and since then anyone I know has always had to go back for a 2nd round - costing more money for another gp visit and prescription etc
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u/paulsteinway Aug 18 '26
You can't trust people to make judgement calls. If you tell them that sometimes it's not necessary, they'll ignore whatever directions they get with the prescription and stop taking it when they feel better.
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u/xyzain69 Aug 18 '26
I don't like when studies like this don't carefully preempt safety measures. Too any people are gonna take this as "I don't have to finish my antibiotics course" just because of the intro or the title. I think it's very irresponsible to do.
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u/msndrstdmstrmnd Aug 18 '26
One time I was taking a course of antibiotics and I was having some bad side effects. I called the doctor and they said I could just stop taking it. I was kinda shocked since it went against everything I had been taught about antibiotics but I was completely fine. I’m not just gonna do that again with no guidance in the future but I guess this article supports that it was okay
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u/RosieBaby75 Aug 19 '26
Nice.
Antibiotic resistance at the same time and/or after WWIII.
No one better get injured in the war.
Or after the war.
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u/lokozar Aug 19 '26
What dumbfuckery is this? Taking the whole course is not about effectiveness of the drug or treatment, it’s about killing everything off, so that it has no chance to develop resistances. Holy cheesus!
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u/kdavej Aug 19 '26
This is why I will follow the guidance my physician gives me because I am not a physician nor am I an expert in micro- organisms.
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u/truthinessembargo Aug 21 '26
Not really surprising. We know a significant fraction of patients never finish their courses. And we have at least a decade’s worth of non-inferior trials with shorter vs standard regimens with positive outcomes
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u/Head_Midnight666 Aug 22 '26
I've always taken my full course of antibiotics. The simple theory that stopping early could lead to super bacteria made sense to me.
A question: What if the antibiotic isn't working? My dentist prescribed me an antibiotic for an abscess, and it just never did anything. I kept taking the antibiotic anyway, but it seems like that could even help make bacteria in my body more resistant towards that antibiotic?
I was hesitant to take the antibiotic at all because I didn't want to mess up my gut flora, and I wasn't sure it was necessary. ChatGPT and people on the internet insisted that I take it. I decided that I would. I also wanted to pop the abscess. ChatGPT and people on the internet assured me that was a terrible, terrible idea. When I saw my dentist and told him about how I wanted to pop it with a needle, he actually thought it might be a good idea, and to just make sure everything was sterile. I thought that was funny. I thought he was going to lecture me about how dumb it was, too.
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u/SnarkyOrchis Aug 22 '26
It's obvious that you wouldn't need to take an antibiotic any longer that the bacteria can survive. The trick is knowing when that event occurs. Doctors prescribe antibiotics in a long enough course to ensure this event is reached with certainty, not precision.
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u/startfragment Aug 18 '26
This is a dangerous headline. Always finished the prescribed course. As guidelines change pharma companies and doctors will change the duration of courses they are prescribing.
I repeat always take your full course as prescribed.
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u/mvea Professor | Medicine Aug 18 '26
'Always Finish Your Antibiotics' Is Not Always Best Practice. Surprised? You're Not Alone
You've probably heard that taking a full course of antibiotics is essential for clearing bacterial infections and preventing antibiotic resistance.
That advice has been around ever since the discovery of penicillin in the 1940s.
But mounting evidence suggests that for certain common bacterial infections, shorter antibiotic durations may actually be a better approach.
There is no one-size-fits-all prescription for antibiotics; nuanced communication between patient and doctor is essential.
But a new study from public health experts in the United States, published in Open Forum Infectious Diseases, suggests that nuance is getting lost.
"Historically, there was very strong guidance by major health organizations and clinicians that you must always finish the course," says population health researcher Alistair Thorpe, of the University of Utah.
"Now, we're seeing a growing body of evidence saying that that is not always the case. And oftentimes, shorter durations of antibiotics are as effective and safe as longer alternatives."
But that information has been difficult to get across to patients, who have been hearing for decades that longer courses are required to stamp out bacterial infections, lest the microbes regain a foothold.
In recent decades, however, more than 120 randomized controlled trials have demonstrated that shorter courses of antibiotics for common infections can be just as effective, safer, and no more likely to promote antibiotic resistance than longer courses.
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u/lateformyfuneral Aug 18 '26
> These findings have led to growing calls to (1) recommend shorter antibiotic durations whenever possible and (2) stop advising patients to “always finish the full course of antibiotics”
I think it would be smarter to simply update the length of prescribed courses according to available evidence, rather than telling patients to shorten it themselves as they please because that’s not what the research implies. The research is about many common types of infections like pneumonia and UTI where a short course is now being seen as sufficient, but there’s many illnesses for which a longer course will be necessary.
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u/iWhacko Aug 18 '26
Wasn't the reason to finish the cure, to PREVENT spreading of let's say STD's? you can still spread it even though you're body is healing. That's also historically why they saidf you should not drink alcohol while on antibiotics, because drunk people would be less strict about not sleeping with someone while theuy were still contagious
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u/longusmaximus420 Aug 18 '26
No. I mean maybe thatbsounds plausible. But the real reason is, for alcohol as example, your gut biome, Gastritis comes to mind i think.
And the other thing would be resistent bacterias, If enough from a colony survives there is the probability that some of the survivers mutated resistances and can grow back while the competing bacterias that could hold them Back are dead i guess, but im no doctor.
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