The end of antibiotic stewardship, 2013 edition

Back in the 1990's when I was a wide-eyed ID fellow, I'd wonder out loud to my co-fellows Sara Cosgrove and Dan Levy why it was that we needed an oncologist's approval to prescribe chemotherapy but any clinician could prescribe antibiotics. My reasoning was that if you make a mistake with chemotherapy in a cancer patient, you only harm that one patient, but when untrained clinicians prescribe antibiotics all willy-nilly they harm the whole planet. Well, it's 2013 and I'm still wide-eyed and have the sinking feeling that antibiotic prescriptions are about to go way beyond willy-nilly. And I'm a bit scared.

The reason for my worry is this paper by Hanne Albert and colleagues in the European Spine Journal. In the study, patients with 6-months of low back pain and Modic 1 changes on MRI were randomized to 100 days of antibiotics (amoxicillin + clavulanic acid). The reasoning behind antibiotics for back pain is a study that found P acnes and C propinquum in surgical specimens from lumbar herniated disks. Anyway, the study reported improved primary and secondary outcomes with treatment and no change with placebo.

So why am I worried?  Just look at the headlines from my google search above. I would normally link to these articles, but I don't want to send traffic to posts that aren't appropriately skeptical of this single trial and the public health implications of giving everyone with back pain 100 days of antibiotics. One UK surgeon was even reported to have said this finding is worthy of the Nobel Prize. Yikes.

For an appropriately skeptical and balanced discussion of this study and the surrounding hype, please read this Observation in BMJ by GP Margaret McCartney. After I read the study and Dr. McCartney's excellent commentary, I forwarded them onto Sara Cosgrove. It was therapeutic for me to share my concerns with an old friend. But now I'm back to panicking.