Why do antibiotics induce a temporary worsening of symptoms before improvement?

From the Guidelines

Antibiotics can induce a temporary worsening of symptoms before improvement due to the Jarisch-Herxheimer reaction, which occurs when large numbers of bacteria die rapidly, releasing toxins and triggering an inflammatory response in the body. This phenomenon is well-documented in the treatment of various bacterial infections, including acute bacterial rhinosinusitis (ABRS) 1. According to the clinical practice guideline update on adult sinusitis, most patients with ABRS feel better within 7 days, and by 15 days, about 90% are cured or improved 1.

Managing Symptoms and Side Effects

To alleviate symptoms, patients can use acetaminophen or ibuprofen for pain and fever relief, as well as saline irrigations or nasal steroid sprays to reduce congestion and inflammation 1. However, it is essential to note that antihistamines and oral steroid medicines should not be used routinely due to their side effects and lack of symptom relief 1.

Antibiotic Treatment and Duration

The decision to use antibiotics should be made cautiously, considering the potential benefits and harms. While antibiotics can provide symptom relief, they also carry risks such as rash, upset stomach, nausea, vomiting, allergic reactions, and the development of resistant germs 1. The guideline suggests that watchful waiting, delaying antibiotic treatment for up to 7 days, can be an effective approach, and antibiotics are usually given for 10 days, but shorter courses may be equally effective 1.

Patient Preferences and Shared Decision Making

Patient preferences play a moderate role in shared decision making, particularly in determining the duration of antibiotic therapy, as shorter courses can reduce adverse events 1. It is crucial for clinicians to discuss the benefits and harms of antibiotic treatment with patients and involve them in the decision-making process.

Conclusion is not allowed, so the answer just ends here.

From the Research

Antibiotic-Induced Endotoxin Release

• Antibiotics can induce the release of endotoxin from Gram-negative bacteria, leading to a temporary worsening of symptoms before improvement 2, 3.
• The release of endotoxin may depend on various factors, including the type of antibiotic, the presence of serum, the type of organism, and the site of antibiotic action 2.
• Different antibiotics may induce the release of different forms of endotoxin, which can have varying effects on the patient 2, 4.

Clinical Implications

• The clinical significance of antibiotic-induced endotoxin release is documented in certain clinical disorders, such as meningitis and urosepsis 2.
• Patients with increased multi-organ failure scores may benefit from treatment with antibiotics known to decrease endotoxin release 2.
• The Jarisch-Herxheimer reaction, an acute deterioration with the initiation of antibiotic therapy, may be related to the release of endotoxin, but the exact mechanism is unclear 3.

Mechanisms and Factors

• The morphology of bacteria and the mode of antibiotic action can impact the release of endotoxin 2.
• The combination of antibiotics with inhibitors of endotoxin or the pro-inflammatory response may help reduce the adverse effects of antibiotic-induced endotoxin release 2.
• The type of pathogen and its virulence may be more important than previously suggested, and Gram-positive pathogens can also contribute to the development of the host response 2.