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"Solutions" Doesn't Provide Any New Answers
Your introduction to the new series, "Solutions to Often-Asked Questions"1 had me looking forward to the feature. However, the first installment fell far short of expectations.
You said that the recommendations were intended to be ones that "are not easily answered from standard textbooks," and "will be as evidence based as possible." But this is not at all what Drs Burroughs and Chambliss did. They provided a nice précis of the available evidence, but their conclusion was at odds with the evidence they presented.
Setting aside rifampin, which unquestionably presents clinical interference with oral contraceptives, the authors present only 1 study that reports different hormone levels with and without antibiotics. But the hormones measured were intrinsic ones (during late pregnancy, no less!), not oral contraceptives, rendering it only tangentially relevant. The other articles of this type are unanimous in their conclusion that antibiotics have no meaningful influence on the serum levels of contraceptive hormones.
The authors correctly state that virtually the only clinical studies claiming a significant deleterious effect of antibiotics on contraceptive efficacy are "case reports or case series." The controlled epidemiological studies uniformly report no adverse interaction.
Finally, Burroughs and Chambliss cited so-called expert opinion, especially Contraceptive Technology (a textbook found in nearly every family practice office), to the effect that patients should be counseled not to rely on their oral contraceptives while using antibiotics. And what is their conclusion? They side with the "experts," and against the overwhelming weight of the actual laboratory and epidemiological evidence.
In short, the authors decided to rely on opinion over evidence, while you promised that it would be "as evidence based as possible," and their main source for this opinion was a ubiquitous textbook, while the purpose of the series is ostensibly to give answers to questions "not easily answered from standard textbooks."
I fail to see how this feature fulfills its description. If these short reviews are going to cite evidence, then ignore it in favor of opinions gleaned from textbooks already on the shelves of most family physicians, why should I waste time reading it?
Robert J. Woolley, MD
Boyton Health Service
University of Minnesota
410 Church St NE
Minneapolis, MN 55455
1. Burroughs KE, Chambliss ML. Antibiotics and oral contraceptive failure. Arch Fam Med. 2000;9:81-82.
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In reply
We appreciate Dr Woolley's feedback about our new feature. He raises a valid point: how should authors of reviews deal with conflicts between references? Our goal in creating this series "was to be as evidence based as possible" but also "to provide clear applicable answers." In this first installment, although much of the evidence was to the contrary, several well-known references recommended that physicians advise patients to use alternative contraception when taking antibiotics. We felt it would have been irresponsible not to discuss these recommendations. However, we did not conclude that patients taking antibiotics should use an alternative form of contraception.
We strive to present all the data as objectively as possible, and let our readers draw their own conclusions. Dr Woolley concluded that there is scant evidence to implicate antibiotics in oral contraceptive pill failures; this indicates to us that we were successful in achieving that goal. We trust that he would also conclude that it would be both morally and legally negligent not to inform patients that many "authorities" recommend alternative contraceptive methods. The decision to use additional contraception should be an informed, shared one between the clinician and patients.
M. Lee Chambliss, MD, MSPH;
Kevin E. Burrough, MD
Family Practice Residency Program
Moses Cone Health Systems
1125 N Church St
Greensboro, NC 27401-1007
(e-mail: lee.chamblis{at}mosescone.com)
Arch Fam Med. 2000;9:505.
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