Antibiotics Ineffective for Chronic Low Back Pain With Disc Herniation: Randomized Trial
Australia: In adult patients with chronic low back pain (LBP) and disc herniation on magnetic resonance imaging (MRI), treatment with amoxicillin-clavulanate did not significantly reduce pain compared to placebo, according to a randomized clinical trial.
Chronic low back pain remains one of the leading causes of disability worldwide, often prompting the use of varied and sometimes controversial treatment strategies. In recent years, antibiotics have been explored as a potential option, particularly in patients with persistent symptoms and imaging evidence of disc herniation. However, evidence supporting their effectiveness has remained inconsistent.
A new randomized clinical trial, published in the JAMA Network Open by Flavia M. Cicuttini and colleagues, sought to evaluate whether antibiotic therapy could provide meaningful pain relief in such patients. The study focused on assessing both the efficacy and safety of amoxicillin-clavulanate over 12 months.
This double-blind, placebo-controlled trial included 170 adults aged 18 to 60 years who had chronic low back pain along with MRI-confirmed disc herniation. Participants were randomly assigned to receive either amoxicillin-clavulanate (500 mg/125 mg) or a matching placebo twice daily for 90 days. The trial used a community-based recruitment approach, with telemedicine enabling remote follow-up.
The trial revealed the following findings:
- Pain intensity at 12 months, assessed using a standard low back pain rating scale, was the primary outcome measure.
- Nearly 90% of participants completed the study and contributed data for the primary outcome.
- No significant difference in pain reduction was observed between the antibiotic and placebo groups at both 3 months and 12 months.
- The lack of benefit remained consistent irrespective of baseline pain severity.
- Subgroup analysis showed no additional benefit of antibiotics in patients with Modic changes on MRI.
- These findings do not support the use of antibiotics even in patients previously thought to benefit from such therapy.
- Adverse events were more commonly reported in the antibiotic group compared to the placebo group.
- Serious adverse events were rare and occurred in one participant in each group.
- Overall, the safety and efficacy profile does not justify the use of antibiotics for chronic low back pain with disc herniation.
The researchers acknowledged limitations, including incomplete biological sampling that restricted assessment of antimicrobial resistance and some missing outcome data at 12 months. Most participants were community-based rather than from specialist settings, which may limit applicability to more complex cases.
Despite this, the study offers strong evidence against the routine use of antibiotics for chronic low back pain with disc herniation. It highlights the need to avoid unnecessary antibiotic use, given the risks of antimicrobial resistance and avoidable side effects.
Overall, the findings reinforce that antibiotics should not be recommended for managing chronic low back pain, even in patients with imaging abnormalities.
Reference:
Cicuttini FM, Wluka AE, Pan F, et al. Efficacy of Antibiotics for Chronic Low Back Pain With Disc Herniation: A Randomized Clinical Trial. JAMA Netw Open. 2026;9(5):e2612848. doi:10.1001/jamanetworkopen.2026.12848
Next Story