JAMA Netw Open
Antibiotics fall short for chronic low back pain linked to disc herniation
Clinical Takeaway: Do not routinely prescribe antibiotics for chronic low back pain with disc herniation, including in patients with Modic changes, as benefits were no better than placebo while adverse events were more common.
Antibiotics are increasingly being used off label for chronic low back pain despite mixed evidence and growing concerns about antimicrobial resistance. This study adds strong evidence against the practice.
A 12-month randomized clinical trial found that prolonged antibiotic therapy didn’t improve chronic low back pain associated with disc herniation compared with placebo.
Researchers randomized 170 adults aged 18 to 60 years with chronic low back pain and MRI-confirmed disc herniation to receive either amoxicillin-clavulanate 500/125 mg twice daily for 90 days or placebo. Follow-up data were available for 89.4% of participants at 12 months.
Pain scores improved modestly in both groups over time, but differences between groups were not statistically or clinically significant. On the Low Back Pain Rating Scale (0-10 scale), pain decreased by 1.0 points in the antibiotic group and 1.1 points in the placebo group at 12 months (adjusted difference, 0.06; 95% CI, −0.58 to 0.70). Similar null findings were seen at 3 months and on visual analog scale pain scores.
Importantly, antibiotics also failed to show benefit in the subgroup with Modic changes — MRI-detected vertebral bone marrow changes previously hypothesized to reflect low-grade bacterial infection.
Adverse events were more common with antibiotics, occurring in 40.0% of treated patients vs. 23.5% with placebo. Three serious adverse events were reported: 2 in the amoxicillin-clavulanate group (an allergic reaction and radiculopathy) and 1 in the placebo group (diarrhea).
The authors concluded that the findings “did not demonstrate the efficacy of antibiotics” for chronic low back pain and “provide important data to prevent their inappropriate and harmful use,” particularly given concerns about antibiotic resistance.
Source: Cicuttini FM, et al. (2026, May 18). JAMA Netw Open. Efficacy of Antibiotics for Chronic Low Back Pain With Disc Herniation: A Randomized Clinical Trial