Re: The antibiotic course has had its day
We welcome the healthy debate sparked by Llewelyn et al’s opinion piece , and strongly support the principle of safely reducing antibiotic course lengths. However, the British Society for Antimicrobial Chemotherapy (BSAC) is unable to currently support a call to drop the ‘complete the course of antibiotics’ recommendation. This is because the evidence in support of this call remains sparse and such advice is potentially confusing for patients.
BSAC highlight the critical importance of considering whether an antibiotic is required in situations when the clinical benefit is likely to be marginal or an effective non-antibiotic treatment is available. This decision should be made before a healthcare professional decides upon the length of an antibiotic course to prescribe. We agree that, in general, course lengths may be too long and hope that research initiatives such as the Antibiotic Reduction and Konservation (ARK) in Hospitals (ARK-Hospital), a project aimed at safely reducing antibiotic use in hospitals [http://modmedmicro.nsms.ox.ac.uk/ark/] that Llewelyn et al lead will illuminate the debate. We strongly encourage hospitals across the UK to participate.
In dropping the existing paradigm now with little evidence to do so, there is a risk that ‘it is OK not to complete the course’ could give an unintended licence to patients not to adhere with other dosage instructions (for example, taking an antibiotic once a day instead of twice a day). This may result in treatment failure and encourage drug resistance. Furthermore, the suggestion that patients should stop taking antibiotics ‘when they feel better’ is too subjective and could lead to patients stockpiling unused antibiotics for future use without first seeking the advice of a doctor. A recent UK study showed that more than one-quarter of 732 patients disagreed with disposing of unwanted antibiotics ; any inappropriate subsequent use will contribute to resistance.
As we enter the era of personalised medicine, for any one individual with a bacterial infection we do not know how long the course of antibiotics should be. Higher-quality evidence is required before prescribing policy changes are implemented. This includes studies that assess the harm that stopping antibiotics early might cause in higher risk or vulnerable patients such as the very young, elderly and those unable to make decisions about their treatment, and how to individualise course lengths to minimise antibiotic exposure whilst maximising clinical benefit. Doctors and patients should always discuss the pros and cons of antibiotics and, if prescribed, what course length is appropriate.
BSAC recommends that the message to the public should remain “follow the advice of the healthcare professional”. Prescribers in hospitals should stop antibiotics when it is clinically safe to do so and base the decision on available evidence, national guidance and clinical judgement. This is also true for prescribers in outpatient and primary care settings where the clinical challenge and monitoring of patients is difficult. We recommend that the current approach of fixed, but generally short course lengths for most bacterial infections should remain. The society welcomes opportunities to continue the debate and work collaboratively with those seeking the robust evidence on which policies and practice should be based.
1 The antibiotic course has had its day: BMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j3418 (Published 26 July 2017) Cite this as: BMJ 2017;358:j3418
2 Seriously resistant: Leeds Citywide Insight Summary Report: 17 July 2017
Competing interests: No competing interests