The antibiotic course has had its day

BMJ 2017; 358 doi: (Published 26 July 2017) Cite this as: BMJ 2017;358:j3418

Antibiotics: Doctor versus patient interaction

What I learnt at university about bacterial infections was quite simple, because I thought I understood the key-message: The host versus microbe interaction decided whether or not to prescribe antibiotics, including for how many days.

What I learnt from this BMJ Analysis article is only that the BMJ is a platform which causes a lot of discussion amongst doctors and a lot of confusion amongst patients. The former is welcome, the latter not, especially because the confusion of the public on ‘stopping the antibiotic course when feeling better’ will augment the global threat of antibiotic resistance. Two reasons:

a) The doctor versus patient interaction. Doctors, claiming to be experts, tell other doctors to change their policy. Patients in the Netherlands, readers of highly rated daily newspapers such as De Volkskrant and Trouw, read the message of stopping any antibiotic course when feeling better. These readers are not aware of the fact that the authors advocate patient centred decision making, which is a dangerous concept when the issue is still under medical debate. My patients want information on diagnosis and prognosis of an expert, being their doctor. Only on this condition, shared decision making may follow. Now however, my patients might think that the antibiotic course I prescribed is not that important, and may preserve half of the course for the next time they will have similar complaints. Thus, courses shortened by patients will result in more frequent use of antibiotics and in more antibiotic resistance. In this way, the public’s incomplete understanding of antibiotic resistance (1) will be further undermined.

b) The host versus microbe interaction. Table 1 suggests a balanced overview of trials assessing the effects of duration of treatment. For my specialty, streptococcal pharyngitis, the cited Cochrane review does not show any effect of duration, because the trials compare 10 days penicillin with 3-6 days of other antibiotics: The classic comparison between apples and pears. Our research-group compared 7 days penicillin with 3 days and with placebo (2), (3). We found for penicillin given for 3 days a tendency to prolong the period of sore throat in the first week and to increase the recurrence rate in the following 6 months. We hypothesized that the short duration of penicillin treatment only suppressed the pathogenic streptococci without eradicating them. Thus, another interaction between host and microbe than antibiotic resistance was possibly harmful to the patients receiving a too-short course.

I was happy to read in today’s newspaper a comment of a Dutch expert, professor of infectious dieases, on the headlines ‘Completing antibiotic course? Nonsense’. He advised the public to ask the GP for advice (4). My conclusion: Patient centred decision making is an illusion when the medical debate is still ongoing.

1) McNulty CA, Nichols T, French DP, Joshi P, Butler CC. Expectations for consultations and antibiotics for respiratory tract infection in primary care: the RTI clinical iceberg. The British Journal of General Practice. 2013;63(612):e429-e436. doi:10.3399/bjgp13X669149.
2) Zwart S, Sachs APE, Ruijs GJHM, Gubbels JW, Hoes AW, de Melker RA. Penicillin for acute sore throat: randomised double blind trial of seven days versus three days treatment or placebo in adults. BMJ : British Medical Journal. 2000;320(7228):150-154.
3) Zwart S, Rovers MM, de Melker RA, Hoes AW. Penicillin for acute sore throat in children: randomised, double blind trial. BMJ : British Medical Journal. 2003;327(7427):1324.
4) Marc Bonten. Maak dat kuurtje toch maar af. Dagblad Trouw, August 8th 2017.

Competing interests: No competing interests

08 August 2017
Sjoerd Zwart
General Practitioner
GP-trainer at University Medical Centre Utrecht
Vloeddijk 40, 8261 GC Kampen, The Netherlands