Martin Llewelyn et al published in July 26th 2017 in the British Medical Journal an article entitled "The antibiotic course has had its day" (1). The authors refer to the relationship between exposure to and the development of resistance to antibiotics, at both the individual and population levels, and promote the reduction of unnecessary use of antibiotics in line with the objectives of the World Health Organization (2). The article mentions the replacement of the commensal flora of subjects receiving antibiotics for resistant strains, the greater risk of developing resistance with prolonged courses of antibiotics and highlights the scarce evidence that support the current treatment duration recommendations. Finally, the authors suggest replacing the term "complete the course" by taking antibiotics "exactly as prescribed".
We share the concept expressed by the authors that a course of antibiotics with pre-established duration and similar for all patients ignores the fact that different subjects respond differently to treatment. However, for most outpatient infections there are no clear predictors of early antibiotic response that allow for the "individualization" of length of therapy in each patient. The authors suggest that "in many situations, stopping antibiotics sooner is a safe and effective way to reduce antibiotic overuse" and suggest that a simple and appropriate alternative would be to advise the patient “to stop when you feel better". In ambulatory practice, where the highest consumption of antibiotics is generated, patients with mild to moderate severity of infection are not usually reassessed in the course of the infectious disease, and for this reason the physician establishes the duration of antibiotic treatment in the first visit. We do not believe that the duration of treatment should be delegated to the patient's discretion, but should be prescribed taking into account the shortest possible duration based on existing evidence.
Although evidence supporting the duration of antibiotic treatment is scarce, in recent years a considerable number of publications have shown that short courses of antibiotics are sufficient to obtain clinical and microbiological cure in most outpatient infections (3- 6).
The Infectious Diseases Society of Argentina has developed recommendations for the treatment of frequent infections in the community to avoid the unnecessary prescriptions of antibiotics, to use those of reduced spectrum and to prescribe short courses of antibiotics (7-11) and thus considerably reduce the burden of antibiotics to which the community is exposed.
Prolonged antibiotic courses should have their days counted, and be replaced by short courses.
1. Llewelyn MJ, Fitzpatrick JM, Darwin E, SarahTonkin-Crine, Gorton C, Paul J, Peto TEA, Yardley L, Hopkins S, Walker AS. The antibiotic course has had its day.
BMJ. 2017 Jul 26;358:j3418. doi: 10.1136/bmj.j3418.
3. Falagas ME, Karageorgopoulos DE, Grammatikos AP, Matthaiou DK. Effectiveness and safety of short vs. long duration of antibiotic therapy for acute bacterial sinusitis: a meta-analysis of randomized trials. Br J Clin Pharmacol 2009; 67: 161-71.
4. Dimopoulos G, Matthaiou DK, Karageorgopoulos DE, Grammatikos AP, Athanassa Z, Falagas ME. Short- versus long-course antibacterial therapy for community-acquired pneumonia : a meta-analysis. Drugs 2008; 68: 1841-54
5. Uranga A, España PP, Bilbao A, et al. Duration of antibiotic treatment in community-acquired pneumonia: a multicenter randomized clinical trial. JAMA Intern Med 2016;358:1257-65. doi:10.1001/jamainternmed.2016.3633. pmid:27455166.
6. Hepburn MJ, Dooley DP, Skidmore PJ, Ellis MW, Starnes WF, Hasewinkle WC. Comparison of short-course (5 days) and standard (10 days) treatment for uncomplicated cellulitis. Arch Intern Med 2004;358:1669-74. doi:10.1001/archinte.164.15.1669 pmid:15302637.
9. Lopardo G, Basombrío A, Clara L, Desse J, De Vedia L, Di Libero E, Gañete M, López Furst MJ, Mykietiuk A, Nemirovsky C, Osuna C, Pensotti C, Scapellato P. Guidelines for management of community-acquired pneumonia in adults. Medicina (B Aires). 2015;75(4):245-57. Spanish.
10. Lopardo G, Pensotti C, Scapellato P, Caberlotto O, Calmaggi A, Clara L, Klein M, Levy Hara G, López Furst MJ, Mykietiuk A, Pryluka D, Rial MJ, Vujacich C, Yahni D. Inter-society consensus for the management of respiratory infections: acute bronchitis and chronic obstructive pulmonary disease. Medicina (B Aires). 2013;73(2):163-73. Spanish.
11. Lopardo G, Calmaggi A, Clara L, Levy Hara G, Mykietiuk A, Pryluka D, Ruvinsky S, Vujacich C, Yahni D, Bogdanowicz E, Klein M, López Furst MJ, Pensotti C, Rial MJ, Scapellato P. Consensus guidelines for the management of upper respiratory tract infections. Medicina (B Aires). 2012;72(6):484-94. Spanish.
Competing interests:
No competing interests
25 September 2017
Gustavo Lopardo
MD, Infectious Diseases Specialist
Nemirovsky Corina (affiliation Hospital Italiano de Buenos Aires)
FUNCEI
French 3037 (C1425AWK) Ciudad de Buenos Aires, Argentina
Rapid Response:
Re: The antibiotic course has had its day
Martin Llewelyn et al published in July 26th 2017 in the British Medical Journal an article entitled "The antibiotic course has had its day" (1). The authors refer to the relationship between exposure to and the development of resistance to antibiotics, at both the individual and population levels, and promote the reduction of unnecessary use of antibiotics in line with the objectives of the World Health Organization (2). The article mentions the replacement of the commensal flora of subjects receiving antibiotics for resistant strains, the greater risk of developing resistance with prolonged courses of antibiotics and highlights the scarce evidence that support the current treatment duration recommendations. Finally, the authors suggest replacing the term "complete the course" by taking antibiotics "exactly as prescribed".
We share the concept expressed by the authors that a course of antibiotics with pre-established duration and similar for all patients ignores the fact that different subjects respond differently to treatment. However, for most outpatient infections there are no clear predictors of early antibiotic response that allow for the "individualization" of length of therapy in each patient. The authors suggest that "in many situations, stopping antibiotics sooner is a safe and effective way to reduce antibiotic overuse" and suggest that a simple and appropriate alternative would be to advise the patient “to stop when you feel better". In ambulatory practice, where the highest consumption of antibiotics is generated, patients with mild to moderate severity of infection are not usually reassessed in the course of the infectious disease, and for this reason the physician establishes the duration of antibiotic treatment in the first visit. We do not believe that the duration of treatment should be delegated to the patient's discretion, but should be prescribed taking into account the shortest possible duration based on existing evidence.
Although evidence supporting the duration of antibiotic treatment is scarce, in recent years a considerable number of publications have shown that short courses of antibiotics are sufficient to obtain clinical and microbiological cure in most outpatient infections (3- 6).
The Infectious Diseases Society of Argentina has developed recommendations for the treatment of frequent infections in the community to avoid the unnecessary prescriptions of antibiotics, to use those of reduced spectrum and to prescribe short courses of antibiotics (7-11) and thus considerably reduce the burden of antibiotics to which the community is exposed.
Prolonged antibiotic courses should have their days counted, and be replaced by short courses.
1. Llewelyn MJ, Fitzpatrick JM, Darwin E, SarahTonkin-Crine, Gorton C, Paul J, Peto TEA, Yardley L, Hopkins S, Walker AS. The antibiotic course has had its day.
BMJ. 2017 Jul 26;358:j3418. doi: 10.1136/bmj.j3418.
2. World Health Organization. Global action plan on antimicrobial resistance 2015. http://www.wpro.who.int/entity/drug_resistance/resources/global_action_p...
3. Falagas ME, Karageorgopoulos DE, Grammatikos AP, Matthaiou DK. Effectiveness and safety of short vs. long duration of antibiotic therapy for acute bacterial sinusitis: a meta-analysis of randomized trials. Br J Clin Pharmacol 2009; 67: 161-71.
4. Dimopoulos G, Matthaiou DK, Karageorgopoulos DE, Grammatikos AP, Athanassa Z, Falagas ME. Short- versus long-course antibacterial therapy for community-acquired pneumonia : a meta-analysis. Drugs 2008; 68: 1841-54
5. Uranga A, España PP, Bilbao A, et al. Duration of antibiotic treatment in community-acquired pneumonia: a multicenter randomized clinical trial. JAMA Intern Med 2016;358:1257-65. doi:10.1001/jamainternmed.2016.3633. pmid:27455166.
6. Hepburn MJ, Dooley DP, Skidmore PJ, Ellis MW, Starnes WF, Hasewinkle WC. Comparison of short-course (5 days) and standard (10 days) treatment for uncomplicated cellulitis. Arch Intern Med 2004;358:1669-74. doi:10.1001/archinte.164.15.1669 pmid:15302637.
7. http://www.sadi.org.ar/recomendaciones-y-consensos/item/26-consenso-inte...
8. http://www.sadi.org.ar/recomendaciones-y-consensos/item/44-recomendacion...
9. Lopardo G, Basombrío A, Clara L, Desse J, De Vedia L, Di Libero E, Gañete M, López Furst MJ, Mykietiuk A, Nemirovsky C, Osuna C, Pensotti C, Scapellato P. Guidelines for management of community-acquired pneumonia in adults. Medicina (B Aires). 2015;75(4):245-57. Spanish.
10. Lopardo G, Pensotti C, Scapellato P, Caberlotto O, Calmaggi A, Clara L, Klein M, Levy Hara G, López Furst MJ, Mykietiuk A, Pryluka D, Rial MJ, Vujacich C, Yahni D. Inter-society consensus for the management of respiratory infections: acute bronchitis and chronic obstructive pulmonary disease. Medicina (B Aires). 2013;73(2):163-73. Spanish.
11. Lopardo G, Calmaggi A, Clara L, Levy Hara G, Mykietiuk A, Pryluka D, Ruvinsky S, Vujacich C, Yahni D, Bogdanowicz E, Klein M, López Furst MJ, Pensotti C, Rial MJ, Scapellato P. Consensus guidelines for the management of upper respiratory tract infections. Medicina (B Aires). 2012;72(6):484-94. Spanish.
Competing interests: No competing interests