Response to Llewellyn et al paper – ‘The antibiotic course has had its day’ in the British Medical Journal

Colin Garner Learn more

Much media interest has arisen from the publication of a paper by Dr Martin Llewellyn and colleagues in the British Medical Journal in which they propose that the duration of antibiotic treatment can, in many cases, be shortened. The authors argue, with little evidence, that failing to complete a prescribed antibiotic course contributes to antibiotic resistance, and that policy makers, educators and doctors should drop this message. The chief argument for this appears that we make indication-specific recommendations for antibiotic duration based on poor evidence. Be this as it may, should we not be seeking the evidence for shorter duration treatments through sound scientific clinical investigation? The authors mention just a handful of studies where duration of treatment has been evaluated by randomised clinical trial. Considering the amounts of antibiotics prescribed, it is surprising that there is such a paucity of data.

Our concern arising from the paper’s findings is that patients will become confused as to whether they should stop their antibiotic treatment when they feel better or when their fever subsides. As Andreas Voss has written, ‘our concern should not be whether we are driving resistance by too long exposure to antibiotics but whether the patient is cured. Antibiotic stewardship, he argues, is namely offering patients the most effective antibiotic, in the correct dosage, the needed application form, for a proven length of course, with as little side-effects and interaction with other medications as possible. In doing so, we may prevent resistance development, but our primary goal was and should remain to offer the best treatment to our patients’.

So let’s have some evidence based medicine here. By all means, seek to reduce antibiotic exposure but do so on the basis of sound science. We need many more studies examining different antibiotics, different infections, different patients, different age groups, ethnicity etc, before we can make broad brush generalisations. Remember that the dose and duration of exposure of most antibiotics has arisen from clinical trials conducted by the manufacturer when they sought marketing authorisation for their drug. In the absence of data, patients should follow the advice of their doctors and not arbitrarily stop taking their antibiotics just because they feel better.