About-face on antibiotic advice

The age-old advice to complete the prescribed course of antibiotics is not evidence-based, British health experts say

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It’s time for clinicians and public-health experts to be honest with patients and tell them the age-old advice to complete the prescribed course of antibiotics is not evidence-based, British health experts say.

“The relation between antibiotic exposure and antibiotic resistance is unambiguous both at the population level and in individual patients,” the experts wrote in an analysis in the BMJ.

“Reducing unnecessary antibiotic use is therefore essential to mitigate antibiotic resistance,” they said.

The problem was that national campaigns across the world, and the WHO, all repeat the advice to complete prescribed antibiotic courses, they wrote. In the UK, it was even included as fact in the curriculum for secondary school children.

“One reason it may be so resilient is that it is simple and unambiguous, and the behaviour it advocates is clearly defined and easy to carry out,” the authors, led by infectious diseases expert Professor Martin Llewelyn of the Brighton and Sussex Medical School, wrote.

But rates of deaths from antibiotic-resistant bugs are rising, underscoring the authors’ point that antibiotics are a vital, precious and finite resource.

Some institutes have begun to subtly revise the messaging, telling patients to take antibiotics “exactly as prescribed”.

However, this didn’t go far enough for the authors, who implored doctors and health groups to explicitly renounce the “complete the course” advice as incorrect and evidence-free.

Fears of undertreatment were also largely unjustified, they said.

The authors pointed to one trial showing that if patients with community-acquired pneumonia used fever resolution as a trigger to stop treatment, that was just as effective as a treatment and also halved their antibiotic use.

A study of hospital-acquired pneumonia also found shorter treatment had the same benefits of longer courses, but led to lower rates of infection recurrence and resistance.

“For opportunist pathogens for which antimicrobial resistance poses the greatest threat, no clinical trials have shown increased risk of resistance among patients taking shorter treatments,” they wrote.

Current recommendations also ignored the fact that different people responded to the same antibiotic differently.

Professor Llewelyn and his colleagues suggested a new message could be that patients should stop antibiotics when they felt better, although they acknowledged more research was needed.

“For most indications, studies to identify the minimum effective treatment duration simply have not been performed.”

Nevertheless, there were some infections that still required a full course, such as tuberculosis, they said. A shorter course for otitis media was also shown to cut the cure rate from 84% to 66% in young children who had five days treatment instead of 10.

But ultimately, the authors said that telling patients to complete their course of antibiotics went against a fundamental medical premise, which was to take as little medication as necessary.

BMJ 2017; online 26 July