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Experts argue against ‘complete the course’ message for antibiotics

Contrary to the persistent message that patients who “complete the course” of antibiotics will avoid antibiotic resistance, it is not based on clinical evidence and receiving treatment longer than necessary can put patients at risk, according to an analysis published in BMJ, and experts advise that policy makers, educators and physicians drop the message and admit it’s incorrect.

“Public communication about antibiotics often emphasizes that patients who fail to complete prescribed antibiotic courses put themselves and others at risk of antibiotic resistance,” Martin J. Llewelyn, PhD, professor of infectious diseases from the department of global health and infection at Brighton and Sussex Medical School in England, and colleagues wrote. “However, the idea that stopping antibiotic treatment early encourages antibiotic resistance is not supported by evidence, while taking antibiotics for longer than necessary increases the risk of resistance.”

In many cases, evidence on the shortest effective treatment duration of antibiotics does not exist, the authors wrote. An antibiotic course can often disregard the fact that patients react differently to the same antibiotic, and many clinicians continue to ignore this, basing their recommendations for length of treatment on poor evidence, explained the authors. Furthermore, the idea that treating patients with too little antibiotics can lead to antibiotic resistance is not supported by clinical data, they added.

The “complete the course” message persists despite its lack of evidence and previous urgings that it should be replaced, possibly because it’s “simple and unambiguous, and the behavior it advocates is clearly defined and easy to carry out,” Llewelyn and colleagues wrote. However, evidence supports that in many cases discontinuing antibiotics sooner can safely and effectively reduce antibiotic overuse.

“The fallacious belief that antibiotic courses should always be completed to minimize resistance is likely to be an important barrier to reducing unnecessary antibiotic use in clinical practice and to developing evidence to guide optimal antibiotic use,” Llewelyn and colleagues wrote. “The idea is deeply embedded, and both doctors and patients currently regard failure to complete a course of antibiotics as irresponsible behavior.”

To change the discussion on antibiotic courses, the researchers believe that the main argument should be that shorter treatment is better for individual patients. A patient’s risk for resistant infection depends on their previous antibiotic exposure, and shortening treatment by reducing that exposure can reduce the risk for resistant infection and improve clinical outcomes, they explained.

Better communication training, point-of-care tests, and using delayed prescriptions are some strategies developed in primary care to help prevent unnecessary antibiotic courses being started; however, strategies to reduce antibiotic overuse aiming to stop treatment 2 to 3 days after patients begin taking them, are difficult to implement in secondary care, they wrote.

“Daily review of the continued need for antibiotics is a cornerstone of antibiotic stewardship in hospitals, but in primary care, where 85% of antibiotic prescriptions are written, no such ongoing assessment is attempted,” the researchers wrote. “Research is needed to determine the most appropriate simple alternative messages, such as stop when you feel better.” – by Savannah Demko

Disclosures: The researchers report no relevant financial disclosures.