I am very disturbed by the discussion that has arisen from the publication of Llewelyn et al's opinion piece.
My concerns are, however, not with the thought challenge Llewelyn et al has laid down upon years of mantra based on conventional wisdom mostly formulated prior the availability of current technology in molecular and genetic microbiology. The idea that there is a set duration of antibiotics treatment to prevent bacterial resistance should be reviewed
Neither did the rapid responses published so far offer adequate reassurance that many experts (who wrote the responses) have a holistic perspective of dealing with infection in a clinical setting.
Llewelyn et al and other clinicians wanting to join in this discussion should be reminded that in our daily work setting we are dealing with infection in a human being in the hospital or at home rather than playing chess on a big petri dish in the lab.
Thus the issue of whether antibiotic duration should be reviewed based on the evidence from a study population is fundamentally flawed built on false assumption.
Different people have different body weights. They have different comorbidities which influenced antimicrobial therapy; some have renal or liver dysfunction which affects drug pharmacokinetics and pharmacodynamics whereas others have genetic susceptibility to certain infections or weakened defense mechanism as in poorly-controlled diabetics.
Antibiotics are only part of the armamentarium available to health professionals in their fight against clinical infection in patients (albeit an important constituent in modern medicine). Improving hygiene and living conditions, improving 'host' health, debulking microbial load, etc, are also important considerations.
A few generations ago doctors and nurses at the coalface of medicine would have been more proactive in toileting/cleaning wounds or draining abscesses, giving basic good advice on skin infection management and organising timely review to monitor progress. I fear nowadays that we are too complacent in our trust and reliance on antibiotics to do the job, in which wounds receive a cursory wash and just handing out a script for a broad-spectrum antibiotic constitute acceptable care in a 6-minute consultation.
Clinicians should also not forget about risk management in the treatment of infection. While many infections may not result in major co-morbidity if treated poorly, other infections in privileged regions of the human body will result in catastrophic outcome if not managed correctly in a timely manner. Bacterial meningitis, meningococcal septicaemia, prosthetic infection, etc, are life changing diagnoses for individuals and communities, and if there is reasonable suspicion or likelihood of occurrence, the drive in anti-microbial stewardship and "evidence-based" practice should not trump individual risk management in the mindless demand for "proof" before weighing in risk-benefit analysis.
Sometimes we may never get the level 1 or 2 evidence that some opinion-makers demand because it is simply no-longer ethical to deny conventional treatment in a randomised control trial.
Therefore the debate on antibiotic therapy is not just about bacterial resistance: it is only one part of multifaceted approach to looking after people who have infections; we should not assume that this debate about dosing or duration can be resolved without addressing the issue of host health and hygiene, microbial debulking and wound toileting, risk management as well as ethical considerations.
Competing interests: No competing interests