Impact of antibiotic side effects and allergies on patient adherence and attitudes: a mixed methods study in England

Recently, while teaching antimicrobial pharmacology to MSci Nursing students, a deceptively simple question arose: should patients always complete the antibiotic course originally prescribed? The familiar instruction to 'finish the course' sounds straightforward, but is increasingly difficult to teach as an absolute rule when antimicrobial stewardship seeks to minimise unnecessary exposure while maintaining clinical effectiveness. Clayton and colleagues make this tension particularly interesting. They report that 42% of respondents did not complete their antibiotic course after experiencing side effects. Yet Figure 3 shows an important distinction: among those who did not complete treatment, 61% reported doing so following healthcare-professional advice, whereas 32% stopped on their own. If most non-completion was professionally advised, is course completion still the right measure of antibiotic adherence?

Our work using molecular point-of-care testing in acute sore throat illustrates the stewardship principle before treatment begins: improving diagnostic discrimination can alter antibiotic prescribing decisions.¹ But why should stewardship become fixed once a prescription has been issued? If significant adverse effects develop and a clinician advises stopping, shortening or changing treatment, completing the original course may no longer represent good adherence. A recent systematic review identified substantial evidence supporting shorter antibiotic durations across several common bacterial infections, although important exceptions and evidence gaps remain.² This is not an argument for patients stopping antibiotics without advice. Rather, it questions whether adherence to the original prescription and adherence to 'the clinically appropriate' treatment plan are necessarily the same. Patient-initiated discontinuation and clinician-directed treatment modification have very different stewardship meanings. Perhaps the more meaningful endpoint is not fidelity or compliance to the prescription as first written, but concordance with the clinically appropriate treatment plan as it evolves. A prescription should only be a starting plan, not an immutable contract. The real dilemma is therefore this: if antimicrobial stewardship is dynamic, why should our definition of adherence remain static?

References

1. Daniels R, El Omda T, Mokbel K. Improving Antimicrobial Stewardship in Acute Sore Throat: Comparison of FeverPAIN and McIsaac Scores with Molecular Point of Care Testing Using Abbott ID NOW. Diagnostics. 2024;14(23):2680. Published 2024 Nov 27. doi:10.3390/diagnostics14232680

2. Mo Y, Tan WC, Cooper BS. Antibiotic duration for common bacterial infections-a systematic review. JAC Antimicrob Resist. 2025;7(1):dlae215. doi:10.1093/jacamr/dlae215