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To reduce the effect of antimicrobial resistance and preserve antibiotic effectiveness, clinical practice guidelines and health policy documents call for the “rational use” of antibiotics that aims to avoid unnecessary or minimally effective antibiotic prescriptions. In this paper, we show that rational use programmes can lead to ethical conflicts because they place some patients at risk of harm – for example, a delayed switch to second-line antibiotics for community-acquired pneumonia is associated with increased fatality rates. Implementing the rational use of antibiotics can therefore lead to conflicts between promoting patients’ clinical interests and preserving antibiotic effectiveness for future use. The resulting ethical dilemma for clinicians, patients and policy makers has so far not been adequately addressed. We argue that existing guidance for acceptable risks in clinical research can help to define risk thresholds for the rational use of antibiotics. We develop an ethical framework that allows clinicians and policy-makers to evaluate policies for rational antibiotic use in six practical steps.

Tackling Anti-microbial Resistance: An Ethical Framework for Rational Antibiotic Use