No high risk antibiotics?

I was astounded to read in the study method that Hickson et al had excluded “high risk” antibiotics (as well as some misclassified low risk antibiotics).¹ To do so is akin to performing a trial of an agent that claims to prevent type 2 diabetes, but excluding obese patients.

Cephalosporins in particular are rapidly losing their usefulness as frontline antimicrobial agents because of their potential to cause Clostridium difficile associated diarrhoea. The loss of these highly effective agents cannot be a good thing.

Any therapy that has the potential to reduce the incidence of diarrhoea associated with C difficile should be investigated with enthusiasm, but it should be done in a meaningful way. To exclude the very people in whom it is particularly important to prevent such diarrhoea—patients taking high risk antibiotics—makes this trial of academic value only.