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to be marginally less likely to result in antibiotic use, an outcome probably related to the slightly increased eff ort involved in returning to the surgery.

Hence, delayed prescription seems an eff ective means of achieving the urgent goal of reducing antibiotic use, and forestalling antibiotic resistance. Additionally, the evidence on when antibiotics should be used needs to be honed. In Little’s study, whether a patient took antibiotics immediately, after a delay, or not at all had little bearing on alleviation of their symptoms. “The patients all got better at roughly the same time”, added Little, “so you’re not really doing anything for most people by prescribing immediately”. All of which fi ts with the National Institute for Health and Care Excellence’s 2008 recommendation that patients with acute sore throats and other respiratory infections either do not receive antibiotics or are supplied with a delayed prescription.

Earlier this year, Little’s group published the results of a large-scale prospective observational cohort study on antibiotic prescription strategies for acute sore throat. They concluded that suppurative complications, concern over which drives antibiotic prescription in primary care, are uncommon and largely minor. Little notes that it is extremely diffi cult to predict which patients are going to have complications. “So you have to prescribe for an awful lot of people to prevent one complication, and most complications are not terribly serious”, he said.

Otto Cars (Uppsala University, Uppsala, Sweden) agrees. “Over the past 5–10 years, a number of good, prospective, placebo-controlled studies have been published showing the marginal eff ects of antibiotics for bronchitis, sinusitis, and otitis media—we cannot simply allow their use to continue just to be on the safe side.”

What kind of reduction we should be aiming for is a moot point. Little cites the example of the Netherlands, which prescribes roughly half the antibiotics as the UK does without any accompanying explosion in complications. Cars is wary of targets, in view of the heterogeneity of patient groups, he would prefer to see guidelines that take into account the available evidence and primary care doctors following them assiduously.

This might not be as straight-forward as it sounds. Little talks of a generation of British general practitioners who have become habituated to prescribing antibiotics, and of patients’ expectations for the prescription. “People attribute getting better to the antibiotics they’ve been given”, he explained.

Patients who have previously been prescribed antibiotics have higher rates of reconsultation, and they might extol the value of the drugs to their friends and family. “Fostering beliefs and medicalising illness is definitely one of the things that keeps the pot boiling”, Little told The Lancet Respiratory Medicine. Moreover, surgeries with low rates of antibiotic prescription tend to have lower consultation rates for respiratory infection, which in turn leads to fewer prescriptions.

So public awareness campaigns, such as those that are having a great effect in Belgium, might also need to play a part in reducing the use of antibiotics. It is a vital task. The pipeline is sparse, but if and when new drugs do become available, they have to be carefully preserved. “We have to come up with a completely new system for use which builds on a much better respect for these essential medicines”, concluded Cars.

Talha Khan Burki

Over the past few months, several papers on antibiotics have helped clarify matters about their use and effi cacy. A study published online in The Lancet Infectious Diseases collated data on antibiotic use in 13 non-EU countries in the WHO European region. The researchers used sales data to estimate over-the-counter purchases and to circumvent gaps in health-care information systems. According to these data, Turkey used the most antibiotics—three times that of neighbouring Armenia—a fi nding that prompted the Turkish Government to establish a national action plan on rational drug use.

Respiratory tract infections account for most of the antibiotic use, and there is increasing evidence that these drugs are both overprescribed and, for the most part, ineffective. A Cochrane review of four studies of 1314 children younger than 5 years, published in February, concluded that “strong support for antibiotic use in preventing ear infections and pneumonia in children with undifferentiated acute respiratory infections” was lacking, although co-author Antonio J L Alves da Cunha (Federal University of Rio de Janeiro, Rio de Janeiro, Brazil) conceded that “more study is needed to improve our knowledge in this subject”.

Still, the findings were broadly in keeping with a pair of studies, both authored by Paul Little (Southampton University, Southampton, UK), on antibiotic use in the UK. The most recent study—a pragmatic, factorial, randomised control trial—assessed delayed prescribing strategies for respiratory tract infections. Nearly all the patients who were immediately prescribed antibiotics took them, whereas only 37% of the patients in the delayed prescription cohorts used the drugs. Of the various methods by which prescription can be delayed, collection from the surgery proved

Antibiotics for respiratory infections: too much, too soon

Lancet Respir Med 2014

Published OnlineMarch 24, 2014

http://dx.doi.org/10.1016/S2213-2600(14)70072-4

For the study on antibiotic use see Articles Lancet Infect Dis

2014; published online March 20. http://dx.doi.

org/10.1016/S1473-3099(14)70071-4

For the Cochrane review see Cochrane Database Syst Rev 2014;

2: CD007880

For Paul Little’s randomised controlled trial see BMJ 2014;

348: g1606

For the National Institute for Health and Care Excellence’s

guidelines see http://www.nice.org.uk/CG069

For the prospective observational cohort study see

Articles Lancet Infect Dis 2014; 14: 213–19

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