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Antimicrobial stewardship: targeting antibiotics, delayed prescribing, and communication skills training for respiratory tract infections

Major contributions by the University of Southampton in trials and cohorts have demonstrated widespread reductions in antibiotic use in respiratory tract infections, thereby contributing in the fight against antimicrobial resistance (AMR).



Respiratory tract infections (RTIs) such as sinusitis and sore throat are the source of 60% of all antibiotic prescriptions. Public health reports on antimicrobial resistance, such as those by the Chief Medical Officer and Lord O’Neill, emphasise the urgency of curbing antibiotic use to reduce the global threat of AMR.

Research challenge

A research group within the University of Southampton’s School of Primary Care, Population Sciences and Medical Education, led by Professor Paul Little, has undertaken most of the key studies of delayed antibiotic prescription.

Funded by the Department of Health, the Medical Research Council and the EU, the group has performed a series of major cohorts and trials since 2000, which addressed:

  • delayed prescription;
  • clinical scores for sore throat;
  • communication skills and point-of-care tests for lower RTIs; and
  • a digital intervention to support handwashing.

This research has fed into major guidelines on antibiotic prescribing worldwide.

UK and international guidance on antibiotic prescribing

Professor Little chaired the original, overarching 2008 NICE clinical guideline CG69 Respiratory tract infections (self-limiting): prescribing antibiotics, which since 2017 has been updated into new guidelines covering acute sinitis, sore throat, otitis media and cough.

These guidelines include key endorsements from the Southampton trials of delayed prescribing, or no offer of antibiotics, for all acute RTIs.

Internationally, Southampton’s delayed prescribing strategies have been advised by US Centers for Disease Control and Prevention (CDC), the American Academy of Paediatrics (AAP), the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and the European Centre for Disease Prevention and Control (ECDC).

FeverPAIN clinical score

The Southampton group developed a new clinical score, FeverPAIN, to inform the use of immediate, delayed and no antibiotics for pharyngitis. It has been shown to both reduce antibiotic use and improve symptom control, and has been recommended by NICE, the Royal College of GPs and Public Health England

FeverPAIN has been used more than 100,000 times and is incorporated into GP clinical systems across the UK.

Royal College of GPs (RCGP) training modules

Professor Little and Professor Michael Moore developed training modules for the RCGP website, known as TARGET, or Treat Antibiotics Responsibly: Guidance, Education, Tools. These incorporate both delayed prescribing and FeverPAIN.

TARGET is the most accessed part of the RCGP website, attracting 69,000 views during 2017/18, and was recommended in the UK government’s five-year strategies for AMR in 2013 and 2019.

Germ Defence intervention for handwashing and COVID-19

In order to minimise the spread of RTIs, particularly in winter seasons and pandemics, Professor Little’s group collaborated with colleagues in the School of Psychology to develop an internet-based behavioural intervention, Germ Defence, supporting the prevention of infection by handwashing. This demonstrated a 15% reduction in episodes of infection, reduced transmission of infection to family members, and reduced attendance in primary care.

In March 2020 Germ Defence was updated for the prevention of COVID-19 by including all methods of reducing infection in the home and rapidly translated into 22 languages. It was also the subject of a clinical trial selected for national prioritisation as an ‘NIHR Urgent Public Health COVID-19 Study’ to help prevent a second wave of infections in autumn 2020.

Key Publications

List of all staff members in
Staff MemberPrimary Position
Paul Little CBEProfessor of Primary Care Research
Michael MooreProfessor of Primary Health Care Research
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