Antibiotic Prescribing in General Practice: A Stewardship Guide
Reducing resistance while treating infections effectively — evidence-based protocols for common GP presentations
Antimicrobial resistance is one of the greatest threats to global health. GPs prescribe approximately 80% of all antibiotics in the UK. This guide covers evidence-based prescribing for the most common GP infections — RTIs, UTIs, skin infections, and ear/throat conditions — with NICE-aligned protocols.
Clinical Decision Support: This article is for educational purposes and supports — not replaces — clinical judgment. Always verify with current national guidelines, BNF, and specialist consultation when needed.
Antimicrobial resistance (AMR) is projected to cause 10 million deaths annually by 2050 if current trends continue. General practitioners prescribe approximately 80% of all antibiotics in the UK, making primary care the most important setting for stewardship interventions. The challenge is balancing the real risk of undertreating serious infections against the population-level harm of overprescribing.
The No-Antibiotic and Delayed Prescribing Strategies
For many common infections, antibiotics provide minimal benefit while contributing to resistance, side effects, and medicalisation of self-limiting illness. The delayed prescribing strategy — giving a prescription to be filled only if symptoms worsen or do not improve within a specified timeframe — has been shown to reduce antibiotic use by 25–40% without increasing complication rates.
| Condition | Antibiotic Benefit | Recommended Strategy |
|---|---|---|
| Acute otitis media (>2 years, mild) | Minimal — NNT ~15 for pain relief | No antibiotic or delayed 72h |
| Acute sore throat (FeverPAIN 0–1) | None | No antibiotic |
| Acute sore throat (FeverPAIN 4–5) | Modest — NNT ~5 for symptom duration | Immediate or delayed 48h |
| Acute sinusitis (<10 days) | Minimal | No antibiotic or delayed 7 days |
| Acute cough/LRTI (no pneumonia) | None for most | No antibiotic; consider delayed |
| Uncomplicated UTI (women) | Significant | Immediate antibiotic |
Urinary Tract Infections
Uncomplicated UTI in Non-Pregnant Women
- First-line: Nitrofurantoin 100 mg MR BD for 3 days (avoid if eGFR <30)
- Alternative: Trimethoprim 200 mg BD for 3 days (avoid if local resistance >20% or used in last 3 months)
- Do not routinely send MSU before treating uncomplicated UTI in women
- Send MSU if: treatment failure, recurrent UTI, pregnant, catheterised, or atypical symptoms
UTI in Men
UTI in men is considered complicated and warrants a 7-day course of antibiotics. Always send MSU before treatment. Consider prostatitis if perineal pain, dysuria, and fever — treat with ciprofloxacin or trimethoprim for 28 days. Refer if recurrent UTI in men to exclude structural abnormality.
Catheter-Associated UTI (CAUTI)
Do not treat asymptomatic bacteriuria in catheterised patients — this is not a UTI and antibiotic treatment increases resistance without clinical benefit. Only treat if symptomatic (fever, rigors, new confusion, loin pain, haematuria).
Respiratory Tract Infections
Community-Acquired Pneumonia: CURB-65 Scoring
| CURB-65 Score | Mortality Risk | Management |
|---|---|---|
| 0–1 | Low (<3%) | Treat at home; amoxicillin 500 mg TDS for 5 days |
| 2 | Intermediate (9%) | Consider hospital admission; amoxicillin + clarithromycin |
| 3–5 | High (15–40%) | Urgent hospital admission; IV antibiotics |
Sore Throat: FeverPAIN Score
- Fever >38°C in last 24h: 1 point
- Purulence on tonsils: 1 point
- Attend rapidly (within 3 days of onset): 1 point
- Severely inflamed tonsils: 1 point
- No cough or coryza: 1 point
- Score 0–1: No antibiotic; Score 2–3: Delayed 48h; Score 4–5: Immediate phenoxymethylpenicillin 500 mg QDS for 5–10 days
Skin and Soft Tissue Infections
- Impetigo (localised): Hydrogen peroxide 1% cream or fusidic acid 2% cream for 5 days
- Impetigo (widespread/systemic): Flucloxacillin 500 mg QDS for 5 days
- Cellulitis (non-purulent): Flucloxacillin 500 mg QDS for 5–7 days; clarithromycin if penicillin allergy
- Cellulitis (purulent/abscess): Consider MRSA — send swab; co-amoxiclav or doxycycline
- Erysipelas: Phenoxymethylpenicillin 500 mg QDS for 5–7 days
Key Clinical Takeaways
- Use delayed prescribing for most RTIs and mild ENT infections — reduces antibiotic use by 25–40%
- Nitrofurantoin 100 mg MR BD for 3 days is first-line for uncomplicated UTI in women
- CURB-65 score guides CAP management: score ≥3 requires hospital admission
- FeverPAIN score guides sore throat prescribing: score 4–5 warrants immediate antibiotics
- Never treat asymptomatic bacteriuria in catheterised patients
- Always document antibiotic indication, dose, duration, and review date