Protecting antibiotics: the Primary Care Research Centre’s world-leading role in antimicrobial stewardship

Antibiotics are life-saving medicines, but their effectiveness cannot be taken for granted.

The more they are used, particularly when they are unlikely to benefit a patient, the greater the opportunity for bacteria to develop resistance. Antimicrobial resistance (AMR) is now one of the world’s greatest health challenges, threatening our ability to treat infections effectively.

For more than three decades, the University of Southampton’s Primary Care Research Centre has been at the forefront of efforts to address this challenge. Its researchers have built an internationally influential body of evidence around one central question: how can clinicians protect patients today while preserving effective treatments for the future?

“Antibiotics are life-saving drugs when used at the right time, but when used inappropriately, they’re potentially causing more harm than good,” explains Professor Nick Francis, Head of the School of Primary Care, Population Sciences and Medical Education.

“What we advocate for is antimicrobial stewardship. This is about the appropriate, targeted use of antibiotics, balancing the benefits of treatment with the harms that can be associated with it.”

Why primary care matters

Around 90% of people’s contact with the NHS takes place in primary care, where between 80% and 90% of antibiotics for human use are prescribed. That makes primary care a critical setting for reducing unnecessary antibiotic use.

Much of Southampton’s research has focused on common respiratory illnesses such as sore throats, coughs, chest infections, colds and ear infections. Many are caused by viruses, against which antibiotics are ineffective. Even when bacteria are involved, patients will often recover without antibiotics.

The challenge is therefore to identify those most likely to benefit from treatment while providing safe and effective care for everyone else.

The Centre approaches this from several directions: changing prescribing practice, identifying which patients need antibiotics, and finding alternative treatments.

Transforming prescribing practice

Southampton’s influence began in the mid-1990s, when researchers, including Professors Hazel Everitt, Paul Little and Michael Moore and Dr Ian Williamson, investigated different approaches to treating sore throats.

In a trial involving 700 patients, participants received either an immediate antibiotic prescription, no prescription or a delayed prescription to use if their symptoms had not begun to settle after three days.

Antibiotics did not reduce the extent or duration of symptoms. However, giving no antibiotics or offering a delayed prescription reduced patients’ belief in the effectiveness of antibiotics and their intention to consult their GP about similar symptoms in future.

Further Southampton trials produced similar findings for sinusitis, ear infections, conjunctivitis and lower respiratory tract infections. A systematic review also found delayed prescribing to be safe and effective for most patients.

This research helped change clinical practice. Delayed prescribing has become an established tool used by GPs across the UK, with Southampton’s evidence informing guidance nationally and internationally.

Identifying who is most likely to benefit

Reducing antibiotic use does not mean withholding necessary treatment. It means targeting antibiotics at those most likely to benefit.

One example is the FeverPAIN clinical score, studied by Professor Paul Little and colleagues in patients with acute sore throats. The score uses patients’ symptoms and clinical signs to help clinicians determine when antibiotics are most likely to be appropriate. Using FeverPAIN reduced antibiotic use by 29% compared with delayed prescribing.

The Centre is now applying the same principle to other patient groups. Professor Nick Francis and Dr Mark Lown are investigating whether people aged 65 and over with uncomplicated chest infections recover as well without antibiotics, and whether a simple blood test could identify those most likely to benefit from treatment.

Research led by PhD student Nour Odeh is also developing an intervention to reduce unnecessary antibiotic use for acute respiratory symptoms among people with asthma.

Finding effective alternatives

Avoiding antibiotics should not mean leaving patients without support. Another strand of Southampton’s research is identifying accessible alternatives that reduce symptoms and support recovery.

A major trial led by Professor Paul Little recruited more than 13,500 adults through GP practices to investigate whether readily available nasal sprays could help people with respiratory infections.

The findings showed that both gel-based and saline nasal sprays reduced the overall duration of illness by around 20%. They also led to a 20% to 30% reduction in days lost from work or normal activities. All interventions studied reduced antibiotic use by more than 25% in relative terms.

The findings demonstrate how accessible alternatives can help patients manage their illness while reducing reliance on antibiotics.

Protecting people at greater risk

Antimicrobial stewardship can be particularly difficult when symptoms are hard to recognise or communicate.

Research led by Professor Nick Francis has examined urinary tract infections among care home residents. People living with dementia may struggle to describe their symptoms, while care home residents have higher rates of asymptomatic bacteriuria, in which bacteria are present without causing an infection. Finding bacteria therefore does not necessarily mean that someone has an infection or will benefit from antibiotics.

Professor Miriam Santer is also investigating alternatives to repeated or long-term antibiotics for women with recurrent urinary tract infections.

Recurrent UTI is commonly defined as two or more infections within six months, or three or more within 12 months. Although long-term antibiotics are widely used to prevent recurrent UTIs, alternatives include vaginal oestrogen, methenamine hippurate, cranberry products and increased fluid intake. However, evidence on their effectiveness, dosage and long-term use is still developing.

Together, this research aims to ensure that patients at greater risk receive appropriate treatment without unnecessary or prolonged exposure to antibiotics.

Changing expectations while protecting patients

Prescribing decisions are influenced not only by clinical evidence, but also by patients’ expectations and what clinicians believe their patients want.

“We have used behavioural science approaches aimed at prescribers and patients,” says Professor Nick Francis. “Clinicians tell us that patients often expect or demand antibiotics, so changing beliefs and perceptions among patients is also important.”

Professors Lucy Yardley, Adam Geraghty and Ingrid Muller have led the behavioural aspects of this research, examining how communication and behaviour-change approaches can support better decisions by clinicians and patients.

Clear communication can help people understand why an antibiotic may not improve their illness, how long their symptoms are likely to last and what they can do to support their recovery. It must be accompanied by effective safety-netting, including advice about warning signs and when to seek further help.

Antimicrobial stewardship is not a choice between prescribing antibiotics and doing nothing. It combines clinical assessment, targeted treatment, practical alternatives, communication and follow-up to provide safe and effective care.

Three decades of evidence and impact

For more than 30 years, the Primary Care Research Centre has helped change how antibiotics are used in general practice.

From establishing delayed prescribing as an everyday clinical tool to identifying who is most likely to benefit from treatment and finding effective alternatives, its research has helped shape a more targeted approach to antibiotic use.

Its work demonstrates that antimicrobial stewardship is not simply about treating fewer people. It is about treating people better, protecting patients from unnecessary harm and preserving life-saving medicines for the future.