Lower respiratory tract infections in the community: towards a more rational approach.

Lower respiratory tract infections (LRTI), such as acute bronchitis, infectious exacerbation of chronic bronchitis and pneumonia, are frequent community-acquired infections affecting both the paediatric and adult population, and are one of the commonest respiratory illnesses observed in daily medical practice [1]. In most cases, LRTI cause a mild clinical picture, usually managed by general practitioners. Only a minority of episodes with a more severe presentation, or affecting patients with chronic diseases , are attended by hospital specialists. Because bacterial organisms are often involved or could potentially complicate the course of LRTI, antibiotic prescription on an empirical basis is the commonest approach, in spite of the benign and self-limited nature of the majority of episodes. Although there is a general acceptance that LRTI is the most frequent cause for antibiotic prescription in general medical practice, precise data about antibiotic regimens are scarce [2]. In addition, the number of drugs potentially active against respiratory pathogens has increased considerably and, consequently, the prescribed regi-mens may differ widely. In this issue of the Journal, two excellent original studies coming from the same group provide fresh data about the current patterns of diagnostic management and antibiotic prescription in LRTI among general practitioners (GPs) of five European countries: France, Germany, Italy, Spain and the United Kingdom. In one of these studies, HUCHON et al. [3] have concluded that antibiotics are excessively prescribed by European GPs; more than 80% of all LRTI, globally considered, are treated with antibiotics. This figure showed little variation as regards the different types of LRTI: community-acquired pneumonia , acute bronchitis, exacerbated chronic bronchitis, and "viral" respiratory tract infection. Even in this last group, 70% of cases were initially managed with antibiotics. In contrast to the relative homogeneity in antibiotic prescription rates, the authors found substantial differences in the characteristics (nature) of antibiotic treatments. According to this, oral penicillins were first choice antibiotics in the UK and France, tetracyclines were preferred in Germany, macrolides were given in Spain, and paren-teral third-generation cephalosporins were commonly prescribed in Italy. The pattern of prescription was relatively independent of the characteristics of LRTI. However, the authors could find no convincing reasons for these striking differences. In an accompanying paper, also published in this issue of the Journal, WOODHEAD et al. [4] assessed the diagnostic management of LRTI by European GPs. These authors concluded that LRTI are, in most cases, managed only on clinical grounds. Therefore, diagnostic tests …