DANISH MEDICAL BULLETIN ϣ Dan Med Bul ϧϪ/ϣϣ November ϤϢϣϣ ABSTRACT INTRODUCTION: High consumption of macrolides has been linked to increased macrolide resistance in the common pathogens of respiratory tract infections (RTIs). According to Danish recommendations, penicillin is the first-choice treatment for RTIs and macrolides should only be pre- scribed when a patient is allergic to penicillin or for treat- ment of mycoplasma pneumonias. The aim of the present study was to explore the prescription of macrolides for different RTIs to patients without penicillin allergy in general practice in Denmark. MATERIAL AND METHODS: This was a cross-sectional study. Data were collected during a three-week period in January 2008 as part of the EU-funded project Health Alliance for Prudent Prescribing, Yield and Use of Antimicrobial Drugs in the Treatment of Respiratory Tract Infections (HAPPY AUDIT). A total of 102 Danish general practitioners partici- pated and registered patients with RTIs according to the Audit Project Odense method. RESULTS: A total of 3,904 patients with RTIs were regis- tered and 1,351 patients received antibiotics. Among these, 198 patients received a macrolide. In all, 136 pa- tients received a macrolide without being allergic to penicillin. This proportion was highest for patients diag- nosed with acute otitis media (71%), acute bronchitis (71%) or pneumonia (76%). CONCLUSION: Overall, there was a considerable overuse of macrolide for treatment of all types of RTIs. The macrolide overuse found in this study cannot be explained by the aetiology of Mycoplasma pneumoniae since there was no epidemic in 2008. FUNDING: Data for the macrolide study were collected from the HAPPY AUDIT study which was funded by the EU. The two first-authors each received DKK 30,000 from the PLU foundation for their work on the article. TRIAL REGISTRATION: The HAPPY AUDIT method was regis- tered and published in the BioMed Central. Antimicrobial resistance is a major concern to the public health and has been associated with inappropriate con- sumption of antibiotics in ecological studies as well as individual patient-level studies [1, 2]. In Denmark, 90% of all antibiotics are prescribed in general practice, and 60-70% of antibiotics are prescribed to patients with re- spiratory tract infections (RTIs) [3, 4]. The majority of the community-acquired RTIs are harmless, self-limiting and often of viral aetiology [4, 5]. Streptococcus pneumoniae and S. pyogenes are the most common and virulent bacterial pathogens in com- munity-acquired RTIs [3]. According to Danish national recommendations, beta-lactam antibiotics are the first- choice treatment for these types of infections as both pathogens are highly susceptible to beta-lactam anti- biotics [6] (see Table 1). Macrolide antibiotics have a broader spectrum than penicillin. According to national Danish recommenda- tions, they should only be prescribed for RTIs if a patient is allergic to penicillin or for pneumonia caused by Myco- plasma pneumoniae [6]. Macrolides are efficient in the treatment of RTIs caused by atypical pathogens due to the intracellular accumulation of macrolides [6]. How- ever, the atypical pathogens are less frequent in Den- mark and RTIs caused by M. pneumoniae primarily occur in epidemics, approximately every five years [7]. Macro- lides are not recommended for upper RTIs caused by M. pneumoniae. Macrolides should only be prescribed to patients with pneumonia when the aetiology of M. pneumoniae has been confirmed by a laboratory test. However, during epidemics, macrolides are in- dicated for the treatment of pneumonia on clinical suspicion of M. pneumoniae aetiology [6]. Macrolide overuse f or treatment of respiratory tract infections in general practice Mette Hinnerskov, Julie Maria Therkildsen, Gloria Cordoba & Lars Bjerrum ORIGINAL ARTICLE Section of General Practice, University of Copenhagen Dan Med Bul 2011;58(11):A4356 Danish national recommendations for antibiotic treatment of respiratory tract infections in general prac- tice. Data obtained from the Danish guideline Medicin.dk [6]. Diagnosis First choice Penicillin allergy Comments Acute otitis media Penicillin V Macrolide Start treatment when child < 6 months or in case of ear secretion Acute sinusitis Penicillin V Macrolide Often self-limiting High CRP indicates treatment Sore throat Penicillin V Macrolide Often self-limiting Start treatment when positive StrepA test + clinical symptoms Acute bronchitis No antibiotics Viral aetiology and self-limiting Pneumonia Penicillin V Macrolide Treatment with macrolide: verified Mycoplasma pneumoniae or suspected during epidemics Exacerbation of COPD Combination of amoxicillin and clavulanic acid T etracycline Start treatment only when there is dyspnoea and coughing with increased purulent sputum COPD = chronic obstructive pulmonary disease; CRP = C-reactive protein. TABLE 1