1. Introduction and purpose European guidelines for treating acute cough/lower respiratory tract infection (LRTI) aim to reduce non-evidence based variation in prescribing, and better target and increase the use of first line antibiotics. The guideline developers faced challenges arising from gaps in the supporting evidence base and hence some recommendations were based on consensus and compromise rather than empirical evidence. The application of these guidelines in primary care is unknown. Antibiotic prescribing for adults with acute cough/LRTI: congruence with guidelines J.Wood* C.Butler* K.Hood* M.Kelly* T.Verheij P.Little A.Torres F.Blasi T.Schaberg H.Goossens *South East Wales Trials Unit (SEWTU), Department of Primary Care and Public Health, School of Medicine, Cardiff University Methods Prospective observational data from patients presenting to primary care with acute cough/LRTI. Clinicians recorded symptoms on presentation, and their examination and management. Patients were followed up with self- complete diaries. ERS-ESCMID guideline recommendation Data available in case report form (CRF) or diary in the GRACE study Suspected or definite pneumonia Must have Acute Cough and one of: Cough – present on the day of inclusion 1.New Focal Chest SignDiminished Vesicular Breathing – present on the day of inclusion Crackles – present on the day of inclusion Rhonchi – present on the day of inclusion 2. DyspnoeaShortness of breath – present on the day of inclusion 3. TachypnoeaRespiratory rate (breaths per minute) – more than 20 per minute 4. Fever Lasting 4 daysHow many days were you unwell before you saw your GP or nurse for this cough? – minimum 4 days Temperature recorded using a disposable thermometer – more than 37.8°c Selected exacerbations of COPD Must have Chronic Obstructive Pulmonary Disease (COPD) and all of: COPD - present on the day of inclusion 1. Increased dyspnoeaShortness of breath – present on the day of inclusion 2. Increased sputum volumePhlegm production – present on the day of inclusion 3. Increased sputum purulenceIf producing phlegm, what colour? – Colour is yellow, green or bloodstained Or Severe COPDPulse Oximitery (% saturation) – less than 90% Aged 75 yrs and fever Must be over 75 years oldAge – over 75 years FeverTemperature recorded using a disposable thermometer – more than 37.8°c Cardiac FailureHeart Failure - present on the day of inclusion Insulin-dependent diabetes mellitusDiabetes - present on the day of inclusion Insulin - present on the day of inclusion Serious Neurological DisorderN/A Results Given patients’ clinical presentation, clinicians could have justified an antibiotic prescription for 1915 (71.2%) patients according to the ERS-ESCMID guideline. 761 (42.8%) of those who were prescribed antibiotics received a first choice antibiotic (i.e. tetracycline or amoxicillin). Ciprofloxacin was prescribed for 37 (2.1%) and cephalosporins for 117 (6.6%). Conclusion A lack of specificity in definitions in the ERS-ESCMID guidelines could have enabled clinicians to justify a higher rate of antibiotic prescription. More studies are needed to produce specific clinical definitions and indications for treatment. First choice antibiotics were prescribed to the minority of patients who received an antibiotic prescription. ERS recommended antibiotics for LRTI PreferredAlternative TetracyclineMacrolides AmoxicillinCo-amoxiclav Levofloxacin Moxifloxacin We explored congruence of both antibiotic prescribing and antibiotic choice with European Respiratory Society- European Society Clinical Microbiology and Infectious Diseases (ERS-ESCMID) guidelines for managing LRTI in the GRACE (Genomics to combat Resistance against Antibiotics in Community-acquired LRTI in Europe; www.grace-lrti.org) dataset. www.grace-lrti.org