Recent reports from the Audit Commission1 and the House of Lords Select Committee2 on resistance to antibiotics have both been critical of general practitioner (GP) prescribing for the excessive use of antibiotics in respiratory illness, the increasing antibiotic resistance of respiratory pathogens, and excessive drug costs in the community. Such criticism of GPs is not new and appears to have little effect on prescribing habits. Why do all doctors prescribe antibiotics so often, is this behaviour amenable to change, and what does it have to do with hospital physicians?

If changes in prescribing in the community are to be achieved, there probably needs to be a better appreciation of the issues which drive it. This understanding is important, not only for those working in primary care, but also for those in hospital practice. Respiratory physicians and microbiologists teach and influence GPs, medical students, and junior doctors. Their advice and example is important but is less influential, especially in primary care, if it does not also reflect and address the difficulties experienced by doctors who have to treat patients whose attitudes and expectations may differ significantly from their own.

This review highlights some of the issues behind dependence on antibiotic prescribing, particularly for respiratory disease. It focuses on managing the commonest presentation of acute respiratory illness: a previously well adult consulting with a new episode of cough and other lower respiratory tract symptoms. This is often called “acute bronchitis”, an imperfect diagnostic label.3For most of these patients the doctor is uncertain whether antibiotics are indicated, but still prescribes them.