Over the past 70 years, antibiotics have influenced and improved the treatment of many symptomatic infections. Unfortunately, antibiotics produce side effects and—regardless of whether they are used appropriately or inappropriately—will ultimately lead to a change in the sensitivity of organisms, which can sometimes lead to a reduction in clinical effectiveness.

Many attempts have been made to implement programmes that are designed to improve the use of antibiotics, particularly in primary care. The linked randomised controlled trial by Butler and colleagues (doi:10.1136/bmj.d8173) describes the most recent of these attempts.1 The authors used social learning theories to develop an extensive and comprehensive educational programme (Stemming the Tide of Antibiotic Resistance; STAR) aimed at reducing antibiotic use in primary care clinics in Wales. Their multifaceted intervention incorporated many of the approaches other reviews have identified as helpful, such as education, feedback, and patient involvement.2 Practices randomised to receive the STAR programme dispensed significantly fewer oral antibiotics (26.1 items/1000 registered patients/year)—a total reduction of 4.2% (95% confidence interval 0.6% to 7.7%). The intervention cost about ₤3000 (€3500; $4713) per practice. The results are similar to (although at the lower end of) reductions seen with other such programmes.3

Is a 4% reduction in use of antibiotics clinically important? The authors found no significant differences in hospital admissions or reconsultations for a …