Plain English Summary
Background and study aims
This study is part of a programme of research into cough/chest infections across 12 European countries. Most people with chest infections probably don’t benefit from antibiotics and inappropriate antibiotic use drives antibiotic resistance, a major global health problem. Some groups of people however might really benefit from antibiotics. The study aims at understanding which subgroups of individuals with chest infections benefit from antibiotics, but also to study antibiotic resistance after antibiotic treatment.
Who can participate?
Throughout Europe 3000 adult patients presenting to primary care with acute cough or other symptoms that suggest a chest infection will take part in this study.
What does the study involve?
If the participating doctors think there is no definite need for antibiotics, participants will be asked to take a 7-day course of tablets to be taken three times a day. The tablets will be either amoxicillin, a very commonly used and safe penicillin-based antibiotic, or a placebo (a tablet without any medication in it). They will not be able to tell whether they will have the real antibiotic or the placebo. Random numbers are used to decide whether participants get antibiotic or placebo to make sure that they have an equal chance of getting either. This is the best way for us to show scientifically whether antibiotics really make a difference. If it is necessary to know whether participants are using an antibiotic or not, the participating doctors will be able to get that information at any time and change the participant’s medication. The participating doctors will also like to take one throat swab at day 8 (extra visit) and at the second study visit (day 28-35). The swab at day 8 will not be taken in all participants. If participants decide they do not want to have a swab taken at day 8 they can still take part in the treatment part of the study.
What are the possible benefits and risks of participating?
The main advantage is that the participating doctors will be well informed about the participants’ illness and will monitor them closely. In the future doctors will be able to provide better management for patients with coughs and chest infections, but this will not benefit the participants during this illness. The main disadvantages are the extra time and discomfort related to taking the additional swabs. The patients who will receive amoxicillin can experience the usual side-effects of penicillin: it can cause mild nausea or diarrhoea, and sometimes it can cause a transient skin rash.
Where is the study run from?
University of Southampton (UK).
When is the study starting and how long is it expected to run for?
October 2007 to April 2010.
Who is funding the study?
EC Sixth Framework Programme.
Who is the main contact?
Prof Paul Little
Prof Paul Little
Primary Medical Care
University of Southampton
Aldermoor Health Centre
Dr Herman Goossens
Laboratory of Medical Microbiology
Vaccine & Infectious Disease Institute (VAXINFECTIO)
University of Antwerp – Campus Drie Eiken
GRACE WP10 Protocol v4.1 18/09/2007; GRACE WP10 Protocol v4.2 21/4/2009 (to extend the study with additional networks and a third inclusion period and, only in five networks in the third inclusion period, with an additional objective with associated samples)
Genomics to combat Resistance against Antibiotics for Community-acquired lower respiratory tract infection (LRTI) in Europe (GRACE) work package 10: Antibiotic Trial One - a randomised placebo-controlled double-blind trial
GRACE AT ONE
This trial aims at understanding which subgroups of individuals with lower respiratory tract infections (LRTI) benefit from antibiotics. A randomised placebo-controlled double-blind trial will be carried out with patients as unit of randomisation to study the clinical effectiveness of antibiotics in community-acquired LRTI.
More details can be found at: http://public.ukcrn.org.uk/search/StudyDetail.aspx?StudyID=4175
GRACE WP10 Protocol v4.1: Southampton and South West Hampshire REC (B), 31/08/2007, ref: 07/H0504/104
GRACE WP10 Protocol v4.2: amendment approved 21/04/2009
The study protocols were approved by ethics committees in all participating countries. The competent authority in each country also gave their approval.
Randomised placebo-controlled double-blind trial
Primary study design
Secondary study design
Randomised controlled trial
Patient information sheet
Not available in web format, please use the contact details below to request a patient information sheet
Lower respiratory tract infection (LRTI)
1. Amoxicillin capsule, gastroenteral use, 3 g a day for 7 days
Primary outcome measures
1. Deterioration of illness: return to doctor with worsening signs, or admission to hospital within 4 weeks of first consultation, measured at one year
2. Symptom severity and duration, duration of symptoms rated moderately bad until symptoms clear, measured by symptom diary (with construct validity), measured at one year
Secondary outcome measures
1. Resource use data, assessed by a review of clinical notes measured at two years
2. Quality of life outcomes for use of economic evaluation (EQ5D), measured at two years
3. Antibacterial resistance in oropharyngeal streptococci measured before, immediately after and four weeks after the interventions in five networks in the third inclusion period
Overall trial start date
Overall trial end date
Participant inclusion criteria
1. Aged 18 and over, either sex
2. Acute or worsened cough is the main presentation suggesting LRTI, less than 28 days duration
3. Not been included earlier in the current GRACE trial
4. Able to fill out study materials
6. Not been on antibiotic treatment in previous month
7. First consultation for this illness episode
Target number of participants
Participant exclusion criteria
1. Allergic to penicillin
2. History/physical examination suggestive of community acquired pneumonia (CAP)
Recruitment start date
Recruitment end date
Countries of recruitment
Belgium, France, Germany, Italy, Netherlands, Poland, Slovakia, Slovenia, Spain, Sweden, United Kingdom
Trial participating centre
University of Southampton
University of Southampton (UK)
Research Governance Office
George Thomas Building 37
Sixth Framework Programme
European Union Sixth Framework Programme, EU Sixth Framework Programme, European Commission Sixth Framework Programme, EC Sixth Framework Programme, FP6
Funding Body Type
Funding Body Subtype
Results and Publications
Publication and dissemination plan
We plan to publish on the overall effect of amoxicillin for acute lower-respiratory-tract infection in primary care when pneumonia is not suspected and on a subgroup analysis of potential high-risk groups. Next we plan to publish on the cost-effectiveness of treatment with amoxicillin for acute lower-respiratory-tract infection in primary care and on the selection and persistence of antibiotic resistance in oral streptococci after such treatment.
Participant level data will be stored in a repository, the GRACE Database and Biobank, which is financially supported through the European Science Foundation (ESF), in the framework of the Research Networking Programme TRACE (Translational Research on Antimicrobial resistance and Community-acquired infections in Europe; www.esf.org/trace) and to consult via its chair Herman Goossens.
Intention to publish date
Participant level data
Stored in repository
Results - basic reporting
2012 results in: http://www.ncbi.nlm.nih.gov/pubmed/23265995
2014 results in: http://www.ncbi.nlm.nih.gov/pubmed/24567620
2015 results in: http://www.ncbi.nlm.nih.gov/pubmed/25748415
2015 results in: http://erj.ersjournals.com/content/early/2015/11/05/13993003.00611-2015
Little P, Stuart B, Moore M, Coenen S, Butler CC, Godycki-Cwirko M, Mierzecki A, Chlabicz S, Torres A, Almirall J, Davies M, Schaberg T, Mölstad S, Blasi F, De Sutter A, Kersnik J, Hupkova H, Touboul P, Hood K, Mullee M, O'Reilly G, Brugman C, Goossens H, Verheij T, , Amoxicillin for acute lower-respiratory-tract infection in primary care when pneumonia is not suspected: a 12-country, randomised, placebo-controlled trial., Lancet Infect Dis, 2013, 13, 2, 123-129, doi: 10.1016/S1473-3099(12)70300-6.
Moore M, Stuart B, COENEN S, Butler CC, Goossens H, Verheij TJ, Little P on behalf of the GRACE consortium, Amoxicillin for acute lower respiratory tract infection in primary care: subgroup analysis of potential high-risk groups, Br J Gen Pract, 2014, 64, 619, e75-e80, doi: 10.3399/bjgp14X677121.
D Gillespie, K Hood, D Farewell, CC Butler, T Verheij, H Goossens, B Stuart, M Mullee, P Little, Adherence-adjusted estimates of benefits and harms from treatment with amoxicillin for LRTI: secondary analysis of a 12-country randomised placebo-controlled trial using randomisation-based efficacy estimators , BMJ Open, 2015, 5, e006160, doi: 10.1136/bmjopen-2014-006160.
J Teepe, P Little, N Elshof, B DL Broekhuizen, M Moore, B Stuart, CC Butler, K Hood, M Ieven, S Coenen, H Goossens, TJM Verheij, Amoxicillin for clinically unsuspected pneumonia in primary care: subgroup analysis, Eur Resp J, 2015, doi: 10.1183/13993003.00611-2015.