PHARMAC have run for around a decade now a campaign for the Wise Use of Antibiotics . Its measure of success has been a lower use of antibiotics and the ensuing cost savings. However, wise use imports the notion of quality use , in other words are we targeting the right antibiotics to the right people?I have not been able to find any evidence of research to enquire into the quality use of antibiotics by PHARMAC despite Coroner Shortland recommending in 2011 that the relevant parties work to provide guidelines for what constitutes suspicion of meningococcal disease warranting immediate iv antibiotic administration.1One of the key messages of PHARMACs campaign is that antibiotics dont work for flu or the common cold. As a result, it is easy to see that fewer antibiotics are prescribed for anything that loosely fulfils the influenza-like illness (ILI) description. However, in asking the quality question one must ask just how proficient are we at accurately diagnosing influenza?BPAC Guidelines for diagnosing influenza are:2During periods of increased influenza prevalence, the acute onset of fever and cough makes a diagnosis of influenza more likely. When prevalence is low, the presence of influenza-like symptoms is less accurate for diagnosing influenza.When a patient presents with symptoms and signs of influenza, four questions are useful to distinguish between influenza and influenza-like illness: Are influenza viruses known to be circulating in the area? Did the patient experience a sudden onset of symptoms? Is the patients temperature significantly raised (> 38\u00b0C)? Does the patient have both systemic and respiratory symptoms, particularly cough? If the answer is yes to all of these questions, influenza is the likely diagnosis.Differential diagnoses include: Other respiratory viral infections, e.g. respiratory syncytial virus, coronavirus, rhinovirus Meningitis Pneumonia Although rare consider malaria in people who have recently travelled to an area where malaria is endemic As a guide for GPs, to say the differential diagnoses include meningitis is potentially confusing as the differential diagnosis includes meningitis as well as meningococcal septicaemia which can have quite a different symptomatology and course of disease.2 For example, a lumber puncture is contraindicated in the case of meningococcal septicaemia because of the risk of DIC and bleeding into the spinal column. Meningococcal septicaemia is not characterised by a stiff/sore neck or photophobia. Conversely, meningitis is not typically characterised by the pathognomonic purpuric rash .It is important to note that the UK Guidelines for Meningococcal Disease note that:3 As few as 5% of childhood meningitis cases have photophobia Neck stiffness ranges from 62% to 75% of childhood meningitis cases Purpuric rash occurs in around 40% of cases during the critical early stages In our experience there is considerable confusion and certainly no consensus about what constellation of symptoms constitutes suspicion of meningococcal disease and thereby requires the immediate administration of appropriate intravenous antibiotics.In the recent cases of 18-year-old Ben Brown of Whangarei who died of meningitis in 2011 and the case of our own son Zachary who died in 2009 of meningococcal septicaemia at the age of 22 years, both men had acute onset of fever in the absence of cough or other respiratory or coryzeal symptoms. Nonetheless a working diagnosis of influenza was made.1,4The justification for a working diagnosis of ILI being reasonable under the circumstances of a circulating influenza virus is usually made on the basis of the assertion that it is possible for there to be fever in the absence of respiratory symptoms and cough in the early stages of acute influenza.The American Family Physician reviewed the natural course of influenza in 2003 and confirmed a clinical picture first described in 1976 (refer to Figure 1 of Am Fam Physician).5 First, influenza is accompanied by an acute onset of coryzeal symptoms at time zero. Second, at the time of peak fever the constellation of symptoms of coryza, headache, myalgia, sore throat, cough and malaise were all present (Figure 1 of Am Fam Physician).5Figure 1. Summary curves of systemic symptoms (fever, muscle aches, fatigue, headache), respiratory symptoms, or nasal symptoms scores. Seven curves (159 infected participants) were considered for the systemic scores (20, 34, 74, 79-82), five curves (132 participants) for the nasal scores (20, 34, 79-81), and two curves (28 participants) for the respiratory scores (28, 75). A score of 1 corresponds to the maximum reported score value (refer to Materials and Methods in ref 6) (Reproduced by kind permission of Professor Fabrice Carrat6)In a 2008 meta-analysis published in Am J Epidemiol6 a similar pattern is described (see Figure 1 above). In particular, peak fever corresponds to 80% of peak nasal symptoms and 70% of peak respiratory symptoms.6I submit that, particularly during a known meningococcal outbreak, acute onset of fever (along with other systemic symptoms such as tachycardia, tachypnoea, vomiting and low blood pressure) in the absence of cough or coryza is reasonable grounds for suspicion of meningococcal disease regardless of the presence of sore neck, photophobia or rash and thus constitutes a reasonable basis for intravenous antibiotics.If possible a blood sample for later culture should also be taken prior to administration of the iv antibiotics. However, it is worth remembering that the definitive diagnosis of meningococcal disease in the case of both Ben and Zachary was made post mortem as is so often the case.There appears to be poor awareness of what properly constitutes ILI. The BPAC Guidelines are disappointingly misleading regarding meningitis and meningococcal septicaemia and there remains no stated guidance on what might reasonably constitute suspicion of meningococcal disease. The time has come to review our guidelines and advice as recommended by Coroner Shortland.1,4