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Background: In 2019, the World Health Organization ranked anti-microbial resistance (AMR) among the 10 greatest global threats to public health. Since 2016, the Innovation Committee of the G-BA aims to sensitize physicians for a restrictive use of antibiotics. In parallel, research on existing non-antibiotic medicines can support strategies to combat AMR.

Aim/scientific question: For treating acute upper respiratory tract infections and otitis media (URTI/AO) antibiotics are often unnecessary but still frequently used. We examined the current incidence of antibiotics in primary care and whether URTI/AO patients treated in homeopathic/anthroposophic ('H/A') practices, which strictly avoid antibiotics, show at least as good recovery as in conventional ('Con') practices.

Material & Methods: In a non-interventional, prospective, controlled study, German family medicine, pediatric, and ENT primary care practices declared themselves as H/A or Con. URTI/AO patients with public health insurance aged 6 months or older (or their legal guardians) consented to the collection of their clinical and treatment data and completed symptom and quality-of-life questionnaires at the current visit, 7 days later, and a daily symptom diary for up to 28 days; also, therapy costs were assessed. Primary outcome was the proportion of patients reporting complete/substantial recovery after 7 days. Statistical analysis for non-inferiority of H/A practices (threshold 5%) was based on causal inference models and Inverse Probability of Treatment Weighting. Relevant confounders were identified by independent experts to balance the study arms against systematic bias of non-random patient allocation.

Results: Between May 2025 and March 2026, 747 patients were recruited and 636 analyzed. Confounder balance was achieved. Antibiotics were prescribed for 16.1% and 3.6% of patients in Con and H/A practices, respectively; complete/major recovery was stated in 72.4% and 79.3%, respectively. Causal analysis revealed odds ratios for the recovery rate of H/A practices of 1.28 (95%-CI: 0.88-1.87) and 1.29 (0.88-1.88) for Per Protocol and Full Analysis Set, respectively, confirming non-inferiority compared to Con practices.

Discussion: The G-BA programs for reduction of antibiotic treatment of acute URTI seem to have succeeded to lower their prescription rates, yet strict non-antibiotic therapy strategies followed in H/A practices may be at least not inferior to current therapies in Con practices.

Take Home Message: Further reduction of antibiotics in URTI is both necessary and possible.

Competing interests: Marcus Reif is a member of the IBS-DR and the DGPharMed. David Martin provided pro bono project-related consulting to the RKI and the BMBFSFJ, is a member of scientific advisory boards (Hufeland Society, Pharmacovigilance Commission of the BfArM), and receives travel expense reimbursement for speaking engagements (BVKJ, DGKJ, DGHNO-KHC, DGÖG, BVÖGD, DGAAP) as well as third-party funding for research projects from the BMBF, the G-BA Innovation Fund, and the Software AG Foundation. Stephan Baumgartner is a member of scientific societies (ISCMR, ESIM, VAEPS, WissHom, DPG).