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Objective. To determine age-specific antibiotic prescription and referral rates in preschool children diagnosed with acute respiratory tract infection (RTI) in primary care. Design. Retrospective cohort study. Setting. Research database of the Netherlands University Medical Center Utrecht Primary Care Network. Subjects. All children aged 0–5 years within the database were included, covering 1998 to 2002 (18,801 child-years). Main outcome measures. Antibiotic prescription and referral rates were determined as percentage of children with at least one prescription or referral within a year, as total number of prescriptions per 1000 child-years, and as percentage of all RTI episodes. Results. Antibiotics, mostly beta-lactam (80%) and macrolides (16%), were prescribed in 35% of RTI episodes. Annually 13% of the children received at least one antibiotic following an RTI. Antibiotics were prescribed in more than half of episodes of LRTI, sinusitis, AOM, and acute tonsillitis, and in 12–15% of episodes of asthma exacerbation, acute laryngitis, influenza acute, and acute upper respiratory infection (including common cold and pharyngitis). Almost 98% of RTIs were managed in primary care. On average 1% of the children were referred to a paediatrician or ENT specialist following RTI per year, especially after AOM (59% of referrals). Compared with older children, those under two years of age were more often treated with antibiotics (relative risk [RR] 1.4, 95% CI 1.3–1.6) and referred (RR 2.3; 95% CI 1.8–3.0). Conclusion. In the Netherlands most episodes of RTIs in preschool children were managed in primary care and this often involves prescription of antibiotics. Children younger than two years of age receive more often antibiotics for RTI and are also referred more, especially for AOM. [ABSTRACT FROM AUTHOR]