The clinical effectiveness and cost effectiveness of antibiotic management strategies for respiratory tract infections (RTIs) (section 2.2.3)

1.1.1.

At the first face-to-face contact in primary care, including walk-in centres and emergency departments, adults and children (3 months and older) presenting with a history suggestive of the following conditions should be offered a clinical assessment.

• acute otitis media
• acute sore throat/acute pharyngitis/acute tonsillitis
• common cold
• acute rhinosinusitis
• acute cough/acute bronchitis.

The clinical assessment should include a history (presenting symptoms, use of over-the-counter or self medication, previous medical history, relevant risk factors, relevant comorbidities) and, if indicated, an examination to identify relevant clinical signs.

1.1.2.

Patients’ or parents’/carers’ concerns and expectations should be determined and addressed when agreeing the use of the three antibiotic prescribing strategies (no prescribing, delayed prescribing and immediate prescribing).

1.1.3.

A no antibiotic prescribing strategy or a delayed antibiotic prescribing strategy should be agreed for patients with the following conditions:

• acute otitis media
• acute sore throat/acute pharyngitis/acute tonsillitis
• common cold
• acute rhinosinusitis
• acute cough/acute bronchitis.

Depending on clinical assessment of severity, patients in the following subgroups can also be considered for an immediate antibiotic prescribing strategy (in addition to a no antibiotic or a delayed antibiotic prescribing strategy):

• bilateral acute otitis media in children younger than 2 years
• acute otitis media in children with otorrhoea
• acute sore throat/acute pharyngitis/acute tonsillitis when three or more Centor criteria¹ are present.

1.1.4.

For all antibiotic prescribing strategies, patients should be given:

• advice about the usual natural history of the illness, including the average total length of the illness (before and after seeing the doctor):

  –

  acute otitis media: 4 days

  –

  acute sore throat/acute pharyngitis/acute tonsillitis: 1 week

  –

  common cold: 1½ weeks

  –

  acute rhinosinusitis: 2½ weeks

  –

  acute cough/acute bronchitis: 3 weeks

• advice about managing symptoms, including fever (particularly analgesics and antipyretics). For information about fever in children younger than 5 years, refer to ‘Feverish illness in children’ (NICE clinical guideline 47).

1.1.5.

When the no antibiotic prescribing strategy is adopted, patients should be offered:

• reassurance that antibiotics are not needed immediately because they are likely to make little difference to symptoms and may have side effects, for example, diarrhoea, vomiting and rash
• a clinical review if the condition worsens or becomes prolonged.

1.1.6.

When the delayed antibiotic prescribing strategy is adopted, patients should be offered:

• reassurance that antibiotics are not needed immediately because they are likely to make little difference to symptoms and may have side effects, for example, diarrhoea, vomiting and rash
• advice about using the delayed prescription if symptoms are not starting to settle in accordance with the expected course of the illness or if a significant worsening of symptoms occurs
• advice about re-consulting if there is a significant worsening of symptoms despite using the delayed prescription.

A delayed prescription with instructions can either be given to the patient or left at an agreed location to be collected at a later date.

Identifying those patients with RTIs who are likely to be at risk of developing complications (section 2.3.3)

1.1.7.

An immediate antibiotic prescription and/or further appropriate investigation and management should only be offered to patients (both adults and children) in the following situations:

• if the patient is systemically very unwell
• if the patient has symptoms and signs suggestive of serious illness and/or complications (particularly pneumonia, mastoiditis, peritonsillar abscess, peritonsillar cellulitis, intraorbital and intracranial complications)
• if the patient is at high risk of serious complications because of pre-existing comorbidity. This includes patients with significant heart, lung, renal, liver or neuromuscular disease, immunosuppression, cystic fibrosis, and young children who were born prematurely
• if the patient is older than 65 years with acute cough and two or more of the following criteria, or older than 80 years with acute cough and one or more of the following criteria:

  –

  hospitalisation in previous year

  –

  type 1 or type 2 diabetes

  –

  history of congestive heart failure

  –

  current use of oral glucocorticoids.

For these patients, the no antibiotic prescribing strategy and the delayed antibiotic prescribing strategy should not be considered.

1.3.1. Prescribing of antibiotics for self-limiting respiratory tract infections in adults and children in primary care

Respiratory tract infection (RTI) is defined as any infectious disease of the upper or lower respiratory tract. Upper respiratory tract infections (URTIs) include the common cold, laryngitis, pharyngitis/tonsillitis, acute rhinitis, acute rhinosinusitis and acute otitis media. Lower respiratory tract infections (LRTIs) include acute bronchitis, bronchiolitis, pneumonia and tracheitis. Antibiotics are commonly prescribed for RTIs in adults and children in primary care. General practice consultation rates in England and Wales show that a quarter of the population will visit their GP because of an RTI each year (Ashworth et al. 2005). RTIs are the reason for 60% of all antibiotic prescribing in general practice, and this constitutes a significant cost to the NHS. Annual prescribing costs for acute cough alone exceed £15 million (Lindbaek 2006).

There is evidence from randomised placebo-controlled trials (RCTs) that antibiotics have limited efficacy in treating a large proportion of RTIs in adults and children (see section 2). These include acute otitis media (AOM), acute cough/acute bronchitis, acute sore throat/acute pharyngitis/acute tonsillitis, acute rhinosinusitis and the common cold. These conditions are largely self-limiting and complications are likely to be rare if antibiotics are withheld. Therefore, these five common RTIs are the focus of this guideline. The inappropriate prescribing of antibiotics has the potential to cause drug-related adverse events, escalate the prevalence of antibiotic-resistant organisms in the community and increase primary care consultation rates for minor illness (Standing Medical Advisory Committee 1998).

Three different antibiotic management strategies can be used for patients with RTIs who present in primary care and other first face-to-face contact healthcare settings (such as emergency departments and walk-in centres): no antibiotic prescribing; delayed (or deferred) antibiotic prescribing (in which an antibiotic prescription is written for use at a later date should symptoms worsen); and immediate antibiotic prescribing. The decision agreed between healthcare professional and patient depends on both the healthcare professional’s assessment of the risk of complications if antibiotics are withheld and the patient’s expectations regarding an antibiotic prescription (Britten N et al. 2008; Butler et al. 1998). Perceived advantages of delayed prescribing as a strategy over no prescribing are that it offers a ‘safety net’ for the small proportion of patients who develop a complication, and that a patient expecting antibiotics may be more likely to agree with this course of action rather than with no prescribing. Delayed prescribing has therefore been advocated as an important management strategy to reduce inappropriate antibiotic prescribing (Little 2005).

Prescribing patterns for antibiotics for RTIs vary widely among general practices. Although delayed prescribing and no prescribing strategies have been advocated since the late 1990s (Little 2005), it is unclear to what extent they have been taken up in primary care in England and Wales.

There is currently no national clinical guideline in the UK relating to antibiotic prescribing in primary care for RTIs that are likely to be self-limiting. There is therefore a need for guidance for primary care and other first-contact healthcare professionals (GPs, nurse practitioners, pharmacists and those working in emergency departments) on:

• which RTIs do not require immediate antibiotic treatment
• which antibiotic management strategies could be offered once a decision has been made that the patient does not need immediate antibiotic treatment
• the clinical and cost effectiveness of delayed prescribing or no prescribing as management strategies during the consultation to ensure the appropriate use of antibiotics for RTIs.

This short clinical guideline aims to improve the care of adults and children (3 months or older) for whom immediate antibiotic prescribing is not clinically indicated by making evidence-based recommendations on antibiotic prescribing strategies. However, this guideline does not cover details of antibiotic regimens for the above five RTIs. Healthcare professionals should refer to the British National Formulary for choice of antibiotic and its dosage.

1.3.2. The NICE short clinical guideline programme

‘Prescribing of antibiotics for self-limiting respiratory tract infections in adults and children in primary care’ (NICE clinical guideline 69) is a NICE short clinical guideline.

For a full explanation of the process, see www.nice.org.uk/guidelinesmanual.

1.3.3. Using this guideline

This document is intended to be relevant to primary care and community settings where face-to-face contact takes place between patients and healthcare professionals. These settings include general practices, community pharmacies, NHS walk-in centres, NHS out-of-hours services and primary medical and nursing care provided in emergency departments. The target population is adults and children (3 months and older) for whom immediate antibiotic prescribing is not indicated.

This is the full version of the guideline. It is available from www.nice.org.uk/CG069. Printed summary versions of this guideline are available: ‘Understanding NICE guidance’ (a version for patients and carers) and a quick reference guide (for healthcare professionals). These are also available from www.nice.org.uk/CG069.

1.3.4. Using recommendations and supporting evidence

The GDG reviewed the evidence and for each clinical question the GDG was presented with a summary of the clinical evidence and, where appropriate, economic evidence derived from the studies reviewed and appraised. From this information the GDG was able to derive the guideline recommendations. The link between the evidence and the view of the GDG in making each recommendation is made explicit in the accompanying evidence to recommendations sections.