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Self-limiting respiratory tract infections - antibiotic prescribing
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Introduction
This pathway covers prescribing of antibiotics for self-limiting respiratory tract infections in adults and children in primary care.
Most people will develop an acute respiratory tract infection (RTI) every year. RTIs are also the commonest acute problem dealt with in primary care – the 'bread and butter' of daily practice. Management of acute RTIs in the past concentrated on advising prompt antibiotic treatment of presumptive bacterial infections. This advice was appropriate, in an era of high rates of serious suppurative and non-suppurative complications, up to and including the immediate post-war period. However, in modern developed countries, rates of major complications are now low. In addition, there is no convincing evidence, either from international comparisons or from evidence within countries, that lower rates of prescribing are associated with higher rates of complications. Therefore much of the historically high volume of prescribing to prevent complications may be inappropriate. After a fall in antibiotic use in the late 1990s, antibiotic prescribing in the UK has now reached a plateau and the rate is still considerably higher than the rates of prescribing in other northern European countries. Most people presenting in primary care with an acute uncomplicated RTI will still receive an antibiotic prescription – with many doctors and patients believing that this is the right thing to do.
There may be several problems with this. First, complications are now much less common, so the evidence for symptomatic benefit should be strong to justify prescribing; otherwise many patients may have unnecessary antibiotics, needlessly exposing them to side effects. Second, except in cases where the antibiotic is clinically necessary, patients, and their families and friends, may get the message from healthcare professionals that antibiotics are helpful for most infections. This is because patients will understandably attribute their symptom resolution to antibiotics, and thus maintain a cycle of 'medicalising' self-limiting illness. Third, international comparisons make it clear that antibiotic resistance rates are strongly related to antibiotic use in primary care. This is potentially a major public health problem both for our own and for future generations; unless there is clear evidence of benefit, we need to maintain the efficacy of antibiotics by more judicious antibiotic prescribing.
Following a review of the evidence, we have tried to produce simple, practical guidance for antibiotic prescribing for all of the common, acute, uncomplicated, RTIs, with recommendations for targeting of antibiotics. The guideline includes suggestions for safe methods of implementing alternatives to an immediate antibiotic prescription – including the 'delayed' antibiotic prescription.
The Guideline Development Group (GDG) recognised the concern of GPs and patients regarding the danger of developing complications. While most patients can be reassured that they are not at risk of major complications, the difficulty for prescribers lies in identifying the small number of patients who will suffer severe and/or prolonged illness or, more rarely, go on to develop complications. The GDG struggled to find much good evidence to inform this issue. This is clearly an area where further research is needed. In the meantime, GPs need to take 'safety-netting' approaches in the case of worsening illness, either by using delayed prescriptions or by prompt clinical review.
Source guidance
The NICE guidance that was used to create the pathway.
Respiratory tract infections. NICE clinical guideline 69 (2008)
Quality standards
Quality statements
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Implementation
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Pathway information
Information for the public
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Patient-centred care
Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If someone does not have the capacity to make decisions, healthcare professionals should follow the Department of Health's advice on consent, the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards. In Wales, healthcare professionals should follow advice on consent from the Welsh Government.
If the person is under 16, healthcare professionals should follow the guidelines in Seeking consent: working with children. If a young person is moving between paediatric and adult services their care should be planned and managed according to the best practice guidance described in the Department of Health's Transition: getting it right for young people.
Updates to this pathway
26 February 2013 Minor maintenance updates.
Supporting information
Glossary
Patient presents with symptoms of a respiratory tract infection
Patient presents with symptoms of a respiratory tract infection
Clinical assessment
Clinical assessment
Clinical assessment
At the first face-to-face contact in primary care, including walk-in centres and emergency departments, offer a clinical assessment, including:
- history (presenting symptoms, use of over-the-counter or self medication, previous medical history, relevant risk factors, relevant comorbidities)
- examination as needed to establish diagnosis.
For information about fever in children younger than 5 years, refer to the NICE clinical guideline on feverish illness in children.
Meningitis
If meningitis is suspected, see the NICE pathway on bacterial meningitis and meningococcal septicaemia.
Tuberculosis
If tuberculosis is suspected, see the NICE pathway on tuberculosis.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeAddress patients' or parents' and or carers' concerns and expectations
Address patients' or parents' and/or carers' concerns and expectations
Address patients' or parents' and/or carers' concerns and expectations
Address patients' or parents'/carers' concerns and expectations when agreeing the use of the three antibiotic strategies (no prescribing, delayed prescribing and immediate prescribing).
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodePatient with acute otitis media, acute sore throat/acute pharyngitis/acute tonsillitis, common cold, acute rhinosinusitis or acute cough/acute bronchitis
Patient with acute otitis media, acute sore throat/acute pharyngitis/acute tonsillitis, common cold, acute rhinosinusitis or acute cough/acute bronchitis
No antibiotic prescribing
No antibiotic prescribing
No antibiotic prescribing
Offer patients:
- reassurance that antibiotics are not needed immediately because they will make little difference to symptoms and may have side effects, for example, diarrhoea, vomiting and rash
- a clinical review if the RTI worsens or becomes prolonged.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeDelayed antibiotic prescribing
Delayed antibiotic prescribing
Delayed antibiotic prescribing
Offer patients:
- reassurance that antibiotics are not needed immediately because they will make little difference to symptoms and may have side effects, for example, diarrhoea, vomiting and rash
- advice about using the delayed prescription if symptoms do not settle or get significantly worse
- advice about re-consulting if symptoms get significantly worse despite using the delayed prescription.
The delayed prescription with instructions can either be given to the patient or collected at a later date.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeAlso consider immediate antibiotic prescribing depending on the severity of the RTI
Also consider immediate antibiotic prescribing depending on the severity of the RTI
No antibiotic, delayed antibiotic or immediate antibiotic
No antibiotic, delayed antibiotic or immediate antibiotic prescribing
No antibiotic, delayed antibiotic or immediate antibiotic prescribing
Depending on clinical assessment of severity, also consider an immediate prescribing strategy for:
- children younger than 2 years with bilateral acute otitis media
- children with otorrhoea who have acute otitis media
- patients with acute sore throat/acute pharyngitis/acute tonsillitis when three or more Centor criteria (presence of tonsillar exudate, tender anterior cervical lymphadenitis, history of fever and an absence of cough) are present.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodePatient at risk of developing complications
Patient at risk of developing complications
Immediate antibiotic prescribing or further investigation and or management
Immediate antibiotic prescribing or further investigation and/or management
Immediate antibiotic prescribing or further investigation and/or management
Offer immediate antibiotics or further investigation/management for patients who:
- are systemically very unwell
- have symptoms and signs suggestive of serious illness and/or complications (particularly pneumonia, mastoiditis, peritonsillar abscess, peritonsillar cellulitis, intraorbital or intracranial complications)
- are 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
- are older than 65 years with acute cough and two or more of the following, or older than 80 years with acute cough and one or more of the following:
- hospitalisation in previous year
- type 1 or type 2 diabetes
- history of congestive heart failure
- current use of oral glucocorticoids.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodePatient advice and information
Patient advice and information
Patient advice and information
Offer all patients:
- advice about the usual natural history of the illness and average total illness length:
- acute otitis media: 4 days
- acute sore throat/acute pharyngitis/acute tonsillitis: 1 week
- common cold: 1.5 weeks
- acute rhinosinusitis: 2.5 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 the NICE clinical guideline on feverish illness in children.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodePaths in this pathway
Pathway created: August 2012 Last updated: February 2013
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