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Self-limiting respiratory tract infections - antibiotic prescribing

Short Text

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

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

Infection prevention and control

These quality statements are taken from the infection prevention and control quality standard. The quality standard defines clinical best practice for infection prevention and control and should be read in full.

Quality statements

Antimicrobial stewardship

This quality statement is taken from the infection prevention and control quality standard. The quality standard defines clinical best practice for infection prevention and control and should be read in full.

Quality statement

People are prescribed antibiotics in accordance with local antibiotic formularies as part of antimicrobial stewardship.

Rationale

Antibiotic resistance poses a significant threat to public health, particularly because antibiotics underpin routine medical practice in both primary and secondary care. To help prevent the development of current and future bacterial resistance, it is important to prescribe antibiotics according to the principles of antimicrobial stewardship, such as prescribing antibiotics only when they are needed (and not for self-limiting mild infections such as colds and most coughs, sinusitis, earache and sore throats) and reviewing the continued need for them. These principles should be set out within local antibiotic guidelines and pathways and be consistent with the local antibiotic formulary. Local antibiotic formularies should indicate a range of antibiotics for managing common infections, and permit use of other antibiotics only on the advice of the microbiologist or physician responsible for the control of infectious diseases.

Quality measures

Structure
a) Evidence of local antibiotic formularies governing the use of antibiotics to ensure that people are prescribed antibiotics appropriately.
Data source: Local data collection.
b) Evidence that local antibiotic formularies are reviewed regularly.
Data source: Local data collection.
c) Evidence of local audits of the appropriateness of antibiotic prescribing.
Data source: Local data collection.
Outcome
Antibiotic prescribing rates (primary and secondary care).
Data source for primary care: National prescribing comparator data available from the Information Services Portal hosted by the Health and Social Care Information Centre, specifically the number of prescription items for antibacterial drugs per Specific Therapeutic Group Age-sex weightings Related Prescribing Unit (STAR-PU), and the number of prescription items for cephalosporins and quinolones as a percentage of the total number of prescription items for selected antibacterial drugs (British National Formulary [BNF], section 5.1).
Data source for secondary care: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that they have antimicrobial stewardship initiatives in place, including local antibiotic formularies for antibiotic prescribing.
Healthcare professionals ensure that when they prescribe antibiotics they do so in accordance with local antibiotic formularies as part of antimicrobial stewardship.
Commissioners ensure that they commission services that have antimicrobial stewardship initiatives and in which people are prescribed antibiotics in accordance with local antibiotic formularies.

What the quality statement means for patients, service users and carers

People are offered antibiotics according to local guidance about which ones are most suitable. This includes not being offered antibiotics if they don't need them (for example, if they have a cold, a sore throat, most coughs or earache). This is to try to reduce the problem of antibiotic resistance, which is when an infection no longer responds to treatment with one or more types of antibiotic and so is more likely to spread and can become serious.

Source guidance

  • Respiratory tract infections – antibiotic prescribing (NICE clinical guideline 69), recommendations 1.3 and 1.4.
  • Expert consensus.

Definitions of terms used in this quality statement

Local antibiotic formulary
A local antibiotic formulary is a local policy document produced by a multi professional team, usually in a hospital trust or commissioning group, combining best evidence and clinical judgement. [Surgical site infection - full guideline (NICE clinical guideline 74)].
A local antibiotic formulary is defined as 'the output of processes to support the managed introduction, utilisation or withdrawal of healthcare treatments within a health economy, service or organisation. [Developing and updating local formularies (NICE medicines practice guideline 1)]
Local policies often limit the antibiotics that may be used to achieve reasonable economy consistent with adequate cover, and to reduce the development of resistant organisms. A policy may indicate a range of antibiotics for general use, and permit other antibiotics only on the advice of the medical microbiologist or physician responsible for the control of infectious diseases. [BNF, section 5.1]
Antimicrobial stewardship
Antimicrobial stewardship is an organisational or healthcare-system-wide approach to promoting and monitoring judicious use of antimicrobial drugs to preserve their future effectiveness. [Adapted from the Department of Health Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infection (ARHAI)'s antimicrobial prescribing and stewardship competencies]
The approach to prescribing in line with the principles of antimicrobial stewardship recommended for secondary care is as follows:
  • Do not start antibiotics without clinical evidence of bacterial infection.
  • If there is evidence or suspicion of bacterial infection, use local guidelines to start prompt, effective antibiotic treatment.
  • Document the following on the medicines chart and in the person's medical notes: clinical indication, duration or review date, route and dose.
  • Obtain cultures – knowing the susceptibility of an infecting organism can lead to narrowing of broad-spectrum therapy, changing therapy to effectively treat resistant pathogens, and stopping antibiotics when cultures suggest an infection is unlikely.
  • Prescribe single-dose antibiotics for surgical prophylaxis if antibiotics have been shown to be effective.
  • Review the clinical diagnosis and the continuing need for antibiotics by 48 hours from the first antibiotic dose and make a clear plan of action – the 'Antimicrobial Prescribing Decision'. The 5 Antimicrobial Prescribing Decision options are: Stop, Switch IV (intravenous) to Oral, Change, Continue, and Outpatient Parenteral Antibiotic Therapy (OPAT).
  • Clearly document the review and subsequent decision in the person's medical notes. [ARHAI's guidance on antimicrobial stewardship 'Start smart - then focus']
The approach to prescribing in line with the principles of antimicrobial stewardship recommended for primary care is as follows:
  • Prescribe an antibiotic only if there is likely to be a clear clinical benefit.
  • Consider a no, or delayed, antibiotic strategy for acute self-limiting upper respiratory tract infections.
  • Limit prescribing over the phone to exceptional cases.
  • Use simple generic antibiotics if possible. Avoid broad-spectrum antibiotics (for example, co-amoxiclav, quinolones and cephalosporins) if narrow-spectrum antibiotics remain effective, because the former increase the risk of Clostridium difficile, methicillin-resistant Staphylococcus aureus (MRSA) and antibiotic resistant urinary tract infections.
  • Avoid widespread use of topical antibiotics (especially those that are also available as systemic preparations, such as fusidic acid). [Adapted from the Health Protection Agency's management of infection guidance for primary care]

Organisational responsibility

This quality statement is taken from the infection prevention and control quality standard. The quality standard defines clinical best practice for infection prevention and control and should be read in full.

Quality statement

Organisations that provide healthcare have a strategy for continuous improvement in infection prevention and control, including accountable leadership, multi-agency working and the use of surveillance systems.

Rationale

It is essential that organisations and agencies work together to coordinate strategies for infection prevention and control across a local area. It is equally important to share information across organisations in order to meet responsibilities for establishing the current position on infection control, monitoring the impact of quality improvement initiatives and ongoing surveillance. Leadership underpins all infection prevention and control, and is vital to ensure that this remains a priority for the organisation as a whole and each person working within it.

Quality measures

Structure
a) Evidence that the organisation includes infection prevention and control within its overall strategy.
Data source: Local data collection.
b) Evidence that the organisation's board is up to date with, and has a working knowledge and understanding of, infection prevention and control.
Data source: Local data collection.
c) Evidence that a lead for infection prevention and control has been assigned and is taking an active role.
Data source: Local data collection.
d) Evidence of support for, and participation in, joint working initiatives beyond mandatory or contractual requirements, to reduce healthcare-associated infections locally.
Data source: Local data collection.
e) Evidence of an adequately resourced surveillance system with specific, locally defined objectives and priorities for preventing and managing healthcare-associated infections.
Data source: Local data collection.
Outcome
Incidence of healthcare-associated infection.
Data source: 2014/15 NHS Outcomes Framework indicator 5.2 and 2014/15 CCG Outcome Indicator Set indicators 5.3 and 5.4 measure incidence of methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile. Data are derived from the mandatory reporting of healthcare-associated infections to Public Health England, which are published by Public Health England and also reported by the Health and Social Care Information Centre through their Indicator Portal.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that a strategy is in place for continuous improvement in infection prevention and control that includes accountable leadership, multi-agency working and surveillance systems.
Healthcare professionals ensure that they implement strategies for continuous improvement in infection prevention and control through accountable leadership, multi-agency working and adhering to the requirements of surveillance systems.
Commissioners ensure that they commission services from organisations that have strategies for continuous improvement in infection prevention and control that include accountable leadership, multi-agency working and surveillance systems.

What the quality statement means for patients, service users and carers

People receive healthcare from organisations that aim to continually improve their approach to preventing infection (for example, by sharing information with other organisations and monitoring rates of infection).

Source guidance

  • Prevention and control of healthcare-associated infections: quality improvement guide (NICE public health guidance 36), quality improvement statements 1, 3 and 6.

Definitions of terms used in this quality statement

Board
A board is defined as a group of members with overall responsibility and accountability for the governance, safety and quality of an organisation. [Expert opinion]

Hand decontamination

This quality statement is taken from the infection prevention and control quality standard. The quality standard defines clinical best practice for infection prevention and control and should be read in full.

Quality statement

People receive healthcare from healthcare workers who decontaminate their hands immediately before and after every episode of direct contact or care.

Rationale

Effective hand decontamination, even after wearing gloves, results in significant reductions in the carriage of potential pathogens on the hands and decreases the incidence of preventable healthcare-associated infections, leading in turn to a reduction in morbidity and mortality. Hand decontamination is considered to have a high impact on outcomes that are important to patients. Although hand hygiene has improved over recent years, remaining misconceptions about this standard principle of infection control are reported and good practice is still not universal.

Quality measures

Structure
a) Evidence of local arrangements to ensure the availability of facilities for hand decontamination.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that all healthcare workers receive training in hand decontamination.
Data source: Local data collection.
c) Evidence of local arrangements to ensure that regular local hand hygiene observation audits are undertaken.
Data source: Local data collection.
Outcome
Incidence of healthcare-associated infection.
Data source: 2014/15 NHS Outcomes Framework indicator 5.2.

What the quality statement means for service providers, healthcare workers and commissioners

Service providers ensure that healthcare workers are trained in effective hand decontamination techniques, and that handrub and handwashing facilities are available so that healthcare workers can decontaminate their hands immediately before and after every episode of direct contact or care.
Healthcare workers ensure that they are trained in effective hand decontamination techniques, and that they decontaminate their hands immediately before and after every episode of direct contact or care, even when gloves have been worn.
Commissioners ensure that they commission services in which healthcare workers are trained in effective hand decontamination techniques and decontaminate their hands immediately before and after every episode of direct contact or care, and that hand hygiene observation audits are carried out regularly.

What the quality statement means for patients, service users and carers

People receiving healthcare are looked after by healthcare workers who always clean their hands thoroughly (using handrub or soap and water), both immediately before and immediately after coming into contact with the person or carrying out care.

Source guidance

Definitions of terms used in this quality statement

Hand decontamination
Hand decontamination is the use of handrub or handwashing to reduce the number of bacteria on the hands. The term is often interchangeable with 'hand hygiene'.
An alcohol-based handrub should be used for hand decontamination before and after direct contact or care, except in the following situations when soap and water must be used:
  • when hands are visibly soiled or potentially contaminated with body fluids or
  • when caring for patients with vomiting or diarrhoeal illness, regardless of whether or not gloves have been worn.
Direct contact or care
Direct contact or care refers to 'hands on' or face-to-face contact with patients. This encompasses any physical aspect of the healthcare of a patient, including treatments, self-care and administration of medication. [NICE clinical guideline 139]

Urinary catheters

This quality statement is taken from the infection prevention and control quality standard. The quality standard defines clinical best practice for infection prevention and control and should be read in full.

Quality statement

People who need a urinary catheter have their risk of infection minimised by the completion of specified procedures necessary for the safe insertion and maintenance of the catheter and its removal as soon as it is no longer needed.

Rationale

Catheter-associated urinary tract infections comprise a large proportion of healthcare-associated infections, and can occur whether a person has either a short-term or a long-term catheter. There is a strong association between duration of urinary catheterisation and risk of infection, and catheters are sometimes inserted inappropriately or there is a delay in removing them. This risk is greatly reduced by complying with all parts of the process for safe catheter insertion, maintenance and removal as soon as it is no longer needed. This is important in terms of both infection prevention and patient comfort and experience.

Quality measures

Structure
Evidence of a written protocol to ensure that people who need a urinary catheter have their risk of infection minimised by the completion of specified procedures necessary for the safe insertion and maintenance of the catheter and its removal as soon as it is no longer needed.
Data source: Local data collection.
Process
a) Proportion of people with a short-term urinary catheter who had their risk of infection minimised by the completion of specified procedures necessary for the safe insertion and maintenance of the catheter and its removal as soon as it is no longer needed.
Numerator – the number of people in the denominator for whom all of the specified procedures were completed for the safe insertion and maintenance of the catheter and its removal as soon as it is no longer needed.
Denominator – the number of people who have had a short-term urinary catheter.
Data source: Local data collection.
b) Proportion of people with a long-term urinary catheter who had their risk of infection minimised by the completion of specified procedures necessary for the safe insertion and maintenance of the catheter and its removal as soon as it is no longer needed.
Numerator – the number of people in the denominator for whom all of the specified procedures were completed for the safe insertion and maintenance of the catheter and its removal as soon as it is no longer needed were completed.
Denominator – the number of people who have had a long-term urinary catheter.
Data source: Local data collection. Audit standards on catheter maintenance are contained in NICE clinical guideline 139 clinical audit tool - catheter maintenance.
Outcome
a) Incidence of healthcare-associated infection.
Data source: 2014/15 NHS Outcomes Framework indicator 5.2 and 2014/15 CCG Outcome Indicator Set indicators 5.3 and 5.4 measure incidence of methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile. Data are derived from the mandatory reporting of healthcare-associated infections to Public Health England, which are published by Public Health England and also reported by the Health and Social Care Information Centre through their Indicator Portal.
b) Incidence of catheter-associated urinary tract infection.
Data source: Local data collection. Health and Social Care Information Centre NHS safety thermometer.

What the quality statement means for service providers, healthcare workers and commissioners

Service providers ensure that systems and facilities are in place to enable staff to complete specified procedures necessary for the safe insertion and maintenance of the catheter and its removal as soon as it is no longer needed, in order to minimise the risk of infection.
Healthcare workers ensure that they complete specified procedures necessary for the safe insertion and maintenance of the catheter and its removal as soon as it is no longer needed, in order to minimise the risk of infection.
Commissioners ensure that they commission services in which specified procedures necessary for the safe insertion and maintenance of the catheter and its removal as soon as it is no longer needed are completed, in order to minimise the risk of infection.

What the quality statement means for patients, service users and carers

People who need a urinary catheter have their risk of infection minimised by healthcare workers carrying out procedures to make sure that the catheter is inserted, looked after and removed correctly and safely. These procedures include things like cleaning hands, using a lubricant when inserting the catheter, emptying the drainage bag when necessary, and removing the catheter as soon as it is no longer needed. A urinary catheter is a thin flexible tube used to drain urine from the bladder.

Source guidance

Definitions of terms used in this quality statement

Urinary catheter
A urinary catheter is a catheter that is inserted in the urethra and remains in place until it is no longer needed. Both short-term (used for 28 days or less) and long-term (used for more than 28 days) urinary catheters are used. [Adapted from NICE clinical guideline 139 - full version and epic3: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England]
Specified procedures necessary for the safe insertion, maintenance and appropriate removal of urinary catheters
Assessing the need for catheterisation
  • Catheterisation should be used only after considering alternative methods of management. The person's clinical need for catheterisation should be reviewed regularly and the urinary catheter removed as soon as possible. The need for catheterisation, as well as details about insertion, changes and care should be documented.
Hand hygiene
  • Healthcare workers must decontaminate their hands and wear a new pair of clean, non-sterile gloves before manipulating a person's catheter, and must decontaminate their hands after removing gloves.
Catheter insertion
  • The meatus should be cleaned before the catheter is inserted, in accordance with local guidelines or policy (for example, with sterile normal saline).
  • An appropriate lubricant from a single-use container should be used during catheter insertion to minimise urethral trauma and infection.
Catheter maintenance
  • Indwelling catheters should be connected to a sterile closed urinary drainage system or catheter valve. Healthcare workers should ensure that the connection between the catheter and the urinary drainage system is not broken, except for good clinical reasons (for example, changing the bag in line with the manufacturer's recommendations).
  • Urinary drainage bags should be positioned below the level of the bladder, and should not be in contact with the floor. The urinary drainage bag should be emptied frequently enough to maintain urine flow and prevent reflux, and should be changed when clinically indicated. A separate and clean container should be used for each person. Contact between the urinary drainage tap and container should be avoided.
  • Urine samples must be obtained from a sampling port using an aseptic technique.
  • The meatus should be washed daily with soap and water as part of routine daily personal hygiene.

Vascular access devices

This quality statement is taken from the infection prevention and control quality standard. The quality standard defines clinical best practice for infection prevention and control and should be read in full.

Quality statement

People who need a vascular access device have their risk of infection minimised by the completion of specified procedures necessary for the safe insertion and maintenance of the device and its removal as soon as it is no longer needed.

Rationale

Vascular access devices are one of the main causes of healthcare-associated infections, and bloodstream infections associated with central venous device insertion are a major cause of morbidity. The risk of infection is greatly reduced by complying with all parts of the process for safe insertion and maintenance of the device and its removal as soon as it is no longer needed.

Quality measures

Structure
Evidence of a written protocol to ensure that people who need a vascular access device have their risk of infection minimised by the completion of specified procedures necessary for the safe insertion and maintenance of the device and its removal as soon as it is no longer needed.
Data source: Local data collection.
Process
Proportion of people with a vascular access device who had their risk of infection minimised by the completion of specified procedures necessary for the safe insertion and maintenance of the device and its removal as soon as it is no longer needed.
Numerator – the number of people in the denominator for whom all of the specified procedures were completed for the safe insertion and maintenance of the device and its removal as soon as it is no longer needed.
Denominator – the number of people who have had a vascular access device.
Data source: Local data collection. Contained in NICE clinical guideline 139 clinical audit tool - vascular access devices.
Outcome
Incidence of vascular access device-related bloodstream infection.
Data source: Local data collection.

What the quality statement means for service providers, healthcare workers and commissioners

Service providers ensure that systems and facilities are in place to enable staff to complete specified procedures necessary for the safe insertion and maintenance of the vascular access device and its removal as soon as it is no longer needed, in order to minimise risk of infection.
Healthcare workers ensure that they complete specified procedures necessary for the safe insertion and maintenance of the vascular access device and its removal as soon as it is no longer needed, in order to minimise the risk of infection.
Commissioners ensure that they commission services in which specified procedures necessary for the safe insertion and maintenance of the vascular access device and its removal as soon as it is no longer needed are completed, in order to minimise the risk of infection.

What the quality statement means for patients, service users and carers

People who need a vascular access device have their risk of infection minimised by healthcare workers carrying out procedures to make sure that the device is inserted, looked after and removed correctly and safely. These procedures include things like using sterile procedures when inserting the device, using the correct antiseptics and dressings, and removing the device as soon as it is no longer needed. A vascular access device is a tube that is inserted into a main vein or artery and used to administer fluids and medication, monitor blood pressure and collect blood samples.

Source guidance

Definitions of terms used in this quality statement

Vascular access device
A vascular access device is an indwelling catheter, cannula or other instrument used to obtain venous or arterial access. Both central and peripheral vascular access devices are available.
Specified procedures necessary for the safe insertion, maintenance and appropriate removal of vascular access devices
General asepsis
  • Healthcare workers must decontaminate their hands before accessing or dressing a vascular access device, using an alcohol handrub or by washing with liquid soap and water if hands are contaminated. An aseptic technique must be used for vascular access device catheter site care, when accessing the system and when administrating intravenous medication.
Skin decontamination
  • The skin should be decontaminated at the insertion site with 2% chlorhexidine gluconate in 70% alcohol and allowed to dry before inserting a vascular access device.
Vascular access device site care
  • A sterile transparent semipermeable membrane dressing should be used to cover the vascular access device insertion site. This should be changed every 7 days, or sooner if it is no longer intact or if moisture collects under the dressing.
  • A single-use application of 2% chlorhexidine gluconate in 70% alcohol (or aqueous povidone iodine) should be used and allowed to dry when cleaning the insertion site during dressing changes.
Vascular access device management
  • A single-use application of 2% chlorhexidine gluconate in 70% alcohol (or aqueous povidone iodine) should be used to decontaminate the access port or catheter hub. The hub should be cleaned for 15 seconds and allowed to dry before accessing the system.
  • Preferably, a sterile 0.9% sodium chloride injection should be used to flush and lock catheter lumens.
  • Administration sets for blood and blood components should be changed when the transfusion episode is complete or every 12 hours (whichever is sooner), or according to the manufacturer's recommendations. Administration sets used for total parenteral nutrition infusions should generally be changed every 24 hours. If the solution contains only glucose and amino acids, administration sets in continuous use do not need to be replaced more frequently than every 72 hours.
Review of vascular access devices
  • Peripheral vascular catheter insertion sites should be inspected during every shift at a minimum, and a visual phlebitis score should be recorded.
  • Central venous catheter insertion sites should be inspected daily.

Educating people about infection prevention and control

This quality statement is taken from the infection prevention and control quality standard. The quality standard defines clinical best practice for infection prevention and control and should be read in full.

Quality statement

People with a urinary catheter, vascular access device or enteral feeding tube, and their family members or carers (as appropriate), are educated about the safe management of the device or equipment, including techniques to prevent infection.

Rationale

Because many people with a urinary catheter, vascular access device or enteral feeding tube manage their own device or equipment, it is important that they and their family members or carers are confident about, and proficient in, infection prevention and control practices and the safe management of the device or equipment.

Quality measures

Structure
Evidence of local arrangements for people with a urinary catheter, vascular access device or enteral feeding tube, and their family members or carers (as appropriate), to be educated about the safe management of their device or equipment, including techniques to prevent infection.
Data source: Local data collection.
Process
Proportion of people with a urinary catheter, vascular access device or enteral feeding tube, and their family members or carers (as appropriate), who are educated about the safe management of their device or equipment, including techniques to prevent infection.
Numerator – the number of people in the denominator who are educated about the safe management of their device or equipment, including techniques to prevent infection.
Denominator – the number of people with a urinary catheter, vascular access device or enteral feeding tube, and their family members or carers (as appropriate).
Data source: Local data collection.
Outcome
a) Incidence of healthcare-associated infection.
Data source: 2014/15 NHS Outcomes Framework indicator 5.2 and 2014/15 CCG Outcome Indicator Set indicators 5.3 and 5.4 measure incidence of methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile. Data are derived from the mandatory reporting of healthcare-associated infections to Public Health England, which are published by Public Health England and also reported by the Health and Social Care Information Centre through their Indicator Portal.
b) People with a urinary catheter, vascular access device or enteral feeding tube, and their family members or carers (as appropriate), feel able to manage their device or equipment.
Data source: Local data collection using a patient survey to demonstrate that patients and carers have understood their education.

What the quality statement means for service providers, healthcare workers and commissioners

Service providers ensure that there are systems in place for people with a urinary catheter, vascular access device or enteral feeding tube, and their family members or carers (as appropriate), to be educated about the safe management of the device or equipment, including techniques to prevent infection.
Healthcare workers ensure that they educate people with a urinary catheter, vascular access device or enteral feeding tube, and their family members or carers (as appropriate), about the safe management of the device or equipment, including techniques to prevent infection.
Commissioners ensure that they commission services in which people with a urinary catheter, vascular access device or enteral feeding tube, and their family members or carers (as appropriate), are educated about the safe management of the device or equipment, including techniques to prevent infection.

What the quality statement means for patients, service users and carers

People who have a urinary catheter, a vascular access device or an enteral feeding tube, and any family members or carers who help them with this equipment, are given information and advice about how to look after the equipment safely and effectively. This includes advice about how to prevent infection. Enteral feeding is a type of feeding used for people who cannot eat normally in which liquid food is given through a tube directly into the gut.

Source guidance

Definitions of terms used in this quality statement

Urinary catheter
A urinary catheter is a catheter that is inserted in the urethra and remains in place until it is no longer needed. Both short-term (used for 28 days or less) and long-term (used for more than 28 days) urinary catheters are used. [Adapted from NICE clinical guideline 139 - full version and epic3: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England]
Vascular access device
A vascular access device is an indwelling catheter, cannula or other instrument used to obtain venous or arterial access. Both central and peripheral vascular access devices are available.
Enteral feeding
Enteral feeding is feeding via a tube that can include any method of providing nutrition via the gastrointestinal tract. [NICE clinical guideline 139 - full guideline]
Education about infection prevention and control
Education for people and their carers about infection prevention and control should always cover the techniques of hand decontamination. In addition education should be provided as follows:

Equality and diversity considerations

People with a cognitive impairment or a lack of mobility may need additional support to undertake hand decontamination and other techniques to prevent infection. Language barriers should not be a reason for not providing advice.
If religious beliefs are a source of concern in relation to the use of alcohol handrubs for hand decontamination, people could be made aware of the official views of religious bodies about the products. If information is available, people should be directed to these sources.

Effective interventions library

Successful effective interventions library details

Implementation

Commissioning

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.

Education and learning

NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.

Service improvement and audit

These resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.

Pathway information

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on:

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 the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, 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.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Updates to this pathway

16 April 2014 The infection prevention and control quality standard has been added 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

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Address 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

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Patient 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

Patient with acute otitis media, acute sore throat/acute pharyngitis/acute tonsillitis, common cold, acute rhinosinusitis or acute cough/acute bronchitis

The Infection control quality standard contains a quality statement about antibiotic prescribing.

Quality standards

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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.

Quality standards

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Source guidance

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Delayed 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.

Quality standards

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Source guidance

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Also 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.

Quality standards

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Source guidance

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Patient 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

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Patient 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

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Paths in this pathway

Pathway created: August 2012 Last updated: April 2014

Copyright © 2014 National Institute for Health and Care Excellence. All Rights Reserved.

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