Practice Guidelines

Antibiotic prescribing for self limiting respiratory tract infections in primary care: summary of NICE guidance

BMJ 2008; 337 doi: http://dx.doi.org/10.1136/bmj.a437 (Published 23 July 2008) Cite this as: BMJ 2008;337:a437
  1. Toni Tan, technical analyst1,
  2. Paul Little, professor of primary care research and general practitioner2,
  3. Tim Stokes, associate director1
  4. on behalf of the Guideline Development Group
  1. 1National Institute for Health and Clinical Excellence, Manchester M1 4BD
  2. 2School of Medicine, University of Southampton, Southampton SO17 1BJ
  1. Correspondence to: P Little p.little{at}soton.ac.uk

    Why read this summary?

    Antibiotics probably provide little benefit for a large proportion of respiratory tract infections that present in primary care. Respiratory tract infections are largely self limiting, and complications are likely to be rare if antibiotics are withheld. However, respiratory tract infections account for 60% of all antibiotic prescribing in primary care,1 and the prescribing patterns for antibiotics vary widely among general practices, without evidence of significant benefit among higher prescribers. Three different management strategies for antibiotics can be used for patients with respiratory tract infection who present in primary care: no antibiotic prescribing; delayed (or deferred) prescribing, in which a prescription is written for use at a later date if symptoms worsen or do not start to settle in the expected timescale; and immediate prescribing. This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) on antibiotic prescribing for self limiting respiratory tract infections in primary care.2

    Recommendations

    NICE recommendations are based on systematic reviews of best available evidence. When minimal evidence is available, recommendations are based on the Guideline Development Group’s opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets.

    Management strategies for antibiotics

    Adults and children (3 months or older) with acute otitis media; acute sore throat, acute pharyngitis, or acute tonsillitis; common cold; acute rhinosinusitis; acute cough or acute bronchitis

    • At the first face to face contact in primary care, offer a clinical assessment that includes a history (presenting symptoms, use of over the counter or self medication, medical history, relevant risk factors, relevant comorbidities) and, if indicated, an examination to identify relevant clinical signs. [Based on the experience of the Guideline Development Group]

    • Address the concerns and expectations of patients, parents, or carers when agreeing with them which of the three antibiotic prescribing strategies to use (no prescribing, delayed prescribing, or immediate prescribing). [Based on the experience of the Guideline Development Group]

    • A no prescribing strategy or a delayed prescribing strategy should be agreed for patients with the above five groups of respiratory tract infection. [Based on the experience of the Guideline Development Group and evidence from published Cochrane and other systematic reviews]

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

      • -Bilateral acute otitis media in children under 2 years

      • -Acute otitis media in children with otorrhoea

      • -Acute sore throat or acute tonsillitis when three or more Centor criteria are present (the Centor criteria are the presence of tonsillar exudate, tender anterior cervical lymphadenopathy or lymphadenitis, history of fever, and an absence of cough).3

    [Based on good quality, individual patient data meta-analysis and randomised controlled trials]

    For all three antibiotic management strategies

    • Advise patients on the usual course of the illness and the average total illness duration (acute otitis media: four days; acute sore throat, acute pharyngitis, or acute tonsillitis: one week; common cold: one and a half weeks; acute rhinosinusitis: two and a half weeks; acute cough or acute bronchitis: three weeks)

    • Advise patients how to manage symptoms, including fever (particularly analgesics and antipyretics). [Based on good quality randomised controlled trials] For information about fever in children younger than 5 years, refer to NICE’s clinical guideline on feverish illness in children.4

    For the no prescribing strategy

    • Reassure patients that antibiotics are not needed because they are likely to make little difference to symptoms and may have side effects

    • Offer a clinical review if the condition worsens or becomes prolonged.

    [Both these points are based on good quality randomised controlled trials]

    For the delayed prescribing strategy

    • Reassure patients that antibiotics are not needed immediately because they are likely to make little difference to symptoms and may have side effects

    • Advise patients on using the delayed prescription if symptoms are not starting to settle in accordance with the expected course of the illness or if symptoms worsen significantly

    • Advise patients to return for a consultation if symptoms worsen significantly despite use of the delayed prescription

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

    [Based on good quality randomised controlled trials]

    Patients with respiratory tract infections who are likely to be at risk of developing complications

    An immediate antibiotic prescription and/or further appropriate investigation and management should be offered to the following patients:

    • Those who are systemically very unwell [Based on the experience of the Guideline Development Group]

    • Those with symptoms and signs suggesting serious illness and/or complications (particularly pneumonia, mastoiditis, peritonsillar abscess, peritonsillar cellulitis, intraorbital and intracranial complications) [Based on the experience of the Guideline Development Group]

    • Those at high risk of serious complications because of pre-existing comorbidity (including patients with heart, lung, renal, liver, or neuromuscular disease, immunosuppression, or cystic fibrosis and young children who were born prematurely) [Based on the experience of the Guideline Development Group]

    • Those who are older than 65 years with acute cough and two or more of the following criteria, and those who are older than 80 years with one or more of the following criteria [Based on moderate quality evidence from observational studies]:

      • -Admission to hospital in the previous year

      • -Type 1 or type 2 diabetes

      • -History of congestive heart failure

      • -Current use of oral glucocorticoids.

    Overcoming barriers

    A key barrier to overcome is the clinician’s habitual prescribing practice and belief in the effectiveness of antibiotics—for example, almost all clinicians habitually prescribe for suspected rhinosinusitis, in contrast with the evidence, which suggests only very modest benefit. Other barriers are the expectations of both patients and clinicians: clinicians need to explain to patients that antibiotics are not necessary for a self limiting respiratory tract infection, and healthcare professionals often overestimate the need for antibiotics for such infection. Healthcare professionals need to address patients’ concerns, perspectives, and expectations about the treatment before negotiating the different antibiotic management strategies. This should encompass not only a careful assessment of any evidence of complications and risks of developing complications, but also provision of information on the natural course of the illness and advice on symptomatic management and careful “safety netting”—that is, advice about when patients should go back to their doctor if symptoms persist or worsen. NICE has developed tools to help organisations implement the guideline.2

    Further information on the guidance

    Background

    General practice consultation rates in England and Wales show that a quarter of the population visit their general practitioner because of a respiratory tract infection each year.5 The inappropriate prescribing of antibiotics for self limiting respiratory tract infection 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.6 This short clinical guideline aims to provide clear guidance on antibiotic management strategies for self limiting respiratory tract infections by giving evidence based recommendations.

    Methods

    This guideline was developed as a short clinical guideline. Short clinical guidelines tackle only part ofa care pathway and are intended to allow the rapid (9-11 month timescale) development of guidelines for areas of care for which the NHS requires urgent guidance. Short clinical guidelines are developed by the NICE technical team using the same methods as existing standard NICE guidelines developed by the National Collaborating Centres (www.nice.org.uk).

    As part of this process, the NICE technical team conducted a systematic search of the literature, assessed the quality of included studies, synthesised and presented the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The Guideline Development Group (comprising healthcare professionals and patient representatives) then discussed the evidence and drew up recommendations. A de novo health economic model was also developed to determine the cost effectiveness of a delayed prescribing strategy compared with an immediate prescribing strategy or a no prescribing strategy for the management of one of the respiratory tract infections covered in the guideline: acute sore throat. The decision to use sore throat as the basis of the economic analysis reflects the fact that sore throat has a high prevalence and that sufficient clinical evidence is available.

    NICE has produced three different versions of the short clinical guideline: a full version, a quick reference guide, and a version for patients and the public. All versions are available from the NICE website.2

    Further research
    • Which subgroups of adults and children with respiratory tract infections presenting in primary care are most likely to benefit from an immediate antibiotic prescribing strategy in terms of symptomatic management and prevention of complications?

    • What is the clinical effectiveness and cost effectiveness of a delayed prescribing strategy compared with a no prescribing strategy and an immediate prescribing strategy for acute sinusitis?

    • What is the clinical effectiveness and cost effectiveness of differing methods of delivering a delayed prescribing strategy in primary care for those presenting with respiratory tract infections?

    • What are the rates of prescription, dispensing, and complications in adults and children with respiratory tract infections when different delayed prescribing strategies or a no prescribing strategy is used? How does any potential difference in risk of developing complications affect the cost effectiveness of either strategy?

    • Which clinical features of children and adults presenting in primary care with respiratory tract infections are associated with the development of serious complications and need for admission to hospital?

    • Do patients’, parents’, and carers’ preferences on antibiotic management strategies (immediate prescribing, delayed prescribing, and no prescribing) for respiratory tract infections differ according to ethnicity and socioeconomic status?

    • How can we best assess the health related quality of life of people with respiratory tract infections, in particular when using generic measures such as the EuroQol-5D quality of life instrument? How can we best apply health related quality of life weights when investigating interventions for short term illnesses such as respiratory tract infections?

    Notes

    Cite this as: BMJ 2008;337:a437

    Footnotes

    • This is one of a series of BMJ summaries of new guidelines, which are based on the best available evidence; they highlight important recommendations for clinical practice, especially where uncertainty or controversy exists.

    • The Guideline Development Group comprised Nicky Coote, Anne Joshua, Paul Little (chair), Cliodna McNulty, Genine Riley, Mike Sharland, Cheryl Salmon, Matthew Thompson, and Mark Woodhead. The NICE Short Clinical Guideline Technical Team comprised Emma Banks, Janette Boynton, Michael Heath, Ruth McAllister, Francis Ruiz, Tim Stokes, and Toni Tan.

    • Contributors: TT drafted the summary, and PL and TS reviewed the content.

    • Funding: The Centre for Clinical Practice (Short Clinical Guidelines Technical Team), part of the National Institute for Health and Clinical Excellence, wrote this summary.

    • Competing interests: None declared.

    • Provenance and peer review: Commissioned; not externally peer reviewed.

    References