Respiratory tract infections antibiotic prescribing Implementing NICE guidance

Respiratory tract infections antibiotic prescribing Implementing NICE guidance 2008 NICE clinical guideline 69

What this presentation covers Background Recommendations Costs and savings Discussion Find out more

Background RTIs are the commonest acute problem dealt with in primary care Most people with RTIs are inappropriately prescribed antibiotics The guideline covers best practice advice on the care of adults and children (3 months and older) with RTIs, for whom immediate antibiotic prescribing is not indicated

Recommendations : Offer a clinical assessment At first face-to-face contact in primary care, patients presenting with a history suggestive of the following should be offered a clinical assessment: - Acute otitis media - Acute sore throat/acute pharyngitis/acute tonsillitis - Common cold - Acute rhinosinusitis - Acute cough/acute bronchitis

Recommendations : Agree an antibiotic prescribing strategy with the patient 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)

Recommendations : Give advice For all antibiotic prescribing strategies, patients should be given: • Advice about the usual natural history of the illness • Advice about managing symptoms, including fever

Recommendations : Antibiotic prescribing options - 1 A no antibiotic prescribing strategy or a delayed antibiotic prescribing strategy should be agreed for most patients with the following conditions: • Acute otitis media • Acute sore throat/acute pharyngitis/acute tonsillitis • Common cold • Acute rhinosinusitis • Acute cough/acute bronchitis

Recommendations : Antibiotic prescribing options - 2 Depending on clinical assessment of severity, patients in the following subgroups can also be considered for immediate antibiotics: • 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 are present

Recommendations : When no antibiotic prescribing is agreed Offer patients: • Reassurance that antibiotics are not needed immediately • A clinical review if the condition worsens or becomes prolonged

Recommendations : When delayed antibiotic prescribing is agreed Offer patients: • Reassurance that antibiotics are not needed immediately • Advice about using the delayed prescription if symptoms are not starting to settle in accordance with the expected course of the illness • Advice about re-consulting if there is a significant worsening of symptoms despite using the prescription

Recommendations : Consider immediate antibiotic prescribing for patients at risk of developing complications (1) Immediate antibiotic prescribing and/or further investigation/management should only be offered to adults and children in the following situations: • If the patient is systemically very unwell • If the patient has symptoms and signs of serious illness and/or complications • If the patient is at high risk of serious complications because of pre-existing comorbidity

Recommendations : Consider immediate antibiotic prescribing for patients at risk of developing complications (2) • If the patient is older than 65 with acute cough and two or more of the following or older than 80 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

Costs and savings per 100, 000 population Recommendations with significant savings Savings (£ per year) A no or a delayed antibiotic prescribing strategy should be agreed for patients with the following conditions: acute otitis media, acute cough/acute bronchitis, acute sore throat/acute pharyngitis/acute tonsillitis, acute rhinosinusitis and common cold – 4, 200 Estimated saving of implementation – 4, 200

Costs and savings The guideline on respiratory tract infections in primary care - antibiotic prescribing is unlikely to result in a significant change in resource use in the NHS

For discussion How does the rate of antibiotic prescribing for RTIs in your practice/PCT compare with the PCT/national average? How could the delayed prescribing strategy be implemented in your surgery/PCT? What methods/tools could be used to help patients take a greater role in self-managing their uncomplicated RTIs? How can we use the NICE Audit Support document to assess local implementation?

Find out more Visit www. nice. org. uk/CG 069 for: • Other guideline formats • Costing report and template • Audit support