Managing respiratory tract infections

1. Managing respiratory tract infections

2. Setting the sceneNICE. Respiratory tract infections. CG69. July 2008 Respiratory tract infections (RTIs) are the most common acute problem in primary care settings - the ‘bread and butter’ of general practice Historically, management of RTIs involved prompt antibiotic treatment Appropriate in an era of high complication rates However, these are now much lower in developed countries No evidence that complication rates are higher in countries with low antibiotic prescribing rates Therefore historical practice may now be inappropriate

3. So what are we saying now? It’s NOT about not prescribing antibiotics. Antibiotics are life saving in some circumstances and often reduce significant morbidity. It’s about the better TARGETING of antibiotics To people who are inherently more likely to have a serious bacterial infection, or to develop a complication from a less serious infection To people who are not inherently at risk but who have symptoms and signs indicating a more serious infection despite their low risk BUT WE MUST REMEMBER THAT Infectious disease remains a major threat to global health Antibiotic resistance presents an alarming threat to public health We all have a part to play – through better targeting of antibiotic prescribing we can protect their benefits for future generations

4. Harms of antibioticssee Common Infections introduction for further details Antibiotics may benefit some people But we can’t predict who will benefit and who will suffer harm Adverse effects Diarrhoea, vomiting or rash: NNH=16 Resistance increases with antibiotic exposure Both in the individual and in the population In an individual the benefits must be carefully weighed against the risks

5. What does NICE say?NICE. Respiratory tract infections. CG69. July 2008 • An immediate antibiotic prescription and/or further appropriate investigation and/or management should only be offered if the patient: • Is systemically unwell • Has symptoms and signs suggestive of serious illness and/or complications (particularly pneumonia, mastoiditis, peritonsillar abscess, peritonsillar cellulitis, intraorbital and intracranial complications) • Is at high risk of serious complications because of pre-existing comorbidity (eg heart, lung, renal, liver or neuromuscular disease, immunosuppression, cystic fibrosis, and young children who were born prematurely) • 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

6. …But for most people antibiotics are unnecessaryNICE. Respiratory tract infections. CG69. July 2008 • Adults and children aged over 3 months presenting with the following conditions should be offered a clinical assessment, including a history and, if indicated, an examination to identify relevant clinical signs: • Acute otitis media • Acute cough/acute bronchitis • Acute sore throat • Acute rhinosinusitis • Common cold • A no-antibiotic or a delayed-antibiotic prescribing strategy should be agreed for patients with these conditions • Patients’ concerns and expectations should be determined and addressed

7. But don’t antibiotics prevent complications?Petersen I, et al. BMJ 2007;335:982; www.npci.org.uk/blog • Serious complications are rare after upper RTIs, sore throat and otitis media • Primary care prescribers should not base their prescribing for these on a fear of serious complications • More than 4000 people would have to be treated to prevent one case of quinsy, mastoiditis or pneumonia • However, NNT=39 to prevent one case of pneumonia after chest infection in people aged 65 years and older

8. Offer the patient reassurance and a safety netNICE. Respiratory tract infections. CG69. July 2008 If no-antibiotics are prescribed, patients should be offered: • Reassurance that antibiotics are not needed immediately because they are likely to make little difference to symptoms and can have side-effects • A clinical review if the condition worsens or becomes prolonged If a delayed-antibiotic strategy is used, patients should also be offered: • Advice about using the delayed prescription if symptoms are not starting to settle in accordance with the expected course of illness or if a significant worsening of symptoms occurs (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)

9. Patient information and advice NICE. Respiratory tract infections. CG69. July 2008 All patients should be given: Advice about the usual natural history of the illness, including the average total length of the illness Acute otitis media: 4 days Acute sore throat / pharyngitis/tonsillitis: 1 week Common cold: 1½ weeks Acute rhinosinusitis: 2½ weeks Acute cough / bronchitis: 3 weeks Advice regarding management of symptoms including fever (particularly analgesics and antipyretics) For children under 5 years see ‘NICE Feverish illness in children’ (NICE CG47)

10. Common coldNICE. Respiratory tract infections. CG69. July 2008 • An immediate antibiotic should be offered in patients: • Who are systemically unwell • With symptoms and signs suggestive of serious illness and/or complications • At high risk of serious complications because of pre-existing comorbidity • As antibiotics have no beneficial effect on the common cold which it is a self-limiting condition, a no-antibiotic or a delayed-antibiotic prescribing strategy should be agreed for most patients • Offer the patient reassurance and a safety net • Explaining that a cold will resolve without treatment, in around 1½ weeks, and providing advice on symptomatic therapy, particularly analgesics and antipyretics, may reassure patients and prevent future consultations

11. Sore throatNICE. Respiratory tract infections. CG69. July 2008 • Antibiotics are unnecessary for most patients with sore throat • An immediate antibiotic prescription should be offered to those: • Who appear unwell with symptoms and signs suggestive of peritonsillar abscess (quinsy) • Who are systemically very unwell or at high risk of serious complications because of pre-existing comorbidity • Depending on clinical assessment of severity, patients can also be considered for an immediate antibiotic prescribing strategy when 3 or more Centor criteria are present • Score 1 each for: history of fever, absence of cough, swollen tender anterior cervical lymph nodes and tonsillar exudate • Score: if 0 then <3% chance of Streptococcal infection (GABHS) If 3 or 4 approx 40% chance of Streptococcal infection (GABHS) • A no-antibiotic or a delayed-antibiotic prescribing strategy should be agreed in most patients • Offer the patient reassurance and a safety net • Offer advice, reassurance that sore throat lasts, on average, 1 week, and analgesics for symptom relief

12. Acute otitis mediaNICE. Respiratory tract infections. CG69. July 2008 • Antibiotics should not be prescribed routinely for AOM. They reduce pain to a small degree but this should be balanced against the risk of causing adverse effects • An immediate antibiotic prescription should be offered to those: • Who appear unwell with symptoms and signs suggestive of mastoiditis • Who are systemically very unwell or at high risk of serious complications because of pre-existing comorbidity • Depending on clinical assessment of severity, an immediate prescribing strategy may be considered for: • Children younger than 2 years with bilateral acute otitis media • Children with acute otitis media and otorrhoea • A no-antibiotic or a delayed-antibiotic prescribing strategy should be agreed in most patients • Offer the patient reassurance and a safety net • Offer advice, reassurance that AOM lasts, on average, 4 days, and analgesics for symptom relief • Paracetamol and ibuprofen have been shown to reduce earache

13. Sinusitis NICE. Respiratory tract infections. CG69. July 2008 • Antibiotics should not be prescribed routinely • An immediate antibiotic should be offered in patients: • Who are systemically unwell • With symptoms and signs suggestive of serious illness and/or complications e.g. intraorbital and intracranial complications • At high risk of serious complications because of pre-existing comorbidity • A no-antibiotic or a delayed-antibiotic prescribing strategy should be agreed in most patients • Offer the patient reassurance and a safety net • Offer advice, reassurance that sinusitis lasts, on average, 2½ weeks, and analgesics for symptom relief

14. Acute bronchitisNICE. Respiratory tract infections. CG69. July 2008 • Antibiotic treatment is not indicated for the majority of otherwise well patients with acute bronchitis • An immediate antibiotic prescription should be offered to those: • Who appear unwell with symptoms and signs suggestive of pneumonia • Who are systemically very unwell or at high risk of serious complications because of pre-existing comorbidity • 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 • A no-antibiotic or a delayed-antibiotic prescribing strategy should be agreed in most patients • Offer the patient reassurance and a safety net • Offer advice, reassurance that acute bronchitis lasts, on average, 3 weeks, and analgesics for symptom relief • There is insufficient evidence to support the use of over-the-counter cough medicines • Patient information leaflets can prevent re-consultation

15. Summary • The rationale for routine antibiotic prescribing for common RTIs is now very weak • Over 4000 people need to be treated in order to prevent 1 serious complication • Therefore prescribers should not base their routine management strategies around the risk of complications • Don’t prescribe immediate antibiotics for RTIs unless other risk factors are present • Consider use of delayed or no-antibiotic strategies • Always offer information, advice and reassurance • Offer a safety net