The clinical effectiveness and cost effectiveness of antibiotic management strategies for respiratory tract infections (RTIs)

1.1.1.

At the first face-to-face contact in primary care, including walk-in centres and emergency departments, adults and children (3 months and older) presenting with a history suggestive of the following conditions should be offered a clinical assessment.

• acute otitis media
• acute sore throat/acute pharyngitis/acute tonsillitis
• common cold
• acute rhinosinusitis
• acute cough/acute bronchitis.

The clinical assessment should include a history (presenting symptoms, use of over-the-counter or self medication, previous medical history, relevant risk factors, relevant comorbidities) and, if indicated, an examination to identify relevant clinical signs.

1.1.2.

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).

1.1.3.

A no antibiotic prescribing strategy or a delayed antibiotic prescribing strategy should be agreed for patients with the following conditions:

• acute otitis media
• acute sore throat/acute pharyngitis/acute tonsillitis
• common cold
• acute rhinosinusitis
• acute cough/acute bronchitis.

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

• bilateral acute otitis media in children younger than 2 years
• acute otitis media in children with otorrhoea
• acute sore throat/acute pharyngitis/acute tonsillitis when three or more Centor criteria¹ are present.

1.1.4.

For all antibiotic prescribing strategies, patients should be given:

• advice about the usual natural history of the illness, including the average total length of the illness (before and after seeing the doctor):

  –acute otitis media: 4 days

  –acute sore throat/acute pharyngitis/acute tonsillitis: 1 week

  –common cold: 1½ weeks

  –acute rhinosinusitis: 2½ 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 ‘Feverish illness in children’ (NICE clinical guideline 47).

1.1.5.

When the no antibiotic prescribing strategy is adopted, patients should be offered:

• reassurance that antibiotics are not needed immediately because they are likely to make little difference to symptoms and may have side effects, for example, diarrhoea, vomiting and rash
• a clinical review if the condition worsens or becomes prolonged.

1.1.6.

When the delayed antibiotic prescribing strategy is adopted, patients should be offered:

• reassurance that antibiotics are not needed immediately because they are likely to make little difference to symptoms and may have side effects, for example, vomiting and rash
• advice about using the delayed prescription if symptoms are not starting to settle in accordance with the expected course of the illness or if a significant worsening of symptoms occurs
• advice about re-consulting if there is a significant worsening of symptoms despite using the delayed prescription.

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.

Click here to continue reading.