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Implementing NICE guidance should reduce inappropriate prescribing of antibiotics in primary care
Action – Clinicians should seek to reach agreement with patients to defer from prescribing antibiotics immediately for most people who present with ear infections, sore throats, sinusitis, coughs and colds.
Immediate prescribing of antibiotics and/or further appropriate investigation and management should only be offered to patients (both adults and children) if the patient is systemically very unwell, if the patient has symptoms and signs suggestive of serious illness and/or complications (particularly pneumonia, mastoiditis, peritonsillar abscess, peritonsillar cellulitis, intraorbital and intracranial complications), if the patient is at high risk of serious complications because of pre-existing comorbidity, and if the patient 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: hospitalisation in the previous year, type 1 or type 2 diabetes; a history of congestive heart failure; current use of corticosteroids.
All patients should be offered advice about the natural history of the disease, how long it is likely to last, and how to manage symptoms.
Prescribers should familiarise themselves with and follow the NICE guidance.
What is the background to this? – After a fall in antibiotic use in the late 1990s, antibiotic prescribing in primary care in England is now increasing and population usage is considerably higher than other northern European countries. Most people presenting in primary care with an acute uncomplicated respiratory tract infection will still receive an antibiotic prescription – with many doctors and patients believing that this is the right thing to do. In most cases, antibiotics are unnecessary as the conditions are self limiting, yet they expose the patient to undesirable side effects. Symptom resolution may be falsely attributed to the taking of antibiotics, and lead to expectation of further antibiotic prescribing for similar situations in the future. Antibiotic resistance rates are a major public concern, and strongly related to antibiotic use in primary care. Therefore, it is important that we are more judicious in the use of antibiotics and only use them where there is clear evidence of benefit [NICE guideline].
The MeReC Bulletin on the management of common infections and the Common Infections (Respiratory Tract) Floor of NPCi provides additional information on the background and evidence for the use of antibiotics, and when they are appropriate to prescribe for respiratory infections in primary care.
What does the guideline recommend?
- The guideline applies to adults and children (older than three months)
- Following clinical assessment, a no antibiotic prescribing strategy or a delayed antibiotic prescribing strategy should be agreed for patients with acute otitis media; acute sore throat/acute pharyngitis/acute tonsillitis; common cold; acute rhinosinusitis or acute cough/acute bronchitis.
- All patients, regardless of the antibiotic prescribing strategy, 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
and advice about managing symptoms, including fever (particularly analgesics and antipyretics).
- 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 (e.g. diarrhoea, vomiting and rash), and a clinical review if the condition worsens or becomes prolonged.
- 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, and 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 should also be given about re-consulting if there is a significant worsening of symptoms despite using the delayed prescription.
- Immediate prescribing of antibiotics and/or further appropriate investigation and management should only be offered to patients (both adults and children) in the following situations:
- if the patient is systemically very unwell
- if the patient has symptoms and signs suggestive of serious illness and/or complications (particularly pneumonia, mastoiditis, peritonsillar abscess, peritonsillar cellulitis, intraorbital and intracranial complications)
- if the patient is 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
- if the patient 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: hospitalisation in the previous year, type 1 or type 2 diabetes; a history of congestive heart failure; current use of corticosteroids.
- 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 (tonsillar exudate, tender anterior cervical lymphadenopathy or lymphadenitis, history of fever and an absence of cough) are present.
The quick reference guide which contains a one-page care pathway for respiratory tract infections can be downloaded from the NICE website.
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