Managing respiratory tract infections

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Managing respiratory tract infections
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Setting the scene NICE. 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

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So what are we saying now?

• Its NOT about not prescribing antibiotics.
  Antibiotics are life saving in some circumstances
  and often reduce significant morbidity. Its
  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

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Harms of antibioticssee Common Infections
introduction for further details

• Antibiotics may benefit some people
• But we cant predict who will benefit and who
  will suffer harm
• Adverse effects
• Diarrhoea, vomiting or rash NNH16
• 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

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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

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But for most people antibiotics are unnecessary
NICE. 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

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But dont antibiotics prevent complications?
Petersen I, et al. BMJ 2007335982
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, NNT39 to prevent one case of pneumonia
  after chest infection in people aged 65 years and
  older

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Offer the patient reassurance and a safety net
NICE. 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)

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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)

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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

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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 lt3 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

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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

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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

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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

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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
• Dont 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