National Institute for Health and Clinical Excellence (NICE)
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NICE short clinical guideline published on antibiotic prescribing for respiratory tract infections

The National Institute for Health and Clinical Excellence (NICE) has today (23 July 2008) published a short clinical guideline on appropriate prescribing of antibiotics for respiratory tract infections (RTIs) in adults and children in primary care. The guideline recommends that alternative prescription strategies are used for patients with RTIs who present in primary care and other first face-to-face contact healthcare settings such as emergency departments and walk-in centres. These strategies are: no antibiotic prescribing; delayed (or deferred) antibiotic prescribing (in which an antibiotic prescription is written for use at a later date should symptoms worsen); and immediate antibiotic prescribing.

Evidence shows that antibiotics have limited effectiveness in treating a large proportion of RTIs in adults and children and complications are likely to be rare if antibiotics are withheld. General practice consultation rates in England and Wales show that a quarter of the population will visit their GP because of an RTI each year and they are the reason for 60% of all antibiotic prescribing in general practice.

Key recommendations in the guideline are:

•At the first face-to-face contact in primary care, including walk-in centres and emergency departments, offer a clinical assessment, including a history and examination to establish diagnosis and exclude complications.

•Negotiate a no antibiotic or delayed antibiotic prescribing strategy for patients with acute otitis media, acute sore throat/pharyngitis/acute tonsillitis, common cold, acute rhinosinusitis or acute cough/acute bronchitis.

•For the no antibiotic prescribing, offer patients reassurance that antibiotics are not needed immediately because they will make little difference to symptoms and may have side effects, and a clinical review if the RTI worsens or becomes prolonged.

•For the delayed antibiotic prescribing, offer patients

−reassurance that antibiotics are not needed immediately because they will make little difference to symptoms and may have side effects
−advice about using the delayed prescription if symptoms do not settle or get significantly worse
−advice about re-consulting if symptoms get significantly worse despite using the delayed prescription

•Consider an immediate prescribing strategy for: children younger than 2 years with bilateral acute otitis media, children with otorrhoea who have acute otitis media, and patients with acute sore throat/acute tonsillitis when three or more Centor criteria are present.

•Offer immediate antibiotics or further investigation/management for patients who:

−have symptoms and signs suggestive of serious illness and/or complications (particularly pneumonia, mastoiditis, peritonsillar abscess, peritonsillar cellulitis, intraorbital or intracranial complications)
−are 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.

•Offer immediate antibiotics or further investigation/management for patients who are older than 65 years with acute cough and two or more of the following, or older than 80 years 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.

Dr Gillian Leng, Deputy Chief Executive, and Executive Lead for this guidance said: “This is the first practical guideline which will help all healthcare professionals to assess adults and children with RTIs to decide whether their condition will improve by taking antibiotics. The guidance will also ensure that they can be followed up by the right people, at the right time and within the right healthcare setting.”

Paul Little, Professor of Primary Care Research and Guideline Development Group Chair said: “Management of RTI’s in the past concentrated on advising prompt antibiotic treatment. However, as rates of major complications are much less common in modern developed countries, so the evidence of symptomatic benefit should be strong to justify prescribing antibiotics so that we are not needlessly exposing patients to side effects.”

Mike Sharland, Consultant Paediatrician and Guideline Development Group member said:
“Every year, over five million antibiotics are prescribed for children in the community - the great majority for upper respiratory tract infections which are nearly always viral. This guideline describes the evidence base for prescribing antibiotics in children with an upper respiratory tract infection and gives clear and concise recommendations for their use.”

Anne Joshua, Associate Director of Pharmacy at NHS Direct and Guideline Development Group member said: “This short clinical guideline brings together everything we know on targeting antibiotics to those who really need them. It sets out very clearly the information that should be provided by healthcare professionals when they are assessing children and adults presenting with RTI symptoms in order to reassure them that they are receiving the most effective course of treatment, based on the most up-to-date evidence.”

Notes to Editors

About NICE

1.The National Institute for Health and Clinical Excellence (NICE) is the independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health.

2.NICE produces guidance in three areas of health:

public health – guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector

health technologies – guidance on the use of new and existing medicines, treatments and procedures within the NHS

clinical practice – guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS.
About the guidance

3.The guidance is available at

4.Respiratory tract infection (RTI) is defined as any infectious disease of the upper or lower respiratory tract. Upper respiratory tract infections (URTIs) include the common cold, laryngitis, pharyngitis/tonsillitis, acute rhinitis, acute rhinosinusitis and acute otitis media. Lower respiratory tract infections (LRTIs) include acute bronchitis, bronchiolitis, pneumonia and tracheitis.

5.Otitis media is a build-up of fluid in the middle ear, the space between the eardrum and the inner ear. Acute otitis media is a short-term ear infection that often comes on suddenly. Chronic otitis media is when ear infections keep coming back, or one infection lasts for a very long time. It often has less severe symptoms, so the infection may be unnoticed and untreated for a long time, which means it can cause more damage than an acute infection.

6.Centor criteria are: presence of tonsillar exudate, tender anterior cervical lymphadenopathy or lymphadenitis, history of fever and an absence of cough.

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