Respiratory tract infections - antibiotic prescribing Implementing NICE guidance ABOUT THIS PRESENTATION: This presentation has been written to help you raise awareness of the NICE clinical guideline on prescribing of antibiotics for self-limiting respiratory tract infections (RTIs) in adults and children in primary care. This guideline has been written for primary healthcare professionals and other staff who care for adults and children with RTIs. The guideline is available in a number of formats. You can download these from the NICE website or order printed copies of the quick reference guide by calling NICE publications on 0845 003 7783 or sending an email to publications@nice.org.uk. Quote reference number N1623. You may want to hand out copies of the quick reference guide at your presentation so that your audience can refer to it. You can add your own organisation’s logo alongside the NICE logo. We have included notes for presenters to help highlight key points to raise in your presentation and to provide supplementary information to the slides. Where necessary, the recommendation will be given in full. Please feel free to adapt, amend or remove these as you see necessary. DISCLAIMER This slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself. 2008 NICE clinical guideline 69

What this presentation covers Background Recommendations Costs and savings Discussion Find out more NOTES FOR PRESENTERS: In this presentation we will start by providing a background to the guideline and why it is important. The guideline contains seven recommendations, which form the care pathway in your quick reference guide. The recommendations for implementation cover the following areas: Assessment of patients with RTIs Antibiotic prescribing strategies Identifying patients with RTIs who are at risk of developing complication. Costs and savings that are likely to be incurred in implementing the guideline are summarised, followed by a suggested list of questions to help prompt discussion. Information on how to find out more about the support provided by NICE is given at the end of this presentation.

Background RTIs are the commonest acute problem dealt with in primary care Most people with RTIs are inappropriately prescribed antibiotics The guideline covers best practice advice on the care of adults and children (3 months and older) with RTIs, for whom immediate antibiotic prescribing is not indicated NOTES FOR PRESENTERS: Key points to raise: This guideline is relevant to primary care and community settings where face-to-face contact takes place between patients and healthcare professionals. These settings include general practices, community pharmacies, NHS walk-in centres, NHS out-of-hours services and primary medical and nursing care provided in emergency departments. The target population is adults and children (3 months and older) for whom immediate antibiotic prescribing is not indicated. Additional information: Most people will develop an acute respiratory tract infection (RTI) every year. Most people presenting in primary care with an acute uncomplicated RTI will receive an antibiotic prescription and there are several problems with this. First, the evidence suggests that most patients will not gain much symptomatic benefit from antibiotics. This means that many patients are having unnecessary antibiotics and are needlessly being exposed to side effects. Second, patients are getting the message from healthcare professionals that antibiotics are helpful for most infections, and thus erroneously attribute their symptom resolution to antibiotics. Third, international comparisons make it clear that antibiotic resistance rates are strongly related to antibiotic use in primary care. This is potentially a major public health problem both for our own and for future generations.

Recommendations : Offer a clinical assessment At first face-to-face contact in primary care, patients presenting with a history suggestive of the following should be offered a clinical assessment: - Acute otitis media - Acute sore throat/acute pharyngitis/acute tonsillitis - Common cold - Acute rhinosinusitis - Acute cough/acute bronchitis NOTES FOR PRESENTERS: Additional information: The five RTIs covered in this short clinical guideline are: acute otitis media (AOM), acute sore throat/acute pharyngitis/acute tonsillitis, the common cold, acute rhinosinusitis and acute cough/acute bronchitis. These are the five most common RTIs consulted for in UK general practice. Recommendation in full: 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.

Recommendations : Agree an antibiotic prescribing strategy with the patient 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) NOTES FOR PRESENTERS: Additional information: A central task of the healthcare professional during the patient consultation is to address the patient’s ideas, concerns and expectations regarding treatment before agreeing a management plan. This is particularly important in consultations for RTIs, when there may be an expectation on the part of the patient that an antibiotic will be required, whereas the opinion of the healthcare professional is that an antibiotic prescription is not clinically indicated immediately. Conversely, there may be an expectation on the part of the healthcare professional that the patient has attended specifically with a view to obtaining an antibiotic prescription whereas the patient is seeking only advice and/or reassurance. Recommendation in full: 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).

Recommendations : Give advice For all antibiotic prescribing strategies, patients should be given: Advice about the usual natural history of the illness Advice about managing symptoms, including fever NOTES FOR PRESENTERS: Key points to raise: Advice about the usual natural history of the illness should include the total length of the illness before and after seeing the doctor. Recommendation in full: 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).

Recommendations : Antibiotic prescribing options - 1 A no antibiotic prescribing strategy or a delayed antibiotic prescribing strategy should be agreed for most patients with the following conditions: Acute otitis media Acute sore throat/acute pharyngitis/acute tonsillitis Common cold Acute rhinosinusitis Acute cough/acute bronchitis NOTES FOR PRESENTERS: Recommendation in full: 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 criteria are present. Centor criteria are: presence of tonsillar exudate, tender anterior cervical lymphadenopathy or lymphadenitis, history of fever and an absence of cough.

Recommendations : Antibiotic prescribing options - 2 Depending on clinical assessment of severity, patients in the following subgroups can also be considered for immediate antibiotics: 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 are present NOTES FOR PRESENTERS: Recommendation in full: 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 criteria are present. Centor criteria are: presence of tonsillar exudate, tender anterior cervical lymphadenopathy or lymphadenitis, history of fever and an absence of cough.

Recommendations : When no antibiotic prescribing is agreed Offer patients: Reassurance that antibiotics are not needed immediately A clinical review if the condition worsens or becomes prolonged NOTES FOR PRESENTERS: ‘Understanding NICE guidance’ – a version for patients and carers – ordering details are at the end of this presnetation A leaflet “get well soon without antibiotics”, which complements this guidance, is available from the DH, ref 284682/ get well soon without antibiotics e-mail dh@prolog.uk.com It may also be downloaded in English, Arabic, Bengali, Simplified Chinese, Hindi, Polish, Portuguese, Punjabi, Slovak, Somali and Urdu from the DH website http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_082502 Further information about antibiotic use is also available from NHS Choices Recommendation in full: 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.

Recommendations : When delayed antibiotic prescribing is agreed Offer patients: Reassurance that antibiotics are not needed immediately Advice about using the delayed prescription if symptoms are not starting to settle in accordance with the expected course of the illness Advice about re-consulting if there is a significant worsening of symptoms despite using the prescription NOTES FOR PRESENTERS: Recommendation in full: 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, diarrhoea, 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.

Recommendations : Consider immediate antibiotic prescribing for patients at risk of developing complications (1) Immediate antibiotic prescribing and/or further investigation/management should only be offered to adults and children in the following situations: If the patient is systemically very unwell If the patient has symptoms and signs of serious illness and/or complications If the patient is at high risk of serious complications because of pre-existing comorbidity NOTES FOR PRESENTERS: Key points to raise: Antibiotics are, in general, ineffective in treating RTIs. However, they may be beneficial for a subgroup of patients who present with an RTI in primary care and who are likely to be at risk of developing complications Recommendation in full: An immediate antibiotic prescription 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 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 criteria: hospitalisation in previous year type 1 or type 2 diabetes history of congestive heart failure current use of oral glucocorticoids. For these patients, the no antibiotic prescribing strategy and the delayed antibiotic prescribing strategy should not be considered.

Recommendations : Consider immediate antibiotic prescribing for patients at risk of developing complications (2) If the patient is older than 65 with acute cough and two or more of the following or older than 80 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 NOTES FOR PRESENTERS: Key points to raise: Antibiotics are, in general, ineffective in treating RTIs. However, they may be beneficial for a subgroup of patients who present with an RTI in primary care and who are likely to be at risk of developing complications Recommendation in full: An immediate antibiotic prescription 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 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 criteria: hospitalisation in previous year type 1 or type 2 diabetes history of congestive heart failure current use of oral glucocorticoids. For these patients, the no antibiotic prescribing strategy and the delayed antibiotic prescribing strategy should not be considered.

Costs and savings per 100,000 population Recommendations with significant savings Savings (£ per year) A no or a delayed antibiotic prescribing strategy should be agreed for patients with the following conditions: acute otitis media, acute cough/acute bronchitis, acute sore throat/acute pharyngitis/acute tonsillitis, acute rhinosinusitis and common cold –4,200 Estimated saving of implementation NOTES FOR PRESENTERS: The information on this slide has been extracted from the NICE costing report, which has been provided by NICE to support implementation of this guidance. It was developed after careful consideration of the available data and by working closely with the guideline developers and other people in the NHS. It is not NICE guidance. Assumptions used in this report are based on assessment of the national average and it is recognised that local practice or circumstances may differ from this. The costs published in this report are estimates only and are not to be taken as the Institute's view of desirable, or maximum or minimum figures. NICE has also provided a costing template to help calculate the local costs associated with implementing this guideline. The costs per 100,000 population are summarised in the table. ADAPTING THIS SLIDE FOR LOCAL USE: We are aware that local factors such as incidence and baseline can vary considerably when compared with the national average. NICE has provided a costing template for you to calculate the financial impact this guideline will have locally. We encourage you to calculate the local impact of this guideline by amending the local variations in the template such as incidence, baseline and uptake. You can then remove the national figures from the table and replace them with your local figures to present to your colleagues. It is recognised that implementation of the recommendations may take place over a number of years. In addition, compliance with NICE guidance is one of the criteria indicating good risk reduction strategies, and in combination with meeting other criteria could lead to a discount on contributions to the NHS Litigation Authority schemes, including the clinical negligence scheme for trusts (CNST). For further information please refer to the costing template and costing report for this guidance on the NICE website.

Costs and savings The guideline on respiratory tract infections in primary care - antibiotic prescribing is unlikely to result in a significant change in resource use in the NHS NOTES FOR PRESENTERS: NICE has worked closely with the guideline developers and other people in the NHS to look at the major costs and savings related to implementing this guideline and found that it is unlikely to result in any significant changes based on national assumptions. However, different areas may vary from the national average and it is important to scrutinise the recommendations likely to have the most significant resource impact locally to make sure that practice matches the national average. In this case this recommendation is: A no antibiotic prescribing strategy or a delayed antibiotic prescribing strategy should be agreed for most patients with the following conditions: acute otitis media, acute cough/acute bronchitis, acute sore throat, acute sinusitis and common cold

For discussion How does the rate of antibiotic prescribing for RTIs in your practice/PCT compare with the PCT/national average? How could the delayed prescribing strategy be implemented in your surgery/PCT? What methods/tools could be used to help patients take a greater role in self-managing their uncomplicated RTIs? How can we use the NICE Audit Support document to assess local implementation? NOTES FOR PRESENTERS: These questions are suggestions that have been developed to help provide a prompt for a discussion at the end of your presentation – please edit and adapt these to suit your local situation. There are likely to be a number of patients who take antibiotics inappropriately and doctors who seem to encourage frequent prescribing. Some of these patients/doctors might benefit from targeted education.

Find out more Visit www.nice.org.uk/CG069 for: Other guideline formats Costing report and template Audit support NOTES FOR PRESENTERS: The guideline is available in a number of formats. The quick reference guide – which summarises the guidance. The full guideline – all the recommendations for healthcare professionals and NHS bodies, details of how they were developed, and reviews of the evidence they were based on. ‘Understanding NICE guidance’ – a version for patients and carers. You can download these from the NICE website or order printed copies of the quick reference guide and ‘Understanding NICE guidance’ by calling NICE publications on 0845 003 7783 or by sending an email to publications@nice.org.uk. Quote reference number N1623 (quick reference guide) or N1624 (‘Understanding NICE guidance’). You may want to hand out copies of the quick reference guide at your presentation so that your audience can refer to it. NICE has developed tools to help organisations implement this guideline, which can be found on the NICE website. Costing tools – a costing report gives the background to the national savings and costs associated with implementation, and a costing template allows you to estimate the local costs and savings involved. Audit support – assists NHS trusts to determine how well they meet NICE recommendations. Related guidance: Feverish illness in children: assessment and initial management in children younger than 5 years. NICE clinical guideline 47 (2007). Available from: www.nice.org.uk/CG047 Medicines concordance and adherence: involving adults and carers in decisions about prescribed medicines. NICE clinical guideline. Publication expected January 2009. See www.nice.org.uk