1. Clinical Scenario: Acute Cough
16 September, 2019
Clinical Scenario
Acute Cough
Presenter notes:
These cases are examples that can be printed out and discussed in pairs or groups, or with the group as a whole.
Allow the participants to discuss the case for 2 minutes and specifically ask several different people what they would do and /or prescribe.
TARGET Antibiotics Presentation - CS:Acute Cough

2. Clinical Scenario: Acute Cough
16 September, 2019
Clinical Scenario
Acute Cough
Please consider the following details:-
45 year old smoker with cough 1/52, green sputum
Temp 37.8°C
Has had several previous episodes of bronchitis and insists antibiotics ‘always help’
PEFR normal
Scattered course creps and wheeze, vesicular breath sounds, no focal crepitation's
Presenter notes:
These cases are examples that can be printed out and discussed in pairs or groups, or with the group as a whole.
Allow the participants to discuss the case for 2 minutes and specifically ask several different people what they would do and /or prescribe.
It may be useful to also change the scenario slightly- how would this change if the patient was 81 years old and had been in hospital 6 months previously.
TARGET Antibiotics Presentation - CS:Acute Cough

3. Available via PHE or RCGP websites with full rationale & references
Clinical Scenario: Acute Cough PHE Antibiotic Prescribing Implementation Tool
16 September, 2019
Clinical Scenario
Acute Cough
ILLNESS
GOOD PRACTICE POINTS
DRUG
ADULT DOSE/ DURATION
Acute cough & bronchitis
NICE RTIs
Antibiotics have little benefit if no co-morbidity. Consider a 7-day delayed antibiotic with advice. Symptom resolution can take 3 weeks.
Consider immediate antibiotics if >80 years of age and one of: hospitalisation in past year; taking oral steroids; insulin-dependent diabetic; congestive heart failure; serious neurological disorder/stroke, or >65 years with two of the above.
Consider CRP if antibiotic is being considered.
No antibiotics if CRP<20mg/L and symptoms for >24 hours; delayed antibiotics if mg/L; immediate antibiotics if >100mg/L.
Amoxicillin
Penicillin allergy: doxycycline
500mg TDS
200mg stat then 100mg OD
5 d
Presenter notes: We suggest you take your local guidance with you
The TARGET website also has the national antibiotic guidance, which is used by most CCGs to develop their local guidance. This is a snapshot of the aims and principles of treatment section of the Management of Infection Guidance for acute cough. As you can see each section has links to other guidance, comments on when antibiotics should be used, recommended first and second line antibiotics dose and duration. For acute cough, we suggest that antibiotics have little benefit if no co-morbidity. We recommend amoxicillin first line; co-amoxiclav is not recommended second line, rather PHE recommends doxycycline second line.
This PHE guidance on the TARGET website, also has an extensive rationale section which is really useful for trainers and trainees, or just when you want a bit more information for yourself or the patient.
Presenter please tell the participants where to find your local guidance and how locums can get extra copies if needed.
Rationale behind recommendations
1. NICE Clinical Guideline 69. Respiratory Tract Infections - antibiotic prescribing for self-limiting respiratory tract infections in adults and children in primary care. July RATIONALE: Describes strategies for limiting antibiotic prescribing in self-limiting infections and advises in which circumstances antibiotics should be considered. A no antibiotic or a delayed antibiotic prescribing strategy should be agreed for patients with acute cough/chronic bronchitis. In the 2 RCTs included in the review, the delay was 7-14 days from symptom onset and antibiotic therapy. Patients should be advised that resolution of symptoms can take up to 3 weeks and that antibiotic therapy will make little difference to their symptoms and may result in side effects. Patients should also be advised to seek a clinical review if condition worsens or becomes prolonged. The evidence behind these statements is primarily from the studies referred to below.
There has been no systematic review of the evidence of length of antibiotic treatment for acute cough or bronchitis when antibiotics are prescribed. However the NICE pneumonia guidance group found evidence for the efficacy of 5 days’ antibiotic to treat pneumonia; therefore it is reasonable to consider that 5 days would also be effective in bronchitis.
2. Fahey T, Smucny J, Becker L, Glazier R. Antibiotics for acute bronchitis. In: The Cochrane Library, 2006, Issue 4. Chichester, UK: John Wiley & Sons, Ltd Accessed RATIONALE: Systematic review of nine studies (4 in primary care). Studies in primary care showed antibiotics reduced symptoms of cough and feeling ill by less than one day in an illness lasting several weeks in total.
3. Chronic cough due to acute bronchitis. Chest. 2006;129:95S-103S. RATIONALE: Clinical guidelines on managing cough associated with acute bronchitis. Large body of evidence including meta-analyses and systematic reviews does not support routine antibiotic use.
4. Wark P. Bronchitis (acute). In: Clinical Evidence. London. BMJ Publishing Group. 2008;07: RATIONALE: Discusses the evidence to support self care and limiting antibiotic prescriptions. Systematic review of 13 RCTs found that antibiotics only modestly improved outcomes compared with placebo.
5. Francis N et al. Effect of using an interactive booklet about childhood respiratory tract infections in primary care consultations on reconsulting and antibiotic prescribing: a cluster randomised controlled trial. BMJ 2009;339:2885. RATIONALE: Utilising an information booklet during primary care consultations for children with RTIs significantly decreased antibiotic use (absolute risk reduction 21.3% (95%CI, p<0.001). Reconsultation occurred in 12.9% of children in intervention group and 16.2% in control group (absolute risk reduction 3.3%, no statistical difference). There was no detriment noted to patient satisfaction in the intervention group.
6. Treatment of acute bronchitis available in Clinical Knowledge Summaries website: Accessed
Acute exacerbation of COPD
1. Anthonisen MD, Manfreda J, Warren CPW, Hershfield ES, Harding GKM, Nelson NA. Antibiotic therapy in exacerbations of chronic obstructive pulmonary disease. Ann Int Med 1987;106: RATIONALE: Describes the cardinal signs of an infective exacerbation of COPD and the evidence for commencing antibiotics. Randomised double blinded cross-over trial showed a significant benefit from using antibiotics. Success rate with antibiotic therapy 68% vs 55% with placebo.
2. Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for Diagnosis, Management, and Prevention of COPD. Management of exacerbations. Updated December Discusses the aetiology, pathophysiology and evidence based therapeutic management of COPD. Antibiotic therapy is stratified according to severity of disease. S. pneumoniae, H. influenzae, M. catarrhalis remain the predominant pathogens in mild disease.
3. Chronic obstructive pulmonary disease. Management of COPD in adults in primary and secondary care. NICE Clinical Guideline 12 February Accessed RATIONALE: A meta-analysis of nine trials found a small but statistically significant effect favouring antibiotics over placebo in patients with exacerbations of COPD. Effect size 0.22 (95% CI, 0.1 to 0.34). Four studies assessed whether there was a relationship between severity of exacerbation and the effectiveness of antibiotic use. Three of these studies suggest that the worse the COPD severity of exacerbation (lung function impairment (FEV1, PEFR), purulence of sputum) then the greater the degree of benefit from antibiotics.
4. El Moussaoui R, Roede BM, Speelman P, Bresser P, Prins JM, Bossuyt PMM. Short-course antibiotic treatment in acute exacerbations of chronic bronchitis and COPD: a meta-analysis of double-blind studies. Thorax 2008;63: RATIONALE: In this meta-analysis they concluded that a short course of antibiotic treatment was as effective as the traditional longer treatment in patients with mild to moderate exacerbations of chronic bronchitis and COPD. The meta-analysis included 21 double-blind randomised clinical trials with 10,698 adults with exacerbation of COPD or chronic bronchitis, no antimicrobial therapy at the time of diagnosis and random assignment to antibiotic treatment for less than or equal to 5 days versus more than 5 days. At early follow-up (<25 days), the summary odds ratio (OR) for clinical cure with short treatment versus conventional treatment was 0.99 (95% CI 0.90 to 1.08). At late follow-up the summary OR was 1.0 (95% CI 0.91 to No trials of amoxicillin or doxycycline were included in the meta-analysis; however there is no microbiological reason that a 5 day course of these agents would be inferior to a 5 day course of clarithromycin in acute exacerbations of COPD.
Available via PHE or RCGP websites with full rationale & references
TARGET Antibiotics Presentation - CS:Acute Cough

4. Clinical Scenario: Acute Cough Feedback
16 September, 2019
Clinical Scenario
Acute Cough
45 year old smoker with cough 1/52, green sputum
Temp 37.8°C
Has had several previous episodes of bronchitis and insists antibiotics ‘always help’
PEFR normal
Scattered course creps and wheeze, vesicular breath sounds, no focal crepitation’s
Antibiotic little benefit as no co-morbidity
Consider no, or 7d back up antibiotic with safety netting
Share a leaflet with the patient – e.g. TARGET RTI leaflet
Advise patient symptom resolution can take 3 weeks
If unsure undertake a CRP
Presenter notes:
These cases are examples that can be printed out and discussed in pairs or groups, or with the group as a whole.
In this case a no, or back-up antibiotic prescription (7 day) strategy with safety netting advice using a patient leaflet (see TARGET) could be used as the symptoms do not suggest immediate antibiotic use is required. But the clinician needs to assess how ”ill” he considers the patient is.
NICE Clinical Guideline 69. Respiratory Tract Infections - antibiotic prescribing for self-limiting respiratory tract infections in adults and children in primary care. July The NICE guidance suggests a no antibiotic or a delayed antibiotic prescribing strategy should be agreed for patients with acute cough/chronic bronchitis. In the 2 RCTs included in the review, the delay was 7-14 days from symptom onset and antibiotic therapy. Patients should be advised that resolution of symptoms can take up to 3 weeks and that antibiotic therapy will make little difference to their symptoms and may result in side effects. Patients should also be advised to seek a clinical review if condition worsens or becomes prolonged.
In a European study of 3,000 primary care patients with acute cough across 13 countries, clinical outcome was similar whether antibiotics were given or not (Butler et al BMJ:339 b 2242).
In an RCT of amoxicillin 1g tds vs placebo in 2061 patients 18yrs and over with acute LRTI when pneumonia was not suspected. New or worsening symptoms were significantly less common in amoxicillin (15.9%) than in the placebo group 19.3% (NNT30). Nausea, rash or diarrhoea were significantly more common in the amoxicillin group (number needed to harm 21). There was no increased benefit in those over 60 yrs (Little et al, Lancet Infect Dis 2013:123-9). In this same patient series those with a history of significant co-morbidities experienced a significantly greater reduction in symptom severity between days 2 & 4. Those with a short prior illness <7days, or non smokers antibiotics provided a modest benefit. (Br J Gen Pract 2014).
TARGET Antibiotics Presentation - CS:Acute Cough

5. What is the evidence for back-up / delayed prescribing?
16 September, 2019
Clinical Scenario
Acute Cough
Duration of Cough After Physician Visit Until Patient Is Feeling Better
Patient satisfaction with treatment
No antibiotic (control Mean SD)
130/181 (72)
Difference due to delayed antibiotic (95% CI)
147/190 (77)
Difference due to Immediate antibiotics (95% CI)
166/194 (86)
p-value
0.005
Presenter notes: There has been much discussion about the use of giving delayed antibiotic prescriptions in acute uncomplicated infections, to reduce antibiotic use and reduce patient expectations (although patients understand the term back-up more easily – so we have now changed to this term. A Cochrane review has recently shown the benefits of this approach, without increasing complications in patients.
This study in acute cough is an exampler. Patients recruited by 37 physicians across Bristol and Southampton were randomised into immediate antibiotics, delayed antibiotics and no antibiotics groups. Of the 807 randomised participants, 272 were randomised to delayed antibiotics.
The cough remained “a slight problem” for a mean of 11.7 days (in 25% the cough lasted 17 days), and moderately bad for a mean of 6.0 days. Compared with no offer of antibiotics, other prescribing strategies did not alter the primary outcomes.
There was no difference in recovery rates and high levels of satisfaction with all strategies. Overall, there were fewer re-attendances with cough following delayed prescribing and immediate antibiotics in the month after the physician visit compared to no antibiotics (mean attendances for delayed, 0.12; immediate, 0.11; and no antibiotics, 0.19; likelihood ratio [LR] test from Poisson regression, P=.04).
Authors concluded that No offer or a delayed offer of antibiotics for acute uncomplicated lower respiratory tract infection is acceptable, associated with little difference in symptom resolution, and is likely to considerably reduce antibiotic use and beliefs in the effectiveness of antibiotics.
A Cochrane review of 11 studies has shown that delayed prescribing reduces antibiotic prescriptions without reducing satisfaction
Outcomes Risk with immediate antibiotics* Risk with delayed antibiotics* Relative effect (95% CI)
Antibiotic use:
delayed versus per per OR 0.04
immediate antibiotics (286 to 401) (0.03 to 0.05)
Patient satisfaction:
delayed versus immediate per per OR 0.65
Antibiotics (795 to 916) (0.39 to 1.10)
Reconsultation rate:  109 per per OR 1.04
delayed versus immediate (63 to 196) (0.55 to 1.98)
antibiotics
 *Anticipated absolute effects* (95% CI)
Spurling GKP, Del Mar CB, Dooley L, Foxlee R, Farley R. Delayed antibiotic prescriptions for respiratory infections. Cochrane Database of Systematic Reviews 2017, Issue 9. Art. No.: CD DOI: / CD pub5.
Little P, Rumsby K, Kelly J, et al. JAMA. 2005;293(24): doi: /jama
TARGET Antibiotics Presentation - CS:Acute Cough

6. Cals et al, BMJ 2009;338:1374, NICE clinical guideline 191
16 September 2019
Evidence for CRP and communication in acute cough in general practice
Clinical Scenario
Acute Cough
Care for LRTI
Antibiotics
prescribed
Usual care
68%
Communication skills and leaflet
33%
CRP to aid diagnosis
39%
Both CRP & communication
23%
I M P A C3 T
NICE: Patients with LRTI symptoms if diagnosis of pneumonia has not been made and it is not clear whether antibiotics are needed
C-reactive protein mg/litre
Management
Less than 20
Do NOT routinely offer antibiotics
Consider delayed antibiotic prescription
Greater than 100
Offer immediate antibiotics
The IMPACT study in the Netherlands showed that use of communication skills with GPs in which they shared information with patients halved antibiotic use. This supports the use of shared information.
CRP alone was also very effective and the combination of both decreased antibiotic use the most.
Click to bring in information about NICE: Thus NICE guidance now suggests that:
For people presenting with symptoms of lower respiratory tract infection in primary care, consider a point of care C-reactive protein test if after clinical assessment a diagnosis of pneumonia has not been made and it is not clear whether antibiotics should be prescribed.
Use the results of the C-reactive protein test to guide antibiotic prescribing in people without a clinical diagnosis of pneumonia as follows:
Do not routinely offer antibiotic therapy if the C-reactive protein concentration is less than 20mg/litre.
Consider a delayed antibiotic prescription (a prescription for use at a later date if symptoms worsen) if the C-reactive protein concentration is between 20mg/litre and 100mg/litre.
Offer antibiotic therapy if the C-reactive protein concentration is greater than 100mg/litre.
NICE clinical guideline 191. Diagnosis and management of community- and hospital-acquired pneumonia in adults. Issued: December Accessed
Reference for the IMPACT study: Effect of point of care testing for C reactive protein and training in communication skills on antibiotic use in lower respiratory tract infections: cluster randomised trial. Jochen W L Cals, Christopher C Butler, Rogier M Hopstaken, Kerenza Hood, Geert-Jan Dinant. BMJ 2009;338:b1374 doi: /bmj.b1374.
Objective To assess the effect of general practitioner testing for C reactive protein (disease approach) and receiving training in enhanced communication skills (illness approach) on antibiotic prescribing for lower respiratory tract infection.
Design: Pragmatic, 2×2 factorial, cluster randomised controlled trial.
Setting: 20 general practices in the Netherlands.
Participants: 40 general practitioners from 20 practices recruited 431 patients with lower respiratory tract infection.
Main outcome measures: The primary outcome was antibiotic prescribing at the index consultation. Secondary outcomes were antibiotic prescribing during 28 days’ follow-up, reconsultation, clinical recovery, and patients’ satisfaction and enablement.
Interventions: General practitioners’ use of C reactive protein point of care testing and training in enhanced communication skills separately and combined, and usual care.
Results: General practitioners in the C reactive protein test group prescribed antibiotics to 31% of patients compared with 53% in the no test group (P=0.02). General practitioners trained in enhanced communication skills prescribed antibiotics to 27% of patients compared with 54% in the no training group (P<0.01). Both interventions
showed a statistically significant effect on antibiotic prescribing at any point during the 28 days’ follow-up. Clinicians in the combined intervention group prescribed antibiotics to 23% of patients (interaction term was nonsignificant). Patients’ recovery and satisfaction were similar in all study groups.
Conclusion Both general practitioners’ use of point of care testing for C reactive protein and training in enhanced communication skills significantly reduced antibiotic prescribing for lower respiratory tract infection without compromising patients’ recovery and satisfaction with care. A combination of the illness and disease focused approaches may be necessary to achieve the greatest reduction in antibiotic prescribing for this common condition in primary care. Trial registration Current Controlled Trials ISRCTN
Cals et al, BMJ 2009;338:1374, NICE clinical guideline 191
TARGET Antibiotics Presentation - CS:Acute Cough

7. A meta analysis of English Primary Care
Evidence: Risk of resistance persists for at least 12 months after your prescribing
16 September, 2019
Clinical Scenario
Acute Cough
Increased risk of
resistant organism
Antibiotic in past
2 months
Antibiotic in past
12 months
RTI
7 studies: n = 2,605
2.4 times
Presenter notes:
Lets take a moment to reflect. What do you think about antibiotic resistance?
Is it important in your practice? (Pause for feedback)
Does your own antibiotic prescribing influence antibiotic resistance in your patients or community? (pause for feedback)
Resistance is now with us in primary care and
The risk of resistance is even greater in the first two months after an antibiotic as shown here for Respiratory Tract infections, but is still higher 12 months after antibiotic use for RTIs.
Individuals prescribed an antibiotic in primary care for a respiratory infection have an increased risk of subsequently carrying resistant organisms – so that the next time they have an infection it may be with one of these antibiotic resistant organism. So in conclusion, any antibiotic use increases our future risk of carrying resistant bacteria, even if it is amoxicillin, as this resistance gene is often linked to others like trimethoprim.
Details of paper:
The review included 24 studies; 22 involved patients with symptomatic infection and two involved healthy volunteers; 19 were observational studies (of which two were prospective) and five were randomised trials. In five studies of urinary tract bacteria (14 348 participants), the pooled odds ratio (OR) for resistance was 2.5 (95% confidence interval 2.1 to 2.9) within 2 months of antibiotic treatment and 1.33 (1.2 to 1.5) within 12 months. In seven studies of respiratory tract bacteria (2605 participants), pooled ORs were 2.4 (1.4 to 3.9) and 2.4 (1.3 to 4.5) for the same periods, respectively. Studies reporting the quantity of antibiotic prescribed found that longer duration and multiple courses were associated with higher rates of resistance. Studies comparing the potential for different antibiotics to induce resistance showed no consistent effects. Only one prospective study reported changes in resistance over a long period; pooled ORs fell from 12.2 (6.8 to 22.1) at 1 week to 6.1 (2.8 to 13.4) at 1 month, 3.6 (2.2 to 6.0) at 2 months, and 2.2 (1.3 to 3.6) at 6 months.
Therefore in conclusion, individuals prescribed an antibiotic in primary care for a respiratory infection have an increased risk of carrying resistant organisms – so that the next time they have an infection it is with a antibiotic resistant organism. The effect is greatest in the month immediately after treatment but may persist for up to 12 months. This effect not only increases the population carriage of organisms resistant to first line antibiotics, but also creates the conditions for increased use of second line antibiotics in the community.
A meta analysis of English Primary Care
Costello et al. BMJ. (2010) 340:c2096.
TARGET Antibiotics Presentation - CS:Acute Cough

8. The Patient Perspective: A 2017 survey showed patients trust GPs’ and nurses’ advice
16 September, 2019
Clinical Scenario
Acute Cough
Presenter notes:
We know patients trust GP’s, nurses and pharmacists to give them advice.
85% of participants in a 2017 survey of 1691 randomly selected members of the English public reported that they trusted their GP’s advice as to whether they needed antibiotics or not; 72% trusted their nurse and 71% trusted their pharmacist. So there is a great opportunity for clinicians and pharmacists to share information with patients about the need or not for antibiotics.
Extra presenter notes:
The 2017 survey also showed that 57% of of participants who had taken antibiotics or had an infection in the last year (received some information about the illness or antibiotics.
Most participants were given information verbally (83%), in the GP surgery (65%). One-fifth (21%) were given the information in a printed format, and the professional went through or discussed the printed information with them in 42%. One in eight (14%) were given information at a pharmacy;–One-fifth how to take antibiotics but far fewer about other things related to antibiotics. About One –tenth  recalled being given some advice about the symptoms.
so there is an opportunity to give more printed information about antibiotics and sef-care.
This survey is also supported by another recent large Eurobarometer survey showing that 90% of the UK public would use their GP as a trustworthy source of antibiotic information.
It’s worth sharing information about the need or not for antibiotics
in consultations, and self care
McNulty et al. Ipsos Mori 2017; Base: All respondents (1,691); Fieldwork: 24th Jan–5thFeb 2017
TARGET Antibiotics Presentation - CS:Acute Cough

9. Prescribing: Consultation rates related to acute cough & cold
16 September, 2019
Prescribing: Consultation rates related to acute cough & cold
Clinical Scenario
Acute Cough
537 UK GP practices
Presenter notes:
So why despite our discussions that we don’t usually prescribe for uncomplicated cases is prescribing increasing as shown in this graph?
Think about your own prescribing – how often do you use amoxicillin for coughs?
This data from general practices in England and Wales from the RCGP GP Research network shows that consultations for coughs and colds has increased since 2000, and the antibiotic prescribing has increased with it. The proportion of cough/cold episodes for which antibiotics were prescribed decreased from 47% in 1995 to 36% in 1999, before increasing to 51% in But there was marked variation in the percentage of patients in each practice that were prescribed antibiotics, in 2011 the 10th to 90th percentile range was 32%–65%. This variation was NOT influenced by age or social group. Variation in prescribing by practices persists.
This study also looked at other infections: the proportion of GP consultations in which patients were prescribed antibiotics for sore throat was 62% in 2011 – but again with a wide range 10th to 90th percentile range of 45%–78%.
There was a similar very wide range for the % of patients prescribed antibiotics who had a consultation for otitis media 63%–97% and all upper respiratory tract infections from 33%–74%.
This suggests that all of us could probably reduce our antibiotic prescribing – but those at the higher end of the range could do so more than others. Think about your own prescribing – do you think you are at the upper end? If yes you may wish to consider CRP more actively
CLICK TO BRING IN: In another longitudinal study Ashworth et al showed that practices that reduced their antibiotic prescribing also reduced their consultations for RTI, suggesting that patients can be retrained not to expect antibiotics and as a result consult less. So reducing your workload – or at least allowing you to concentrate on other things!
Extra presenter notes from reference: Hawker et al. J Antimicrob Chemother. 2014: doi: /jac/dku291.
Trends in antibiotic prescribing in primary care for clinical syndromes subject to national recommendations to reduce antibiotic resistance, UK 1995–2011: analysis of a large database of primary care consultations.
This study measured trends in antibiotic prescribing in UK primary care in relation to nationally recommended best practice.
Patients and methods: A descriptive study linking individual patient data on diagnosis and prescription in a large primary care database, covering 537 UK general practices during 1995–2011.
Results: The proportion of cough/cold episodes for which antibiotics were prescribed decreased from 47% in 1995 to 36% in 1999, before increasing to 51% in There was marked variation by primary care practice in 2011 [10th–90th percentile range (TNPR) 32%–65%]. Antibiotic prescribing for sore throats fell from 77% in 1995 to 62% in 1999 and then stayed broadly stable (TNPR 45%–78%). Where antibiotics were prescribed for sore throat, recommended antibiotics were used in 69% of cases in 2011 (64% in 1995). The use of recommended short-course trimethoprim for urinary tract infection (UTI) in women aged 16–74 years increased from 8% in 1995 to 50% in 2011; however, a quarter of practices prescribed short courses in≤16% of episodes in 2011.
For otitis media, 85% of prescriptions were for recommended antibiotics in 2011, increasing from 77% in All these changes in annual prescribing were highly statistically significant (P,0.001).
Conclusions: The implementation of national guidelines in UK primary care has had mixed success, with prescribing for coughs/colds, both in total and as a proportion of consultations, now being greater than before recommendations were made to reduce it. Extensive variation by practice suggests that there is significant scope to improve prescribing, particularly for coughs/colds and for UTIs.
Ashworth et al BJGP Variations in antibiotic prescribing and consultation rates for acute respiratory infection in UK general practices 1995–2000. analysed data from the General Practice Research Database, including all registered patients from 108 practices between 1995 and For each practice, numbers of consultations for acute respiratory tract infections and the proportion of consultations resulting in an antibiotic prescription were obtained. An age- and sex-standardised consultation ratio (SCR) and standardised prescription ratio (SPR) were calculated for each practice. We evaluated whether SPR and SCR values were associated.
The results showed that for the mid-year data (1997), the crude consultation rate for all acute respiratory infections ranged from 125–1110 per 1000 registered patients at different practices; the proportion of consultations with antibiotics prescribed ranged from 45–98%. After standardising for varying age and sex structure of practice populations, practices with lower SPR values had lower SCR values (r = 0.41; P<0.001). This association was observed in each study year. Moreover, practices that demonstrated reductions in SPR between 1995 and 2000 also showed reductions in SCR (r = 0.27; P = 0.005).
In a longitudinal study, practices who reduced prescribing experienced a reduced consultation rate
Thus patients can be retrained not to expect antibiotics reducing your consultations
Hawker et al J AC 2014; Ashworth et al BJGP 2005.
TARGET Antibiotics Presentation - CS:Acute Cough

10. 16 September, 2019
Prescribing: 50% of total are amoxicillin Your Data October 2015 – September 2016
Clinical Scenario
Acute Cough
Total antibacterial Items/STAR-PU Vs Co-amoxiclav, Cephalosporin and Quinolone % Items
Presenter notes:– Antibiotic prescribing data is available from the NHS England Antibiotic Quality Premium monitoring dashboard here:
Or data is available from FingerTips:
This is free to access on the NHS England web site and will be updated at the start of each month. You should be able to access prescribing data for your CCG and insert it onto this slide.
This scatter plot shows the variation in total number of antibiotic items on the vertical Y axis, and the % of the total that the co-amoxiclav, cephalosporin and quinolone items make up, on the horizontal X axis. As you can see there is a wide variation in use in total items across England, but also here locally in this CCG (seen in the darker dots). There is an even greater variation in the use of co-amoxiclav, cephalosporins and quinolones.
This dot represents where you fall in the distribution compared to others in this CCG and nationally.
You are … [describe location on the chart]
The variation suggests that there is an opportunity for you to decrease your prescribing. Even if you are very low and can rightly feel proud about your practice prescribing – we still prescribe almost double that in the Netherlands.
TARGET Antibiotics Presentation - CS:Acute Cough

11. The Patient Perspective: What do patients do when they have an RTI?
16 September, 2019
Clinical Scenario
Acute Cough
1,707 ≥16y in England Jan 2017
959, 56% throat, ear, sinus, chest infection or cough, flu
33% carried on most of their usual daily activities/ routine
23% took extra rest
34% took OTC medicine for symptoms
18% used alternative medicine (honey, herbal) for symptoms
5% Got advice from friend/family colleague
11% asked pharmacy for advice (6% in 2011)
22% Contacted or visited GP surgery
3% visited NHS walk in, 3% GP OOH, 2% Hosp A&E
3% used NHS choices, 1% telephoned NHS 111
0.4% took left-over antibiotics
Presenter notes: Do patients expect antibiotics for RTIs?
In a 2017 face to face survey in randomly selected homes, 56% of 1707 participants reported having an RTI in the past 12 months. We asked the 969 (74%) participants reporting cough, throat, ear, sinus, chest infection or flu symptoms in the last year VQ03 - Thinking of your MOST RECENT illness which of the following actions, if any, did you take as a result? A third reported that they carried on most of their usual activities or work (33% with no variation with age, but significantly higher in social grade AB, or higher education)), or took non-prescription medications available over the counter (34% ). One fifth (18%, women 21% vs men 14%) took other honey or herbal remedies, or took extra rest (23%, under 34 years more likely and if single or no children). Less than one-in-twenty sought advice from friends, colleagues or family, although this was significantly higher in younger participants years (12%).
Use of websites for advice was very low, with only 3% seeking advice from websites
One-tenth asked for advice at their pharmacy, while one-fifth (22%) contacted their local doctor’s surgery.
Those who worked part-time (18%) were significantly more likely to have asked for advice at a pharmacy.
Those with no educational qualifications versus those with any qualifications, and those over 65 years than those under 25 years, were significantly more likely to contact their GP or (no formal qualification 35% p<0.05 compared to all other groups; over 64 years 28% vs under 25 years 17%, p<0.05).
If they had used a face to face health care service all were most likely to have last visited their doctors surgery (79%) but this was significantly lower in the younger age groups compared to those over 55 years (65% 15-24y, 71% y VS 94% 55-64y, 90% 65Y+ p<0.05 ).
Younger patients were more likely to have visited an NHS walk in centre and said this was their last visit (21% 15-24y vs 0-1% over 55years).
Younger participants year olds were significantly more likely to have used the NHS choices website (8%), visited an NHS walk in centre (6%) which is significantly higher than all other age groups except year olds (5%) or contacted NHS 111 (3%), than most other age groups
McNulty, Lecky, Butler. Ipsos MORI survey January 2017
TARGET Antibiotics Presentation - CS:Acute Cough

12. McNulty, Lecky, Butler. Ipsos MORI survey January 2017
The Patient Perspective 2017 n=249 Why they visited GP with RTI (not cold/runny nose)
30% Needed treatment to help symptoms
24% Symptoms severe (breathing 11%, sleep 14%)
26% Symptoms lasted longer than I expected
15% Worried illness could get worse
11% Wanted to know the cause
9% I usually go to doctor’s surgery with these symptoms
8% I already have another health condition
Clinical Scenario
Acute Cough
What did they expect?
38%
Expected antibiotics
18%
Advice on need for antibiotics
34%
Other treatment for symptoms
17%
To find out cause
25%
Advice about self-care
13%
Rule out more serious illness
Information about illness duration 4%
For referral to hospital/specialist
McNulty, Lecky, Butler. Ipsos MORI survey January 2017

13. The Patient Perspective: Back-up/delayed Prescribing: What patients do
16 September, 2019
Clinical Scenario
Acute Cough
Women compared with men (6% vs 4%)
Presenter notes:
This survey of the public showed that 5% of 3,385 members of the general public in 2017 reported being given a Back-up /delayed antibiotic prescription, so the strategy is being used a little by GPs.
Click to bring in 42% reported not taking the antibiotic
Of those 165 participants reporting being given a delayed/back-up antibiotic prescription, 57% reported starting to take it and 42% said they did not. (The sample size is too small to say any more about this group offered delayed antibiotics. )
When asked to score the acceptability of being given a delayed/back-up antibiotic out of 10 (where 1 completely unacceptable and 10 completely acceptable) the mean score was 8.5, with 59% scoring completely acceptable, and only 5 (3%) respondents scored 1.
The commonest indication for a delayed/back-up antibiotic, as in 2014, was for chest infection, but urine infection now constitutes 16% (7% in 2014).
So what is the Implication? With the continued low use, and lack of understanding of what it is by the general public and more than a quarter opposing the practice – more education and explanation will be needed, but the suggestion of great variation by area suggests that local activity may be having an affect
Further notes for presenter: - other questions were asked about delayed antibiotics
One-fifth of the general public (21%) know something about delayed /back-up antibiotic prescriptions s; and 14% of them fully aware, with a further 7% knowing the name or something about the practice. Women, those with children and those in social grades AB were more informed. This understanding is surprisingly slightly lower than in But interestingly, The North (30%) and south West (18%) were significantly more likely to be fully aware than all other areas –
It would be interesting to speculate why this is – there has been a lot of AMS activity in the Northern area through the North of England Commissioning Support (NECS) using the TARGET leaflet, whereas North West and London have less activity. The RCTs of delayed prescribing have been undertaken in several areas within the South West, but not all.
Support for delayed/backup antibiotic prescribing. Interestingly although there were slightly less fully aware of the term in 2017, than in 2014,  slightly more were supportive of the practice for throat, ear or urine infections, With a few percent more being strongly or tending to favour the practice, and a few percent less being strongly opposed.
Women compared with men, those with children, and younger (under 35 years) compared with older (over 55 Years) more likely to support. There is no difference by social grade. Not surprisingly if they knew something about the practice of delayed/back –up prescribing they were more likely to support it (fully 54% for throat), than those who were not aware of the practice (37%). The North were significantly more likely to strongly support delayed prescribing for infections, but the differences were not as great as for awareness
42% reported not taking the antibiotic
Acceptability score 1-10 Mean score 8.5
McNulty et al. Ipsos Mori 2017; Base: All respondents (3,385); Fieldwork: 24th Jan -12thFeb 2017
TARGET Antibiotics Presentation - CS:Acute Cough

14. TARGET antibiotics presentation 18.09.14
TARGET: Patient Information Leaflets
Treating Your Infection RTI Leaflet
16 September, 2019
Treating your infection RTI leaflet
Clinical Scenario
Acute Cough
Can be personalised
‘Most are better by’ section to help patients know when to (re) consult
Safety netting
Extra presenter notes: It would be useful to print off a copies of this leaflet and take enough with you for each GP. They can be found at
The treating your infection leaflet has been developed through extensive feedback with patients and clinicians over the last 2 years. It is designed to be shared with the patient and completed with them during the consultation. Its aim is to increase the patients confidence to self-care, and to facilitate the use of back-up antibiotic, but it also allows the patients to go away with something, so ending the consultation on a positive note.
Bring in personalised text box
All sections can be personalised and added to by the GP. And it is important to share it with the patient and add extra infections , self-care instructions in the third column and alarm symptoms in the fourth column that may be required.
Bring in ‘most get better by’ text box
The ‘usually lasts’ section allows patients to understand not only for this consultation but also others when they should consult. This section has consistently been seen as very useful by patients of all ages.
Bring in safety netting box
Whatever the infection, in this era of antibiotic resistance and with increasing numbers of elderly or vulnerable patients, it is extremely important to give some clear safety netting instructions. These are some that can be used and saved by patients.
Bring in back-up prescription box
The back-up prescription can reduce antibiotic prescribing by about 30 to 40%, and is extremely useful for particularly demanding patients or just before a weekend to reduce visits to out of hours services.
Bring in information box
Although most patients know they shouldn’t take antibiotics for coughs and colds, far fewer know that sinusitis, ear infections and sore throats and many other infections get better on their own without antibiotics.
Likewise they know little about antibiotic resistance, so we should take every opportunity to educate them.
In % of antibiotics were taken without a prescription, this is a particular problem in patients under 24 years. So take the opportunity to stress not to share antibiotics.
There is a READ code for delayed/ back-up antibiotics or leaflet given and if you Read code the infections featured the leaflet with EMIS and some other systems this leaflet will appear on your computer via the patient.co.uk system.
Extra notes for presenter: Most prescribers have access to many leaflets, both paper ones and ones that can be printed off their computer system or the web. However, not all information resources are based on the best available evidence or have been developed through rigorous processes. The Antibiotic Information Leaflet has been developed through over 24 months of literature searching, consultation, focus groups with patients and staff, drafting and revision.
Overview of the leaflet
To use this leaflet properly, it is important that clinicians use it as a tool to interact with patients, rather than just handing it to them as a ‘parting gift’. In order to communicate this effectively you must make sure that you are very familiar with its content. Please make sure that, in addition to completing this training, you take some time to thoroughly familiarise yourself with the leaflet before you start using it. .
Back-up prescription
Information about antibiotics & AMR
Read codes: Delayed:8CAk, Leaflet: 8CE
TARGET Antibiotics Presentation - CS:Acute Cough

15. TARGET: e-Bug & TARGET pictorial TYI leaflet
16 September, 2019
Clinical Scenario
Acute Cough
Operated by
Public Health England
Presenter notes:
Teaching about antibiotic use and resistance is particularly challenging with lower ability groups. Lower participant ability often find the current self-care leaflets available on TARGET and patient.co.uk difficult to understand. In a pilot e-Bug course community users were not engaged by text based self-care leaflets. Initial discussions with community groups indicated that many do not know how long common infections usually last, what they can do to look after themselves and where or when to get appropriate help if their symptoms worsen. Therefore, this formed the basis of the aims of the pictorial leaflet; Managing Your Infection Leaflet: A step-by-step guide on how to manage your infection.
The aims of the pictorial leaflet for self-limiting respiratory tract infections are:
To increase the public understanding about the length of time symptoms of common infections usually last
To increase the public’s confidence on how to self-care appropriately for common infections
To increase public knowledge about what symptoms should prompt them to seek help from their GP practice or other health professional
To increase awareness about the importance of using tissues and handwashing to prevent the spread of infection
To increase the public’s trust in the pharmacists advice
The leaflet is found on the TARGET website next to the TARGET RTI leaflet.
TARGET Antibiotics Presentation - CS:Acute Cough

16. TARGET: Acute Cough Audit
16 September, 2019
Clinical Scenario
Acute Cough
The TARGET website has audit templates for:
Acute otitis media
UTI
Sore Throat
Acute Cough
Otitis Externa
Acute Rhinosinusitis
The TARGET audits can be used to identify how compliant prescribers are with PHE and NICE prescribing guidance. The audits are carried out in excel and will auto calculate your compliance against guidelines.
Excel template auto calculates prescribing compliance for you!
TARGET Antibiotics Presentation - CS:Acute Cough

17. TARGET: Resources for clinical and waiting areas
16 September, 2019
Clinical Scenario
Acute Cough
Posters for Display
Presenter notes:
These posters and videos may make a difference to patient expectations about when to expect antibiotics, IF used in the waiting room where patients can see them and IF they have the time to digest the information. In % of the general public surveyed remembered seeing the first poster and 95% of these correctly answered that antibiotics don’t help most coughs and colds. Used alone without any other strategies posters will make little difference to patients expectations for antibiotics, but they can be used to reduce expectations and can be used as a prompt for dialogue –
“you may have seen from the posters or videos in the waiting room that we in this practice encourage responsible antibiotic prescribing”
The videos were developed with patients and each animal cartoon video appealed to different people. A recent small survey of their use showed that those patients who saw them remembered the messages – however often the video sound was muted, chairs were pointing in the wrong direction or the video screen was off. If you intend to use them please don’t make this mistake.
Videos for patient waiting areas
TARGET Antibiotics Presentation - CS:Acute Cough

18. What actions can you agree with you team for this year?
Acute cough: Reflect on actions your practice can take to improve prescribing
16 September, 2019
Evidence
Most patients with acute cough do not require antibiotics
reducing antibiotic prescribing can reduce consultations
Patients trust you to give reassurance and advice
QP demands sustained reduction of total antibiotics in primary care, with items/STAR-PU < 2013/14 mean performance value of items/STAR-PU.
Clinical Scenario
Acute Cough
Presenter notes:
Thus
Most patients with acute cough do not require antibiotics
Reducing antibiotic prescribing can reduce consultations
Patients trust you to give reassurance and advice
What actions can we agree for this year?
Try to get to get participants to suggest some of the things that others have used in their practice – including the things on this list. The next slide details them
Use antibiotic guidance so consistent approach in practice – use the local or direct to the PHE one with rationale on the RCGP website, and make sure used by all in the practice
Use NO, or back-up antibiotic and safety net – discuss how this could be done in their practice
Use the TARGET leaflet: discuss how they use leaflets and if they know about the TARGET leaflet
Consider CRP to guide in difficult cases or for clinicians with particularly high antibiotic use
Consider and audit of antibiotic use in acute cough using the resource on the RCGP website
Complete the free RCGP RTI clinical course
What actions can you agree with you team for this year?
TARGET Antibiotics Presentation - CS:Acute Cough

19. Clinical Scenario: Acute Cough Action Planning
16 September, 2019
Clinical Scenario
Acute Cough
Action planning for next 12 months: Agree What, How, Who, When
Promote use of PHE or local antimicrobial / management of infection guidelines by all in practice
Consider use of CRP point of care testing when considering antibiotics and/or doubt the need for antibiotics (it is not recommended in all patients with acute cough only in line with PHE guidance, if there is diagnostic uncertainty or patient pressure or antibiotic being considered)
Encourage use of TARGET Treating Your Infection – Respiratory Tract infection (TYI-RTI) leaflet and share on clinical system.
Encourage consistent message from different staff and when patients re-attend.
Perform and encourage others to preform audit. Re-audit in 4 months - identify a date when you will repeat the audit.
Record actions required, especially when compliance with primary care guidance is less than 80%.
Reduce co-amoxiclav use.
Consider developing a target for antibiotic prescribing rate. e.g. 1 in 3 immediate, 1 in 3 delayed, 1 in 3 no antibiotic)
Make use of TARGET toolkit.
Presenter notes:
Thus
Most patients with acute cough do not require antibiotics
Reducing antibiotic prescribing can reduce consultations
Patients trust you to give reassurance and advice
What actions can we agree for this year?
Try to get to get participants to suggest some of the things that others have used in their practice – including the things on this list, and get them to agree who should be responsible to take the action forward and by when.
Use antibiotic guidance so consistent approach in practice – use the local or direct to the PHE one with rationale on the RCGP website, and make sure used by all in the practice
Use NO, or back-up antibiotic and safety net – discuss how this could be done in their practice
Use the TARGET leaflet: discuss how they use leaflets and if they know about the TARGET leaflet
Consider CRP to guide in difficult cases or for clinicians with particularly high antibiotic use
Consider and audit of antibiotic use in acute cough using the resource on the RCGP website
Complete the free RCGP RTI clinical course
TARGET Antibiotics Presentation - CS:Acute Cough