Respiratory tract infections -

antibiotic prescribing
Implementing NICE guidance

2008

NICE clinical guideline 69

 What this presentation covers

Background

Recommendations

Costs and savings

Discussion

Find out more

 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
 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
 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)
 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

 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
 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
 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
 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
 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
 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
 Costs and savings
per 100,000 population

Savings
Recommendations with significant 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 –4,200
 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
 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?
 Find out more

Visit www.nice.org.uk/CG069 for:

• Other guideline formats

• Costing report and template
• Audit support