Respiratory tract infections (RTIs) are the commonestacute problem dealt with in primary care. Most will be selflimiting and in this case the risk of complications is likelyto be small.

However the dilemma for the clinician is being able to spotwhether an apparently minor RTI may be something morecomplicated. Careful decisions also have to be madeabout when to prescribe antibiotics.

What is a self-limiting infection?Self-limiting RTIs will resolve on their own without treat-ment and will have no long term effect on a person’shealth.

NICE says the duration of uncomplicated RTIs are:

l Acute otitis media: 4 days

l Acute sore throat/acute pharyngitis/acute tonsillitis:1 week

l Common cold: 10 days

l Acute rhinosinusitis: 21/2 weeks

l Acute cough/acute bronchitis: 3 weeks

The clinical assessment should include a history (present-ing symptoms, use of over-the- counter or self medica-tion, previous medical history, relevant risk factors,relevant comorbidities) and examination to identify rele-vant clinical signs (temperature, respiratory rate and cap-illary refill time in children under 5).

It is important to understand why the patient is presentingat this point in their illness and what their ideas, concernsand expectations are.

The NICE 2008 Res-piratory tract infec-tions (self limiting):prescribing antibi-otics guideline sayswhile most patientscan be reassuredthat they are not atrisk of major compli-cations, the diffi-culty for prescriberslies in identifyingthe small number ofpatients who willsuffer severe and/or prolonged illness or, more rarely, goon to develop complications. The Guideline DevelopmentGroup struggled to find much good evidence to informthis issue and says this is an area where further researchis needed.

How to deal with patients expecting an antibioticDr Gruffydd Jones, GP Principal and Joint Policy LeadPCRS-UK, says many patients will come in expecting an-tibiotics. The clinician should evaluate whether immediateantibiotics are needed (see box) and if not address theirconcerns and expectations, explain why an antibiotic will

Volume 2 Issue 4 December 201518

Primary Care Respiratory UPDATE

Fran Robinson talks to Dr Kevin Gruffydd-Jones, PCRS-UK policy advisor and author of the PCRS-UK opinion sheet on cough

Managing dilemmas in respiratory tract infectionsand antibiotics prescribing

GETTING THE BASICS RIGHT

Dec layout2_Layout 1 08/12/2015 16:41 Page 20

not cure their symptoms and educate them that theircondition will be self limiting.

If the patient is still worried, issuing them with a delayedantibiotic prescription can be an effective strategy.

A paper published in the BMJ in March 2014 by Paul Little,Professor of Primary Care Research, University ofSouthampton, and chair of the NICE Respiratory tractinfections (self limiting): prescribing antibiotics guideline,found that patients judged not to need immediate antibi-otics but given a delayed antibiotic prescription resultedin fewer than 40% of patients using antibiotics.1 Impor-tantly, when these patients were interviewed again theysaid they would be less likely to come back to the doctorin future because they understood that antibiotics wereunlikely to resolve a self limiting infection. Patients givena delayed antibiotic had the same symptom outcomes asthose given an immediate prescription.

When the no antibiotic prescribing strategy is adopted,patients should be offered:

l Reassurance that antibiotics are not needed immedi-ately because they are unlikely to make significantdifference to symptoms and may have side effects

l A clinical review if their condition worsens or becomesprolonged

When the delayed antibiotic prescribing strategy isadopted, patients should be offered:

l Reassurance that antibiotics are not needed immedi-ately because they are unlikely to make significantdifference to symptoms and may have side effects

l Advice about using the delayed prescription if symp-toms are not starting to settle in accordance with theexpected course of the illness or if a significant wors-ening of symptoms occurs

l Advice about re-consulting if there is a significantworsening of symptoms despite using the delayedprescription.

Volume 2 Issue 4 December 2015 19

Primary Care Respiratory UPDATE

When should antibiotics be prescribed?

No antibiotics or delayed antibiotic prescriptionsshould be given when patients have:

l Acute otitis medial Acute sore throat/acute pharyngitis/acute

tonsillitis

l Common cold

l Acute rhinosinusitis

l Acute cough/acute bronchitis.

Unless patients are systemically unwell and/or have: l Bilateral acute otitis media (in children younger

than 2 years)

l Acute otitis media (in children with otorrhoea)l Acute sore throat/acute pharyngitis/acute

tonsillitis when three or more Centor criteriaare present:

o Fever(>38degC) o Tender cervical lymphadenopathy o Tonsillar exudate o Absence of coughl Signs of community acquired pneumonia (CAP)

(see below) - in which case they should beconsidered for an immediate antibiotic prescrib-ing strategy

Or:

l Patients have signs of developing complications l If the patient is at high risk of serious complica-

tions because of pre-existing comorbidity. Thisincludes patients with significant heart, lung,renal, liver or neuromuscular disease, immuno-suppression, cystic fibrosis, and young childrenwho were born prematurely

l If the patient is older than 65 years with acutecough and two or more of the following criteria,or older than 80 years with acute cough and oneor more of the following criteria:

o hospitalisation in previous year o type 1 or type 2 diabetes o history of congestive heart failure o current use of oral glucocorticoids

Dec layout2_Layout 1 08/12/2015 16:41 Page 21

Volume 2 Issue 4 December 201520

Primary Care Respiratory UPDATE

Community Acquired Pneumonia (CAP) The typical symptoms of CAP are acute onset cough,fever, breathlessness and pleuritic chest pain, The BTSGuidelines on Community Acquired Pneumonia 2009state that a diagnosis of CAP should be considered in thepresence of typical symptoms and a patient who is sys-temically unwell (e.g. temperature > 38 deg C), presenceof new focal signs in the chest and no other obviousexplanation for these signs.

Recent NICE guidelines on pneumonia say that in primarycare a chest X-ray is not essential to make a diagnosis ofCAP. They recommend that a point of care C-reactive pro-tein (CRP) blood test should be used to help decide whetherpatients presenting with mild pneumonia need antibiotics.However Dr Gruffydd Jones says this is an extra refinementwhich isn't currently available for most clinicians in UK gen-eral practice. The test is carried out routinely in a number ofother countries but there is a cost issue about buying theequipment for GP surgeries in the UK. For many GP’s CRPtesting has to be carried out in a local laboratory.

NICE advises:

l do not routinely offer antibiotics if the C-reactiveprotein concentration is less than 20 mg/litre

l consider a delayed antibiotic prescription if theC-reactive protein concentration is between 20 and100 mg/litre

l do offer antibiotic therapy if C-reactive proteinconcentration is greater than 100 mg/litre

NICE also advises GPs to use the CRB65 risk score whenmaking a judgement about whether patients should bereferred to hospital. The CRB65 score assigns pointsbased on the criteria of Confusion, raised Respiratory rate(>30/min in adults) low Blood pressure (<90/60) andolder age (≥65).

NICE says GPs can consider home-based care for patientswith a score of zero, but should consider hospital assess-ment for other patients, particularly those with a score oftwo or higher.

Dr Gruffydd Jones says that clinical judgement is stillimportant especially in the systemically unwell patient.

Treatment of CAPThe vast majority of patients with CAP have a mild formof the disease and can be managed effectively in thecommunity by GPs.

NICE says if an antibiotic is needed patients should begiven a five day course of a single antibiotic (e.g. amoxi-cillin 500mg tds or Clarithromycin 500mg tds) and askedto come back if their symptoms do not improve withinthree days. Patients should be told their fever will subsidewithin a week but it may take up to six months for themto get completely back to normal.

Management of acute cough in children and adults Acute cough is a common presentation and whether it’sa child or an adult it is usually associated with a viral upperRTI. In the absence of any significant co-morbidity acutecough is likely to be self-limiting clearing up within threeweeks. However, 10 to 15% of patients return within onemonth.

Dr Gruffydd-Jones says the most important differentialdiagnosis of acute cough in adults is: have they got pneu-monia and are they going to require antibiotics?

He recommends a safety net approach - ask patients toreport back if their cough is not better in three weeksbecause this may be the first indication of a chronic con-dition. In a child it could be the first presentation ofasthma or bronchiectasis and it important to rememberan inhaled foreign body. In particular, a child who has apersistent wet cough for more than 4 weeks may havepersistent bacterial bronchitis, a condition which mightneed a 2-4 week course of broad spectrum antibiotics.

In an adult it may be the first presentation of COPD,bronchiectasis or lung cancer. Indications which re-quire further investigation in adults include suspicionof inhaled foreign body or haemoptysis, prominentsystemic illness, suspicion of lung cancer (Red Flag).

Dec layout2_Layout 1 08/12/2015 16:41 Page 22

Volume 2 Issue 4 December 2015 21

Primary Care Respiratory UPDATE

BronchiolitisBronchiolitis is the most common disease of the lowerrespiratory tract during the first year of life.

Symptoms include:

l a rasping and persistent dry coughl rapid or noisy breathing l brief pauses in breathingl feeding less and having fewer wet nappiesl vomiting after feedingl being irritable

In primary care the condition may be confused with thecommon cold though the presence of lower respiratorytract signs (wheeze and/or crackles on auscultation) in aninfant would be consistent with bronchiolitis.

The symptoms are usually mild and may only last a fewdays and can be managed at home without needingtreatment. In some cases the disease can cause severeillness and infants will need to be treated in hospital.

Bronchiolitis is a viral infection so antibiotics arenot indicated. NICE says corticosteroids are notrecommended.

Reference1. Delayed antibiotic prescribing strategies for respiratory tract infections in primary care: pragmatic, factorial, randomised controlled trial. BMJ 2014;348:g1606 http://www.bmj.com/content/348/bmj.g1606

The advice in this article has been collated from the following guidelines: • Respiratory tract infections (self-limiting): prescribing antibiotics. NICE guidelines

CG69, July 2008 https://www.nice.org.uk/guidance/cg69• Pneumonia in adults: diagnosis and management. NICE guideline CG191 December 2014. https://www.nice.org.uk/guidance/cg191 • BTS guidelines of the management of community-acquired pneumonia in adults

2009. https://www.brit-thoracic.org.uk/guidelines-and-quality-standards/commu-nity-acquired-pneumonia-in-adults-guideline

• PCRS-UK Opinion sheet on community acquired pneumonia in adults. September2013 https://www.pcrs-uk.org/system/files/Resources/Opinion-sheets/os33_pneumonia.pdf

• BTS guidelines for the management of community acquired pneumonia in adults:update 2009. http://thorax.bmj.com/content/64/Suppl_3/iii1.full

• BTS guidelines on cough management 2006. https://www.brit-thoracic.org.uk/guidelines-and-quality-standards/cough-in-adults-recommenda-tions

• Bronchiolitis in children: diagnosis and management. NICE guideline. June 2015https://www.nice.org.uk/guidance/ng9

• Antimicrobial stewardship: system and processes for effective antimicrobial medi-cine. NICE 2015. http://www.nice.org.uk/guidance/ng15

Learning Objectives

After reading this article you will understand:

l How to deal with a self-limiting RTI

l When antibiotics should be prescribed for an RTI

l How to deal with patients who demand an antibiotic whenthey don’t need one

Ideas for further study and reflection:

l Conduct a search of patients who were given antibioticsfor an RTI and ask yourself whether those antibiotics wereprescribed appropriately.

l Read the NICE guideline Antimicrobial stewardship: sys-tem and processes for effective antimicrobial medicine useto find out more about how to use antibiotics effectively

l Are you confident you could spot when a respiratoryinfection is CAP? Read up the BTS and NICE guidance anddownload the PCRS-UK opinion sheet on CAP.

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