RESPIRATORY TRACT INFECTIONS

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RESPIRATORY TRACT INFECTIONS Powered By Docstoc
					Common infections: Respiratory tract
infections
Slide 1: Managing respiratory tract infections


This short presentation is one of a series of resources available via NPCi on the management of
common respiratory tract infections (RTIs). A range of online learning materials on common infections
can also be accessed via the common infections floor of NPCi. The first part of this presentation
summarises the basic principles around antibiotic prescribing. We will also highlight the key points
from the NICE guidance on RTIs. The subsequent slides consider the management of five common
infections of the respiratory tract: common cold, sore throat, otitis media, sinusitis and acute bronchitis.

Slide 2: Setting the scene


Let’s briefly consider the wider context for this workshop. RTIs are the most commonly encountered
acute problem in primary care, perhaps even the ‘bread and butter’ of general practice. In the past, the
management of RTIs would have involved prompt antibiotic treatment for anything considered to be a
bacterial infection. This was appropriate, up to and immediately after, the post-war period, when rates
of complications following common infections were generally much higher than in the modern era.
However complications are now much more uncommon in developed countries, due, for example to
better living conditions and nutrition. Yet many people presenting in general practice still receive an
antibiotic. There are several problems with this approach; these include the emergence of bacterial
resistance, the medicalising of self-limiting illness, which could equally well be managed in other ways,
and exposure to drug side effects. Therefore historical practice may no longer now be appropriate.

Slide 3: So what are we saying now?


In these workshops we aren’t saying that antibiotics should never be prescribed for common acute
RTIs. However, because of the emergence of antibiotic resistance in recent years, they should be
considered as a finite resource. We need to better target their use to those patients with serious
bacterial infections, who are at risk of suffering severe or prolonged illness, or are in danger of
developing complications. Antibiotic resistance rates are highly correlated with antibiotic use in primary
care and therefore inappropriate prescribing of these drugs can lead to major public health problems.
This means we need to try and maintain the effectiveness of antibiotics by prescribing them carefully,
targeting treatment to those at greatest risk, and those most likely to benefit. During this short
presentation we’ll look at the recommendations within NICE guidance on how to identify those patients
most at risk and how to target antibiotic treatment most appropriately.

Slide 4: Harms of antibiotics

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This resource has been produced with the support of a number of NHS individuals and organisations. It is intended as a template from which you
can produce local versions adapted to your own local needs.
In the past, prompt antibiotic treatment was considered necessary to prevent complications of acute
RTIs. However, complications are now rare and many patients receive antibiotics unnecessarily,
becoming needlessly exposed to their adverse effects. For example, a Cochrane review showed that a
child with acute otitis media is almost as likely to experience increased harm as any increased benefit
following antibiotic treatment. Fifteen patients need to be treated with antibiotics to gain pain relief in
one extra patient at Days 2–7. However, for every 16 patients treated with antibiotics, one extra will
suffer harms such as diarrhoea, vomiting or rash. In addition, we can’t tell when prescribing an
antibiotic, whether that individual patient will benefit, or whether they will suffer harm. This issue is
discussed further in the less than 60 minute workshop on otitis media.


And as we’ve said, antibiotic resistance increases with increasing exposure to antibiotics, either on an
individual or population basis. It’s also worth considering that there is some evidence that antibiotic
prescribing encourages repeat attendance by patients, who may conclude that antibiotics are
necessary for what would otherwise be self-limiting infections. Patients may assume their symptoms
have resolved because of the antibiotic, not because the infection would have resolved in that time
anyway. The bottom line here is that, in each person the benefits of antibiotic prescribing need to be
balanced against the risks for that individual and for the population. We’ll now look at the
recommendations in the NICE guideline on common acute RTIs in more detail.

Slide 5: What does NICE say?


NICE recommends that antibiotics should be offered immediately, with or without further appropriate
investigation or management, in certain cases as shown here. For example, if the patient is likely to
have a serious bacterial infection, or is at risk of suffering a prolonged or severe illness or
complications, or if he/she is systemically unwell or has pre-existing comorbidities such as heart or
lung disease.



Slide 6: But for most people antibiotics are unnecessary


However NICE recommends that the majority of adults and children aged over 3 months with common
RTIs, who are otherwise well, should not normally receive antibiotics. They add that patients’
concerns and expectations should be assessed and addressed; however, that shouldn’t be taken to
imply that NICE are suggesting that prescribers should respond to patient demands for an immediate
antibiotic where this is not clinically appropriate.

Slide 7: But don’t antibiotics prevent complications?


A recent study looked at the risk of serious complications among patients with RTIs given antibiotics
and those not given antibiotics, in a large UK general practice sample. It found that more than 4000
people without other risk factors, presenting with sore throat, otitis media or other upper RTIs, would
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This resource has been produced with the support of a number of NHS individuals and organisations. It is intended as a template from which you
can produce local versions adapted to your own local needs.
have to be treated with antibiotics to prevent one case of quinsy, mastoiditis or pneumonia. However,
in patients with lower RTIs, especially older people, antibiotics may be useful in preventing
pneumonia: 39 people aged 65 years and older would need to be treated with antibiotics to prevent
one case of pneumonia, compared with 119 people aged 16–64 years.


This study reassures us that, although antibiotics do slightly reduce the rate of complications of upper
RTIs, these are now so rare that several thousands of patients would need to be treated — and
exposed to the risk of unpleasant side effects — to prevent one complication. The bottom line as
NICE suggest, is that primary care prescribers should not base their prescribing for sore throats, otitis
media or other upper RTIs on a fear of serious complications. For people presenting with lower RTIs it
is important to assess their baseline risk of pneumonia, assess the signs and symptoms and their
severity and then consider, on the basis of all this, which antibiotic management strategy should be
used.

Slide 8: Offer the patient reassurance and a safety net


NICE stresses the need for safety-netting approaches if the patient’s illness worsens or becomes
prolonged, either by use of delayed antibiotic prescriptions or by offering a prompt clinical review. If a
delayed prescription is given, patients should be given advice on using it if symptoms worsen or aren’t
resolving as expected. Similarly, if symptoms worsen despite using the delayed prescription, the
patient should be advised to re-consult.

Slide 9: Patient information and advice


It’s important that patients understand that the symptoms of some common infections can last for a
prolonged period. Either written or structured verbal information can be helpful here. For example, the
average duration of symptoms of acute cough is 3 weeks. [Note to presenters: do you have local
patient information leaflets for RTIs? If so, refer to them here. If not, recommend other sources
such as CKS/Prodigy leaflets which may be printed off from practice computer systems during
a consultation] This means that many patients will have symptoms lasting much longer than this,
whereas in other patients the illness will resolve quite quickly. Patients should be advised that, while
often unpleasant, these are self-limiting illnesses, and, for the majority of patients, antibiotics make
little difference to symptoms, and may confer side effects. Advice on use of symptomatic treatments,
such as analgesics and antipyretics should also be offered when appropriate. The NICE guideline on
‘feverish illness in children’ gives information on treating fever in children aged less than 5 years. The
patient decision aids on the common infections floor of NPCi may also help to convey these
messages. Let’s now consider management strategies for individual common RTIs.



Slide 10: Common cold


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This resource has been produced with the support of a number of NHS individuals and organisations. It is intended as a template from which you
can produce local versions adapted to your own local needs.
The common cold is a mild, self-limiting illness that is usually caused by a virus. Symptoms typically
resolve in around 10 days but can sometimes last up to 3 weeks.


Although antibiotics have shown a slight benefit in reducing the duration of acute purulent rhinitis, they
have not been shown to improve other cold symptoms. Any clinical benefit of antibiotics is likely to be
small, and patients may suffer adverse effects. As most patients with the common cold will recover
without antibiotics, they should only be used in patients who are at risk of suffering prolonged or
severe illness or complications, for example, if they are systemically unwell or have pre-existing
comorbidities.


For patients who don’t need immediate antibiotics, a safety net should be offered just in case their
illness worsens or becomes prolonged, for example, a prompt clinical review or a delayed prescription.
Patients should be given advice on using the delayed prescription if symptoms worsen or aren’t
resolving as expected. Similarly, if symptoms worsen despite using the delayed prescription, the
patient should be advised to re-consult.


Analgesics or anti-inflammatory drugs are appropriate to relieve pain or fever. There is little or no
evidence to support the use of other symptomatic treatments. Explaining that a cold will resolve
without treatment, and providing advice on symptomatic therapy, may reassure patients and prevent
future consultations.

Slide 11: Sore throat


Sore throat is a self-limiting illness which for the majority of patients will resolve in around 1 week.
Serious complications are rare and antibiotics are not routinely indicated. They should only be used in
patients who are at risk of suffering prolonged or severe illness or complications, for example, if they
are systemically unwell or have pre-existing comorbidities.


Clinical prediction rules such as the CENTOR criteria may help target those who are most likely to
have a streptococcal infection and who therefore, are most likely to benefit from antibiotic treatment.
However antibiotics may make little or no difference even to those with mild or moderate bacterial
infections.


Remember that patients given antibiotics for a sore throat are more likely to re-attend if they have a
subsequent infection. Not giving antibiotics has been shown to reduce future consultation rates.
However, a safety net should be offered just in case illness worsens or becomes prolonged, for
example, a prompt clinical review or a delayed prescription. Patients should be given advice on using
the delayed prescription if symptoms worsen or aren’t resolving as expected. Similarly, if symptoms
worsen despite using the delayed prescription, the patient should be advised to re-consult. Advice and


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This resource has been produced with the support of a number of NHS individuals and organisations. It is intended as a template from which you
can produce local versions adapted to your own local needs.
reassurance should be offered in all cases and analgesics can be recommended for symptom relief if
necessary.

Slide 12: Acute otitis media


Acute otitis media in children is also largely a self-limiting condition. Parents can be reassured that
complications are very uncommon and the great majority of children recover without treatment in
around 4 days.


Antibiotic treatment should not be offered routinely because any benefit in terms of pain reduction is
balanced out by an increased risk of adverse effects, such as vomiting, diarrhoea or rash. However, a
safety net should be offered just in case illness worsens or becomes prolonged, for example, a prompt
clinical review or a delayed prescription. Patients should be given advice on using the delayed
prescription if symptoms worsen or aren’t resolving as expected. Similarly, if symptoms worsen
despite using the delayed prescription, the patient should be advised to re-consult.


Antibiotics may however be useful for some patients where the benefits may outweigh the risks of
adverse effects, for example, those who are systemically unwell or have pre-existing comorbidities.
Other subgroups of children who may benefit include those with symptoms suggestive of mastoiditis,
or who have otorrhoea, or who are younger than 2 years with bilateral acute otitis media.


Paracetamol or ibuprofen can be used for symptomatic relief of pain and fever. Other treatment
options appear to have little benefit.



Slide 13: Sinusitis


Neither should antibiotics be used routinely in sinusitis because 80% of patients will recover within 2
weeks without using them.


Antibiotics should be reserved for those patients who are at risk of suffering prolonged or severe
illness or complications, for example, those who are systemically unwell or have pre-existing
comorbidities.


A strategy of watchful waiting is appropriate for most patients. NICE recommends that a safety net
should be offered just in case illness worsens or becomes prolonged, for example, a prompt clinical
review or a delayed prescription. Patients should be given advice on using the delayed prescription if
symptoms worsen or aren’t resolving as expected. Similarly, if symptoms worsen despite using the
delayed prescription, the patient should be advised to re-consult.



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This resource has been produced with the support of a number of NHS individuals and organisations. It is intended as a template from which you
can produce local versions adapted to your own local needs.
Patients should be reassured that sinusitis will resolve without antibiotic treatment, although it may last
for several weeks. Advice on symptomatic therapy should also be offered. Analgesics may be useful
to relieve pain and fever.

Slide 14: Acute bronchitis


Finally, the majority of patients with acute cough associated with a RTI will do well without antibiotics.
However, we need to carefully exclude those with suspected pneumonia as best we can because they
are at much greater risk and need to be treated with antibiotics. Assessing the patient’s
characteristics, such as age and the presence of comorbidities; checking vital signs, and assessing
the severity of those signs, including measuring saturated oxygen using pulse oximetry where
possible, and by listening for any new focal signs in the chest, can help to exclude patients at risk of
pneumonia, and also determine if there is a need for hospital admission. In patients who are unlikely
to have pneumonia, management should then centre on patient reassurance, with the provision of a
patient information leaflet, and perhaps a delayed antibiotic prescription. Antipyretics or analgesics
may be offered where appropriate, but there is little evidence to support the use of other symptomatic
treatments such as cough suppressants.

Slide 15: Summary


So to summarise, there is now good published evidence that the routine prescribing of antibiotics for
common RTIs is no longer appropriate, may expose the patient to unnecessary side effects, and
increase the risk of resistance both at the individual and population level.


Over 4000 people with a common RTI would require treatment with an antibiotic in order to prevent
one serious complication. Therefore, given what we have said about the much greater risks of side
effects and antibiotic resistance, it’s no longer appropriate for prescribers to base their management
strategies for RTIs around the prevention of rare serious complications.


The bottom line is that the immediate prescription of an antibiotic for uncomplicated RTIs should be
reserved for those with risk factors for developing more serious complications, such as chronic heart
or lung disease, or diabetes. Consider instead the use of delayed- or no-antibiotic strategies, backed
up by written or structured verbal information and advice about the self-limiting nature of these
conditions, their natural time course and symptom management. Finally, offer the safety net of a
consultation should symptoms worsen unexpectedly or persist beyond the expected timeframe.




af1103a7-31d7-405e-8eca-60dbc53efaad.doc 11/10/2010                                                                     Page 6 of 6

This resource has been produced with the support of a number of NHS individuals and organisations. It is intended as a template from which you
can produce local versions adapted to your own local needs.