Guidance
Rationale and impact
Rationale and impact
These sections briefly explain why the committee made the recommendations and how they might affect practice.
All first contact with NHS services
Recommendations 1.1.1 and 1.1.2
Why the committee made the recommendations
The committee agreed that it was important to consider sepsis in people with a suspected acute respiratory infection (ARI) because, in their experience, sepsis was often secondary to a respiratory infection.
They also agreed that people whose symptoms can be managed at home should be given self-care advice and information about when to seek medical help. They also noted most ARIs are self-limiting.
Remote contact with NHS services at first presentation
Recommendations 1.2.1 to 1.2.4
Why the committee made the recommendations
There was no evidence on remote assessments for people with suspected ARI so the committee used their expertise and experience to make recommendations.
People contacting NHS services remotely do not have equal access to, or ability to use, digital technology. The committee agreed it was important to check the person is capable of using the technology being proposed and to offer alternatives, when necessary. They acknowledged that most remote assessments were by telephone and that most people could communicate that way.
People might have difficulties communicating if they have symptoms such as wheezing or breathlessness. The committee noted that the NHS has a duty to provide reasonable adjustments for people who need them, for example, face-to-face appointments or home visits.
There was insufficient evidence to make a recommendation about using specific symptoms and signs to diagnose pneumonia, and no evidence in this area for other types of ARIs. As a result, the committee was unable to be specific about the symptoms and signs that indicate a serious ARI. However, using their expertise and experience, they gave some examples of symptoms and signs that might indicate a more serious lower respiratory tract infection.
The committee agreed that it is not always possible to carry out an assessment remotely, because either the person with suspected ARI is having difficulties communicating or because the presentation of symptoms and signs is unclear. They noted that while remote assessments can be a useful tool for identifying people without serious illness, there were advantages to seeing a person face-to-face. They also emphasised that people with serious illness (including pneumonia and non-infective causes of their symptoms and signs) need to be seen face-to-face so a more thorough assessment can be carried out.
The committee agreed that if a person were ill enough to need antimicrobials, then, for safety reasons, they should be seen face-to-face. However, they were aware that some people are unable or find it difficult to attend face-to-face appointments. There might also be cases where the prescriber was confident in their diagnosis and the need for antimicrobials and so a face-to-face assessment was not needed.
The committee agreed that the face-to-face assessment could be in a range of different settings. For many people, face-to-face assessment at a general practice or elsewhere on the acute respiratory infection pathway, for example, ARI hubs, would be the right solution, but if a person was very ill or deteriorating quickly, then it would be important to direct them to an emergency department or arrange an emergency ambulance if required.
The committee was keen to explore whether any of the established early warning scores such as NEWS2 or CRB65 could help with decision making during remote assessments, including when and where to refer people, so they made a recommendation for research on using early warning scores in different settings.
How the recommendations might affect practice
Many people already have remote assessments with NHS services, through services such as NHS 111 or telephone appointments with general practice. These recommendations will help healthcare practitioners decide whether a person with an ARI needs to be seen in person and should improve antimicrobial stewardship by reducing the number of antimicrobials prescribed without a face-to-face assessment.
In-person contact with NHS services at first presentation
Recommendations 1.3.1 to 1.3.7
Why the committee made the recommendations
The committee was concerned that most of the evidence looked at older people, and that data for other groups (particularly those with protected characteristics) was not available. They also noted an absence of evidence about ARI during pregnancy and the post-partum period. They ensured that the specifications for the recommendations for research covered these gaps in the current evidence base.
The committee was disappointed with the overall amount and quality of evidence, which meant that they were unable to make recommendations that gave clear answers about what action a healthcare practitioner should take in a specific clinical situation.
The committee considered people who had an ARI but did not have pneumonia, for example, people with influenza (flu) or a common cold. They agreed that even though many ARIs are self-limiting, some people, such as those with comorbidities or multimorbidity and people who are frail, are more likely to have a poor outcome. Because of this, the thresholds for treatment or referral might need to be lowered.
The evidence showed that point-of-care (POC) microbiological tests for people with suspected ARIs were not accurate enough to determine whether an infection was bacterial or viral. The economic evidence for POC single pathogen tests was sparse and demonstrated no cost effectiveness and there was no evidence for POC multi-pathogen tests. The committee wanted clearer data about the accuracy of POC microbiological tests to be able to give more specific advice in future, so they made a recommendation for research on point-of-care microbiological tests. In the meantime, they agreed that clinical assessment was more reliable than POC tests for making a diagnosis and determining whether antimicrobials are needed.
The evidence for flu testing showed that some tests were reliable at identifying people with and without flu; however, the committee did not recommend them because the decision to prescribe antivirals for flu-like illness was based mainly on seasonal advice from the UK Health Security Agency (UKHSA). They noted that flu tests could be useful for surveillance and for infection control, but that was outside the remit of this guideline.
The committee agreed that the current evidence base for C‑reactive protein (CRP) testing is limited. They discussed some of the limitations of CRP testing, namely:
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a sample taken early in the course of infection can be falsely reassuring
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CRP response is unreliable for certain groups of people, for example, the very elderly, or during pregnancy and the post-partum period, who might not have typical CRP responses
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many primary care settings do not have access to point-of-care CRP testing.
The committee emphasised that prescribing decisions should never be made on the basis of CRP testing alone. Bearing all of this in mind, they agreed that CRP testing could support clinical decision making if, after clinical assessment, a lower respiratory tract infection was suspected but it was unclear if antibiotics were needed.
The evidence showed that using a CRP test result of 100 mg/litre or more as the threshold for giving antibiotics means that most people who test positive will have an infection. However, it also means that some infections may be missed. As the threshold gets lower, the chances of infections being missed reduces. However, the number of people who test positive but do not have an infection, increases. The committee agreed that a higher threshold was better in terms of antimicrobial stewardship.
The committee was concerned that antimicrobial resistance could not easily be factored into economic evaluations of ARI interventions and they made a recommendation for research on costing antimicrobial stewardship to address this.
Clinical diagnosis of pneumonia
The evidence showed that CRB65 might be a useful tool to estimate mortality risk. The committee agreed that it can serve as a useful check on clinical judgement when assessing the severity of pneumonia after a clinical diagnosis has been made. However, they noted that any results need to be considered in the context of other factors such as comorbidities or pregnancy and agreed that confusion can be very hard to assess in some people, for example, if they have a learning disability or autism. The committee discussed the thresholds for referral that were used by the 2014 NICE pneumonia guideline committee and agreed that they matched their expertise and experience.
The committee noted that further research is needed to validate both CRB65 and NEWS2 (the newer version of NEWS) in face-to-face assessments in primary care, community settings and ARI hubs. Therefore, they made a recommendation for research on using early warning scores in different settings to explore this.
The committee noted the importance of ARI hubs and ARI virtual wards in caring for people with ARI outside of hospital settings, but there is not enough evidence at present to make explicit recommendations about them.
How the recommendations might affect practice
The evidence suggests that the recommendations may reduce rates of inappropriate antimicrobial prescribing for people with ARI, and as well as reducing expenditure on unnecessary and ineffective treatments, this is good antimicrobial stewardship. The recommendations about microbiological testing and using CRB65 formed part of NICE's guideline on pneumonia and should not have any additional resource impact.