1 Guidance

The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance.

The clinical effectiveness and cost effectiveness of antibiotic management strategies for respiratory tract infections (RTIs)

1.1 At the first face-to-face contact in primary care, including walk-in centres and emergency departments, adults and children (3 months and older) presenting with a history suggestive of the following conditions should be offered a clinical assessment:

  • acute otitis media

  • acute sore throat/acute pharyngitis/acute tonsillitis

  • common cold

  • acute rhinosinusitis

  • acute cough/acute bronchitis.

    The clinical assessment should include a history (presenting symptoms, use of over-the-counter or self medication, previous medical history, relevant risk factors, relevant comorbidities) and, if indicated, an examination to identify relevant clinical signs.

1.2 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).

1.3 A no antibiotic prescribing strategy or a delayed antibiotic prescribing strategy should be agreed for patients with the following conditions:

  • acute otitis media

  • acute sore throat/acute pharyngitis/acute tonsillitis

  • common cold

  • acute rhinosinusitis

  • acute cough/acute bronchitis.

    Depending on clinical assessment of severity, patients in the following subgroups can also be considered for an immediate antibiotic prescribing strategy (in addition to a no antibiotic or a delayed antibiotic prescribing strategy):

  • bilateral acute otitis media in children younger than 2 years

  • acute otitis media in children with otorrhoea

  • acute sore throat/acute pharyngitis/acute tonsillitis when three or more Centor criteria are present.

1.4 For all antibiotic prescribing strategies, patients should be given:

  • advice about the usual natural history of the illness, including the average total length of the illness (before and after seeing the doctor):

    • acute otitis media: 4 days

    • acute sore throat/acute pharyngitis/acute tonsillitis: 1 week

    • common cold: 1½ weeks

    • acute rhinosinusitis: 2½ weeks

    • acute cough/acute bronchitis: 3 weeks

  • advice about managing symptoms, including fever (particularly analgesics and antipyretics). For information about fever in children younger than 5 years, refer to 'Feverish illness in children' (NICE clinical guideline 47).

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

  • reassurance that antibiotics are not needed immediately because they are likely to make little difference to symptoms and may have side effects, for example, diarrhoea, vomiting and rash

  • a clinical review if the condition worsens or becomes prolonged.

1.6 When the delayed antibiotic prescribing strategy is adopted, patients should be offered:

  • reassurance that antibiotics are not needed immediately because they are likely to make little difference to symptoms and may have side effects, for example, diarrhoea, vomiting and rash

  • advice about using the delayed prescription if symptoms are not starting to settle in accordance with the expected course of the illness or if a significant worsening of symptoms occurs

  • advice about re-consulting if there is a significant worsening of symptoms despite using the delayed prescription.

    A delayed prescription with instructions can either be given to the patient or left at an agreed location to be collected at a later date.

Identifying those patients with RTIs who are likely to be at risk of developing complications

1.7 An immediate antibiotic prescription and/or further appropriate investigation and management should only be offered to patients (both adults and children) in the following situations:

  • if the patient is systemically very unwell

  • if the patient has symptoms and signs suggestive of serious illness and/or complications (particularly pneumonia, mastoiditis, peritonsillar abscess, peritonsillar cellulitis, intraorbital and intracranial complications)

  • if the patient is at high risk of serious complications because of pre-existing comorbidity. This includes patients with significant heart, lung, renal, liver or neuromuscular disease, immunosuppression, cystic fibrosis, and young children who were born prematurely

  • if the patient is older than 65 years with acute cough and two or more of the following criteria, or older than 80 years with acute cough and one or more of the following criteria:

    • hospitalisation in previous year

    • type 1 or type 2 diabetes

    • history of congestive heart failure

    • current use of oral glucocorticoids.

      For these patients, the no antibiotic prescribing strategy and the delayed antibiotic prescribing strategy should not be considered.

  • National Institute for Health and Care Excellence (NICE)