Most people will develop an acute respiratory tract infection (RTI) every year. RTIs are also the commonest acute problem dealt with in primary care – the 'bread and butter' of daily practice. Management of acute RTIs in the past concentrated on advising prompt antibiotic treatment of presumptive bacterial infections. This advice was appropriate, in an era of high rates of serious suppurative and non-suppurative complications, up to and including the immediate post-war period. However, in modern developed countries, rates of major complications are now low. In addition, there is no convincing evidence, either from international comparisons or from evidence within countries, that lower rates of prescribing are associated with higher rates of complications. Therefore much of the historically high volume of prescribing to prevent complications may be inappropriate. After a fall in antibiotic use in the late 1990s, antibiotic prescribing in the UK has now reached a plateau and the rate is still considerably higher than the rates of prescribing in other northern European countries. Most people presenting in primary care with an acute uncomplicated RTI will still receive an antibiotic prescription – with many doctors and patients believing that this is the right thing to do.
There may be several problems with this. First, complications are now much less common, so the evidence for symptomatic benefit should be strong to justify prescribing; otherwise many patients may have unnecessary antibiotics, needlessly exposing them to side effects. Second, except in cases where the antibiotic is clinically necessary, patients, and their families and friends, may get the message from healthcare professionals that antibiotics are helpful for most infections. This is because patients will understandably attribute their symptom resolution to antibiotics, and thus maintain a cycle of 'medicalising' self-limiting illness. Third, international comparisons make it clear that antibiotic resistance rates are strongly related to antibiotic use in primary care. This is potentially a major public health problem both for our own and for future generations; unless there is clear evidence of benefit, we need to maintain the efficacy of antibiotics by more judicious antibiotic prescribing.
Following a review of the evidence, we have tried to produce simple, practical guidance for antibiotic prescribing for all of the common, acute, uncomplicated, RTIs, with recommendations for targeting of antibiotics. The guideline includes suggestions for safe methods of implementing alternatives to an immediate antibiotic prescription – including the 'delayed' antibiotic prescription.
The Guideline Development Group (GDG) recognised the concern of GPs and patients regarding the danger of developing complications. While most patients can be reassured that they are not at risk of major complications, the difficulty for prescribers lies in identifying the small number of patients who will suffer severe and/or prolonged illness or, more rarely, go on to develop complications. The GDG struggled to find much good evidence to inform this issue. This is clearly an area where further research is needed. In the meantime, GPs need to take 'safety-netting' approaches in the case of worsening illness, either by using delayed prescriptions or by prompt clinical review.
This is one of the new National Institute for Health and Clinical Excellence (NICE) short clinical guidelines. The methodology is of the same rigour as for the standard NICE clinical guidelines, but the scope is narrower, and the development and consultation phases have been compressed. In particular, the detailed issues surrounding the diagnosis of acute RTIs and the use of diagnostic tests during the consultation could not be adequately dealt with in such a short timescale. We hope that the guideline will be welcomed by those who manage and experience the clinical care of acute respiratory infections.
Professor of Primary Care Research, GP and Chair, Guideline Development Group