GETTING THE BASICS RIGHT

Transcription

1 GETTING THE BASICS RIGHT Managing diemmas in respiratory tract infections and antibiotics prescribing Dr Kevin Gruffydd-Jones and Dr Katherine Hickman Respiratory tract infections (RTIs) are the commonest acute probem deat with in primary care. Most wi be sefimiting, and in this case the risk of compications is ikey to be sma. The diemma for the cinician, however, is being abe to spot whether an apparenty minor RTI may be something more compicated. Carefu decisions aso have to be made about when to prescribe antibiotics. Antimicrobia resistance is one of the biggest threats to humanity. On 21 September 2016, 193 countries in the United Nations agreed a andmark decaration to rid the word of drug-resistant infections or superbugs. The majority of antibiotics in the UK are prescribed in primary care and we a have a responsibiity to prescribe responsiby. What is a sef-imiting infection? Sef-imiting RTIs wi resove on their own without treatment and wi have no ong-term effect on a person s heath. NICE says the duration of uncompicated RTIs are: Acute otitis media: 4 days Acute sore throat/acute pharyngitis/acute tonsiitis: 1 week Common cod: 10 days Acute rhinosinusitis: 2.5 weeks Acute cough/acute bronchitis: 3 weeks The cinica assessment shoud incude a history (presenting symptoms, use of over-the-counter or sef-medication, previous medica history, reevant risk factors, reevant comorbidities) and examination to identify reevant cinica signs (temperature, respiratory rate and capiary refi time in chidren under 5). It is important to understand why the patient is presenting at this point in their iness and what their ideas, concerns and expectations are. The NICE 2008 Respiratory tract infections (sef-imiting): prescribing antibiotics guideine says that, whie most patients can be reassured that they are not at risk of major compications, the difficuty for prescribers ies in identifying the sma number of patients who wi suffer severe and/or proonged iness or, more rarey, go on to deveop compications. The Guideine Deveopment Group strugged to find much good evidence to inform this issue and says this is an area where further research is needed. How to dea with patients expecting an antibiotic Dr Gruffydd Jones, GP Principa and Joint Poicy Lead PCRS-UK, says many patients wi come in expecting antibiotics. The cinician shoud evauate whether immediate antibiotics are needed (see Box). If not needed, the cinician shoud address their concerns and expectations, expain why an antibiotic wi not cure their symptoms and educate them that their condition wi be sef-imiting. Voume 5 Issue 1 SPRING

2 When shoud antibiotics be prescribed? No antibiotics or deayed antibiotic prescriptions shoud be given when patients have: Acute otitis media Acute sore throat/acute pharyngitis/acute tonsiitis Common cod Acute rhinosinusitis Acute cough/acute bronchitis Uness patients are systemicay unwe and/or have: Biatera acute otitis media (in chidren younger than 2 years) Acute otitis media (in chidren with otorrhoea) Acute sore throat/acute pharyngitis/acute tonsiitis when three or more Centor criteria are present: o Fever (>38 o C) o Tender cervica ymphadenopathy o Tonsiar exudate o Absence of cough Signs of community acquired pneumonia (CAP) (see beow), in which case they shoud be considered for an immediate antibiotic prescribing strategy Or: Patients have signs of deveoping compications If the patient is at high risk of serious compications because of pre-existing comorbidity. This incudes patients with significant heart, ung, rena, iver or neuromuscuar disease, immunosuppression, cystic fibrosis and young chidren who were born prematurey If the patient is oder than 65 years with acute cough and two or more of the foowing criteria, or oder than 80 years with acute cough and one or more of the foowing criteria: o hospitaisation in previous year o type 1 or type 2 diabetes o history of congestive heart faiure o current use of ora gucocorticoids The Roya Coege of Genera Practitioners has produced a tookit TARGET (Treating Antibiotics, Guidance, Education, Toos). It incudes a range of resources that can be used to support prescribers and patients responsibe antibiotic use and aid with difficut conversations with regard to antibiotic prescribing. These incude eafets for the patients which aim to increase their confidence to sefcare. They incude information on iness duration, sef-care advice, prevention advice and information on when to re-consut. Posters and videos for the TV in the waiting room are aso avaiabe. If the patient is sti worried, issuing them with a deayed antibiotic prescription can be an effective strategy. A paper pubished in the BMJ in March 2014 by Pau Litte, Professor of Primary Care Research, University of Southampton and Chair of the NICE Respiratory tract infections (sef-imiting): prescribing antibiotics guideine, found that patients judged not to need immediate antibiotics but given a deayed antibiotic prescription resuted in fewer than 40% of patients using antibiotics. 1 Importanty, when these patients were interviewed again they said they woud be ess ikey to come back to the doctor in future because they understood that antibiotics were unikey to resove a sef-imiting infection. Patients given a deayed antibiotic had the same symptom outcomes as those given an immediate prescription. When the no antibiotic prescribing strategy is adopted, patients shoud be offered: An onine too, the Fever PAIN Cinica Score, can aso be used to determine whether or not a patient needs an antibiotic when they present with a sore throat. The score consists of five items: Fever during previous 24 hours Puruence Attend rapidy ( 3 days) Very infamed tonsis No cough/coryza Using the sore throat too enabes rapid cacuation of the score, gives a treatment guide and provides a summary to cut and paste into the notes. Reassurance that antibiotics are not needed immediatey because they are unikey to make a significant difference to symptoms and may have side effects A cinica review if their condition worsens or becomes proonged 32 Voume 5 Issue 1 SPRING 2018

3 When the deayed antibiotic prescribing strategy is adopted, patients shoud be offered: Reassurance that antibiotics are not needed immediatey because they are unikey to make a significant difference to symptoms and may have side effects Advice about using the deayed prescription if symptoms are not starting to sette in accordance with the expected course of the iness or if a significant worsening of symptoms occurs Advice about re-consuting if there is a significant worsening of symptoms despite using the deayed prescription. Community Acquired Pneumonia (CAP) The typica symptoms of CAP are acute onset cough, fever, breathessness and peuritic chest pain. The BTS Guideines on Community Acquired Pneumonia 2009 state that a diagnosis of CAP shoud be considered in the presence of typica symptoms and a patient who is systemicay unwe (eg, temperature >38 o C), presence of new foca signs in the chest and no other obvious expanation for these signs. Recent NICE guideines on pneumonia say that in primary care a chest X-ray is not essentia to make a diagnosis of CAP. They recommend that a point of care C-reactive protein (CRP) bood test shoud be used to hep decide whether patients presenting with mid pneumonia need antibiotics. However, Dr Gruffydd Jones says this is an extra refinement which is not currenty avaiabe for most cinicians in UK genera practice. The test is carried out routiney in a number of other countries but there is a cost issue about buying the equipment for GP surgeries in the UK. For many GPs, CRP testing has to be carried out in a oca aboratory. NICE advises: Do not routiney offer antibiotics if the CRP concentration is <20 mg/l Consider a deayed antibiotic prescription if the CRP concentration is mg/l Offer antibiotic therapy if the CRP concentration is >100 mg/l NICE aso advises GPs to use the CRB65 risk score when making a judgement about whether patients shoud be referred to hospita. The CRB65 score assigns points based on the criteria of Confusion, raised Respiratory rate (>30/min in aduts) ow Bood pressure (<90/60) and oder age ( 65). NICE says GPs can consider home-based care for patients with a score of zero, but shoud consider hospita assessment for other patients, particuary those with a score of two or higher. Dr Gruffydd Jones says that cinica judgement is sti important, especiay in the systemicay unwe patient. Treatment of CAP The vast majority of patients with CAP have a mid form of the disease and can be managed effectivey in the community by GPs. NICE says that, if an antibiotic is needed, patients shoud be given a five-day course of a singe antibiotic (eg, amoxiciin 500 mg tds or carithromycin 500 mg tds) and asked to come back if their symptoms do not improve within 3 days. Patients shoud be tod their fever wi subside within a week but it may take up to 6 months for them to get competey back to norma. Management of acute cough in chidren and aduts Acute cough is a common presentation, and whether it s a chid or an adut, it is usuay associated with a vira upper RTI. In the absence of any significant co-morbidity, acute cough is ikey to be sef-imiting but 10 15% of patients return within 1 month. Dr Gruffydd Jones says the most important differentia diagnosis of acute cough in aduts is: Does the chid have pneumonia and are they are going to require antibiotics? He recommends the foowing safety net approach: ask patients to report back if their cough is not better in 3 weeks because this may be the first indication of a chronic condition. In a chid it coud be the first presentation of asthma or bronchiectasis and it is important to remember an inhaed foreign body. In particuar, a chid who has a Voume 5 Issue 1 SPRING

4 persistent wet cough for more than 4 weeks may have persistent bacteria bronchitis, a condition which might need a 2 4-week course of broad-spectrum antibiotics. In an adut it may be the first presentation of COPD, bronchiectasis or ung cancer. Red fags, which are indications for further investigation in aduts, incude haemoptysis, prominent systemic iness and suspicion of ung cancer. Bronchioitis Bronchioitis is the most common disease of the ower respiratory tract during the first year of ife. Symptoms incude: a rasping and persistent dry cough rapid or noisy breathing brief pauses in breathing feeding ess and having fewer wet nappies vomiting after feeding being irritabe In primary care the condition may be confused with the common cod, athough the presence of ower respiratory tract signs (wheeze and/or crackes on auscutation) in an infant woud be consistent with bronchioitis. The symptoms are usuay mid, may ony ast a few days and can be managed at home without needing treatment. In some cases, the disease can cause severe iness and infants wi need to be treated in hospita. Bronchioitis is a vira infection so antibiotics are not indicated. NICE says corticosteroids are not recommended. Learning objectives After reading this artice you wi understand: How to dea with a sef-imiting RTI When antibiotics shoud be prescribed for an RTI How to dea with patients who demand an antibiotic when they don t need one Ideas for further study and refection: Conduct a search of patients who were given antibiotics for an RTI and ask yoursef whether those antibiotics were prescribed appropriatey Read the NICE guideine Antimicrobia stewardship: system and processes for effective antimicrobia medicine use to find out more about how to use antibiotics effectivey Are you confident you coud spot when a respiratory infection is CAP? Read up the BTS and NICE guidance References 1. Litte P, Moore M, Leydon G, et a. Deayed antibiotic prescribing strategies for respiratory tract infections in primary care: pragmatic, factoria, randomised controed tria. BMJ 2014;348:g The advice in this artice has been coated from the foowing guideines: Respiratory tract infections (sef-imiting): prescribing antibiotics. NICE guideine CG69, Juy Pneumonia in aduts: diagnosis and management. NICE guideine CG191, December BTS guideines on the management of community-acquired pneumonia in aduts PCRS-UK Opinion sheet on community acquired pneumonia in aduts, September BTS guideines for the management of community acquired pneumonia in aduts: update BTS guideines on cough management Bronchioitis in chidren: diagnosis and management. NICE guideine NG9, June Antimicrobia stewardship: system and processes for effective antimicrobia medicine. NICE guideine NG15, August TARGET Antibiotic Tookit. Fever PAIN Cinica Score. Continued on page Voume 5 Issue 1 SPRING 2018

5 Continued from page Feedback from our Lay Reference Group We asked our Lay Reference Group for their views on antibiotics and deayed prescriptions. They a said they were aware of the issues around antimicrobia resistance and woud take antibiotics ony if they reay needed them. Barbara Preston, who has bronchiectasis, says she routiney takes azithromycin 3 times a week because this reduces the number of courses of other antibiotics she needs to take when she gets an infection from eight or nine to two to three a year. She says she needs to take antibiotics for minor infections otherwise they take a hod and then she has to take a stronger course of medication. I reay worry about taking antibiotics so often, not so much for my sake, as I wi amost certainy become immune to the antibiotics I take eventuay, but for the future of word medicine. I do worry that I m adding to the present crisis of antibiotic resistance, she says. Amanda Roberts, who has asthma, is aso reuctant to take antibiotics. On the few occasions she is strugging to keep a id on her asthma despite stepping up her respiratory medications, she has been offered antibiotics by her GP but she says she ony takes them in extremis. Nei Jackson, who has who has apha-1 antitrypsin deficiency, says if he was given a deayed prescription for an antibiotic he woud hope this woud be accompanied by a detaied conversation with the prescriber about when to take it. He said he woud aso find it hepfu for that information to be written down as he woud probaby forget it after eaving the surgery if an infection was making him fee poory. This artice was first pubished in Primary Care Respiratory Update in December 2015 and has been updated, edited and adapted for repubication in 2018.