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Consider delayed antibiotic prescriptions
NICE CG69: Respiratory tract infections (self-limiting): prescribing antibiotics (July 2008) provides guidance on the prescribing of antibiotics for self-limiting respiratory tract infections in adults and children over 3 months old in primary care.
Annual vaccination is essential in all those at risk of complications from influenza. Guidance may change from year to year. Check the Public Health England (PHE) website (seasonal influenza) for latest updates.
Patients under 13 years- follow Public Health England (PHE) Influenza Advice.
Oseltamivir and zanamivir are not licensed for use unless influenza is circulating in the community. In England, the formal announcement is made by the Department of Health.
Treat 'at risk' patients, when influenza is circulating in the community ideally within 48 hours of onset (within 36 hours for zanamivir treatment in children) or in a care home, where influenza is likely. For otherwise healthy adults antivirals are not recommended.
At risk groups:
See Public Health England (PHE) Influenza Advice regarding whether to use oseltamivir or inhaled zanamivir. In general use oseltamivir in all cases except in the severely immunocompromised where the predominate circulating strain is H1N1 or the infection is with an oseltamivir resistant strain.
Refer to individual SPCs before prescribing
See NICE TA168: Amantadine, oseltamivir and zanamivir for the treatment of influenza (February 2009).
Oseltamivir and zanamivir are recommended, within their marketing authorisations, for the post-exposure prophylaxis of influenza if all of the NICE TA circumstances apply.
Oseltamivir and zanamivir are not recommended for routine prophylaxis of seasonal influenza; they may be given for post-exposure prophylaxis when the virus is circulating in the community.
Amantadine is not recommended for the prophylaxis of influenza.
Vaccination is the first-line intervention to prevent influenza and its complications. This guidance should not detract from efforts to ensure that all eligible people receive vaccination.
See 5.3.4 Influenza
The information below is based on NICE NG84 Sore throat (acute): antimicrobial prescribing (January 2018).
Acute sore throat (including pharyngitis and tonsillitis) is self-limiting and often triggered by a viral infection of the upper respiratory tract.
Symptoms can last for around 1 week, but most people will get better within this time without antibiotics, regardless of cause (bacteria or virus). On average, antibiotics shorten the duration of symptoms by about 16 hours over 7 days, and the number of people improving with antibiotics is similar to the number experiencing adverse effects, such as diarrhoea.
For children under 5 years who present with fever refer to NICE NG143: Fever in under 5s: assessment and initial management (November 2021).
Self-care advice:
The following are not recommended due to a lack of evidence: non-medicated lozenges, mouthwashes, or local anaesthetic mouth spray without antiseptic.
NHS England (NHSE) have published new prescribing guidance for various common conditions for which over the counter (OTC) items should not be routinely prescribed in primary care (quick reference guide). One of these conditions is acute sore throat.
Many products for coughs, colds, and sore throats are cheap to buy and are readily available OTC along with advice from pharmacies. Some self-care medicines are available from shops and supermarkets. Please click here for further information, exceptions, and a patient leaflet.
The poor sensitivity and specificity of the previous sore throat grading criteria (CENTOR) have led to these being replaced with the FeverPAIN criteria.
FeverPAIN criteria are used to identify patients most likely to benefit from antibiotics. Higher scores suggest more severe symptoms and likely bacterial strep cause. (1 point for each, maximum score of 5):
Scores
Consider a 5-10 day prescription (delayed for 7 days) for patients presenting with symptoms which do not start to improve within the next 3 to 5 days or if they worsen rapidly or significantly at any time.
Reassess at any time if; symptoms worsen rapidly or significantly, or patient becomes very unwell.
In all cases offer self-care advice, no scoring system can ever be completely accurate, consider safety net precautions.
Invasive Group A Streptococcal infections and other bacteria have increased in incidence and need to be assessed rapidly in hospital. Maintain a high index of suspicion in patients with a high fever, severe muscle aches, confusion, unexplained D&V, local muscle tenderness, or severe pain out of proportion to external signs, hypotension, and a flat red rash over large area of the body, conjunctival suffusion.
Consider antibiotic treatment if confirmed Group A streptococcus infection in a household member and patient presents with symptoms suggestive of Group A streptococcal infection, including acute sore throat.
Chronic carriage of Group A streptococcus: These are apparent bacteriological treatment failures without illness or immunological response. They have a low risk of spread and a low risk of suppurative and non-suppurative complications. Antibiotics are not required.
The usefulness of throat swabs is limited by:
Immediate prescription of antibiotics is recommended in patients who:
Please see local referral guidelines if recurrent acute tonsillitis/ tonsillectomy.
(including pregnancy)
See 5.1.1 Penicillins, 5.1.3 Tetracyclines, and 5.1.5 Macrolides
The information below is based on NICE NG91 Otitis media (acute): antimicrobial prescribing (March 2018).
Acute otitis media is a self-limiting infection that mainly affects children; it can be caused by viruses and bacteria with symptoms lasting for about three days, but can last for up to one week.
Self-care advice:
The following are not recommended due to a lack of evidence: decongestants or antihistamines.
The routine commissioning of Otigo (phenazone with lidocaine) ear drops is not accepted in Devon for the treatment of acute otitis media pain (see Commissioning Policy for more information).
Most children and young people get better within three days without antibiotics.
Antibiotics make little or no difference in reducing ear pain and their use should be balanced against the risk of causing adverse effects such as vomiting, diarrhoea or rashes. Antibiotics make little difference to the number of children with common complications of acute otitis media such as recurrence of infection, short term hearing loss and perforated eardrum; and make little difference to the number of children whose symptoms improve. Complications (such as mastoiditis) are rare with or without antibiotics.
Advise to seek medical help if symptoms do not start to improve after 3 days if the child or young person becomes very unwell.
For children under 5 years who present with fever refer to NICE NG143: Fever in under 5s: assessment and initial management (November 2021)
Consider a delayed prescription for use if symptoms do not start to improve within 3 days. Advise to seek medical help if symptoms worsen rapidly or significantly at any time.
Consider a delayed prescription or immediate prescription of antibiotics in:
Offer an immediate prescription in:
For children under 3 months, have a low threshold for prescribing antibiotics or admitting.
Reassess at any time if symptoms worsen rapidly or significantly, taking account of:
(including pregnancy)
See 5.1.1 Penicillins, 5.1.3 Tetracyclines, and 5.1.5 Macrolides
If worsening of symptoms on first choice taken for at least 2 to 3 days.
If worsening of symptoms on second line treatment option, taken for at least 2-3 days, or penicillin allergy consult local microbiologist.
Please see guidance section in Chapter 12. Ear, nose & oropharynx – 12.1.1 Otitis externa.
The information below is based on NICE NG79 Sinusitis (acute): antimicrobial prescribing (October 2017).
Acute sinusitis is self-limiting and usually triggered by a viral infection of the upper respiratory tract.
Symptoms can last for 2 to 3 weeks – most people will get better within this time without treatment, regardless of cause (bacteria or virus).
For children under 5 years who present with fever refer to NICE NG143: Fever in under 5s: assessment and initial management (November 2021)
Self-care advice:
The following are not recommended due to a lack of evidence: oral decongestants, antihistamines, mucolytics, steam inhalation, or warm face packs.
Consider prescribing a nasal corticosteroid for 14 days for adults and children aged 12 years and over (unlicensed use), see section 12.2.1 Drugs used in nasal allergy. Be aware that nasal corticosteroids may improve symptoms but are not likely to affect how long they last; could cause systemic effects, particularly in people already taking another corticosteroid; and may be difficult for people to use correctly.
Consider a 5 day prescription (delayed for 7 days) for patients presenting with symptoms for around 10 days or more with no improvement, taking account of evidence that antibiotics make little difference to how long symptoms last, or the proportion of people with improved symptoms (refer to 1st line treatments below).
Immediate prescription of antibiotics is recommended in the following patients (refer to 2nd line treatments below):
If systemically very unwell, symptoms and signs of a more serious illness or condition, or at high risk of complications, refer to "2nd line".
(including pregnancy)
See 5.1.1 Penicillins, 5.1.3 Tetracyclines, and 5.1.5 Macrolides
If systemically very unwell, symptoms and signs of a more serious illness or condition, at high risk of complications, or if worsening of symptoms on first choice taken for at least 2 to 3 days.
If worsening of symptoms on second line treatment option, taken for at least 2-3 days, or penicillin allergy consult local microbiologist.