Respiratory tract infection – antibiotic prescribing. Scope consultation: 30 July – 28 August 2007
Type
Orde
r No
SH
SH
1
2
SH
3
Stakeholder
Abbott Laboratories Ltd
Addenbrookes Hospital, Cambridge
University Hospital NHS Trust
ARHAI
Section
number
Comments
Response
This organisation was approached but did not respond
This organisation was approached but did not respond
Gen
Overall this is a well thought through scope. My chief
concern relates to only including guidance for children aged
over 2 years. I can see no good rationale to the exclusion of
children aged under 2 years.
For 2005 the incidence of community antibiotic prescribing
for children in the UK was 643/1000 children for those aged
< 2 years, 690/1000 for the 2-5 year olds, 366/1000 for
those 6-10, and 325/1000 for those aged 11-15.
Therefore by excluding children aged under 2, the NICE
guidance would not cover approximately one third of all
community antibiotic prescribing in UK children.
The under 2s are in fact the key group to target for NICE
guidance. Concerns around potential harm following
delayed or non-prescribing are highest in this group,
although there is very limited evidence that complications
are increased. Influencing families and prescribers
behaviour at this young age is likely to considerably
influence prescribing for minor infections throughout
childhood. The recent introduction of conjugate
pneumococcal vaccination within the UK has significantly
reduced the risk of serious bacterial infections in the under 2
age group, but this is not widely appreciated by families or
GP’s who have seen this as a meningitis vaccination.
Viral infections are very common in this age group, and
there is good recent published data on the frequency of viral
isolates from young children with URTI.
NICE clinical guideline 47 on feverish illness in children
provides very limited guidance on antimicrobial prescribing
for the great majority of children presenting with a fever who
will have an URTI.
It is therefore very difficult to see why children aged under 2
1
Noted. After detailed consideration
and review of current available
literature, the technical team agree
the exclusion age should be lowered
to < 3 months so that it would be in
line with the NICE Febrile Illness in
Children Guideline.
Respiratory tract infection – antibiotic prescribing. Scope consultation: 30 July – 28 August 2007
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Stakeholder
Section
number
SH
4.0
Association of Medical
Microbiologists
4.1.1
SH
4.1
4.3.1 (e)
SH
4.2
Association of Medical
Microbiologists
Association of Medical
Microbiologists
SH
5
Association of the British
Pharmaceuticals Industry,(ABPI)
General
SH
6
AstraZeneca UK Ltd
General
Comments
should be excluded from this optimal practice guidance.
Failure to include this group runs the risk of seriously
reducing the impact of this potentially very important NICE
guidance for children. After many years of a consistent
reduction there is evidence of increased community
antibiotic prescribing rates for children. It is therefore illogical
to exclude guidance for possibly the most important group
within this Scope in terms of antimicrobial resistance.
Both the RCPCH and ARHAI would strongly encourage
NICE to reconsider the exclusion of children aged under 2
years from this Scope guidance. Both ARHAI and NICE very
much welcome the forthcoming guidance and are happy to
help in the process.
Although we appreciate that this initiative is directed towards
children over the age of 2yrs, there is also professional
concern amongst our paediatric microbiologists over the use
of antibiotics in younger children. Certainly there is a drive
within paediatric centres to recognise viral infections and not
to routinely prescribe antibiotics for these conditions.
Advice over the use of specific analgesics, together with
supporting evidence, would be most welcome
The AMM and RCPath are very happy to support this
initiative, and will actively contribute to further work on the
topic. The scope has been widely disseminated and
discussed amongst microbiologists, but at this stage we
have no further comments other than those made at the
Stakeholder meeting, and those outlined above.
The ABPI welcomes this guideline recognising that this is a
difficult area where guidance would be helpful and
appropriate both for health care professionals and patients
with self-limiting RTIs.
This organisation responded and said that it has no
comments to make
2
Response
Noted. After detailed consideration
and review of current available
literature, the technical team agree
the exclusion age should be lowered
to < 3 months so that it would be in
line with the NICE Febrile Illness in
Children Guideline.
Analgesics will be addressed in the
guideline.
Noted, thank you
Noted, thank you
Respiratory tract infection – antibiotic prescribing. Scope consultation: 30 July – 28 August 2007
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SH
SH
SH
SH
SH
7
8
9
10
11
12.0
Barts & The London NHS Trust
Bayer plc
Bedfordshire PCT
Bio-Stat Diagnostic Systems
Bolton Council
British In Vitro Diagnostics
Association
SH
12.1
British In Vitro Diagnostics
Association
SH
12.2
British In Vitro Diagnostics
Association
Section
number
General
3
4.3.2
Comments
This organisation was approached but did not respond
This organisation was approached but did not respond
This organisation was approached but did not respond
This organisation was approached but did not respond
This organisation was approached but did not respond
BIVDA welcomes the opportunity to respond to the NICE
consultation on the draft scope for the guideline on
prescribing antibiotics for self-limiting respiratory tract
infections.
BIVDA believes that there is a need for a national clinical
guideline in relation to antibiotic prescribing for RTIs. BIVDA
recognises that antibiotic prescriptions in the UK at 34
million per year are 33% higher than the EU average.
These costs are considerable and could be reduced by
more efficient and appropriate prescribing by GPs. BIVDA
also acknowledges the wide variance in prescribing patterns
for antibiotics for RTIs. This suggests that there is a
particular need for better guidance to GPs and education to
patients to encourage a more prudent use of antibiotics.
BIVDA believes that inappropriate prescribing of antibiotics
has increased the prevalence of antibiotic resistance.
Greater resistance amongst patients leads to a growing
prevalence in further illness and more eventual cost to the
NHS. In the last few years, the growth of antibiotic-resistant
bacteria has led to the emergence of a number of superbugs
– MRSA and C Difficile in particular – which have had a
huge financial cost for the NHS, as well as leading to patient
mortalities and a substantial public health concern.
BIVDA is extremely concerned that diagnosis has effectively
been excluded from the scope of the guideline. We believe
that rapid diagnostics – specifically the swab kits to test for
Streptococcus A – have a vital role to play in the prescription
of antibiotics for RTIs. Streptococcus A is a serious infection
which, if not treated by an antibiotic, can lead to much more
serious infections, such as rheumatic fever in children. The
3
Response
Noted, thank you
Noted
Due to the restricted nature of a short
clinical guideline, it is not possible to
include a review of various rapid
diagnostic tests for individual RTIs.
It should also be noted that this is a
fast evolving area with currently
Respiratory tract infection – antibiotic prescribing. Scope consultation: 30 July – 28 August 2007
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Comments
exclusion of diagnostics from the scope of this guideline is a
wasted opportunity and undermines the central aim of the
guideline – “to provide recommendations for good practice
that are based on the best available evidence of clinical and
cost effectiveness”.
The rapid diagnostic test for Strep A is extremely
straightforward and enables GPs to differentiate immediately
between bacterial and viral aetiologies, thus avoiding
inappropriate prescription of antibiotics for viral infections.
Tests for bacterial resistance give faster, more accurate
microbiology, ensuring that the patient gets the appropriate
antibiotic sooner. This minimises use of inappropriate
antibiotics, reducing selection for resistance and saving
costs.
BIVDA is not advocating the use of rapid diagnostic tests for
Strep A in every diagnosis for RTIs. Instead we would
propose that the guideline make clear that GPs should
consider the use of diagnostic tests when prescribing
antibiotics for RTI. This would continue to give discretion to
the GP, allowing him or her to use a rapid diagnostics test
where it was felt there was a particular need to identify
beyond doubt whether an infection was bacterial or viral.
BIVDA believes that diagnostics play a vital role in
prescribing for RTIs, even for those relatively low level RTIs
which are covered by the guideline – the common cold, flulike illnesses, earache, sore throat, acute cough and acute
sinusitis. Aside from the rapid diagnostic test for Strep A,
mentioned above, diagnostic tests can also identify which
antibiotics are active against the patient’s infection – giving
the doctor the information needed to choose the right
antibiotic. Using the right antibiotic is fundamental to
successful treatment; using the wrong antibiotic wastes time
and money, extends the period of illness and may
4
Response
limited data from UK primary care
populations.
It would be appropriate to offer this
specific topic for consideration by the
NICE Topic Selection Process as a
potential future Technology Appraisal
or Clinical Guideline.
Respiratory tract infection – antibiotic prescribing. Scope consultation: 30 July – 28 August 2007
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Comments
exacerbate the emergence of resistance, endangering
patients.
Evidence from France has shown that there was a 48%
reduction in the use of antibiotics for pharyngitis after the
introduction of a rapid diagnostic test for Strep A. Strep
diagnostics tests are currently a prominent part of the
strategy being taken forward in France and other European
countries to reduce unnecessary antibiotic prescribing, with
positive initial results. Given this evidence, it seems
inexplicable that NICE are planning to exclude rapid
diagnostic tests from the scope of the guideline.
BIVDA is aware that the exclusion of rapid diagnostic testing
may be due to the reporting schedule and timeframe for the
development of this particular guideline. BIVDA would urge
NICE to include diagnostic tests. However, if this is not
possible, BIVDA would welcome the possibility of a further
guideline which would focus on diagnostics, either in relation
to RTIs specifically or diagnostics more generally in primary
care. For instance, it would be useful to have a guideline on
RTIs, lower and upper, which acknowledged the vital role
that CRP testing can play in identifying infection. This is
currently under used and can be crucial in identifying the
early stages of pneumonia and other more serious
infections.
Progress on developing rapid testing is a growing area in
the UK and plays a vital role in appropriate diagnosis and
treatment of patients. The cost implications for ignoring
rapid diagnostic testing are serious, given the knock on
effects of inappropriate prescribing in terms of further illness
and more serious conditions. For this reason, BIVDA
believes that any cost incurred by further investment in
diagnostic testing kits would certainly be justified by cost
savings in the longer term.
5
Response
Respiratory tract infection – antibiotic prescribing. Scope consultation: 30 July – 28 August 2007
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SH
SH
13
14
15
SH
16.0
Stakeholder
British Infection Society
British National Formulary (BNF)
British Paediatric Respiratory
Society
British Society for Antimicrobial
Chemotherapy
Section
number
General
Comments
BIVDA would welcome the opportunity to discuss with NICE
the possibility of including diagnostic testing in this guideline
or a future one.
This organisation was approached but did not respond
This organisation was approached but did not respond
This organisation responded and said that it has no
comments to make
The British Society for Antimicrobial Chemotherapy warmly
welcomes and supports this proposal to develop and optimal
practice review on the topic “Prescribing of antibiotics for
self-limiting respiratory tract infection in adults and children
in primary care.
Response
Noted, thank you
The topic is appropriate since there is evidence that
antibiotics are prescribed inappropriately for these
conditions, that there is wide variation between practices
and individual GPS, which is not explained by population
variations and that harm (antibiotic resistance and side
effects in the individual) results from this.
However compared to other European countries there are
few with lower antibiotic prescription rates that the UK and
the margin for further reduction in antibiotic prescription
overall may not be that great. Harm may ensue from
inappropriate withholding of antibiotics, especially if an
incorrect initial diagnosis is made.
SH
16.1
British Society for Antimicrobial
Chemotherapy
General
We consider that the scope and nature of the review
process is generally appropriate.
In assessing the evidence relevant to prescribing the time of
the intervention in relation to the onset of symptoms/disease
needs to be taken into account. Too many studies in primary
care do not clearly identify this interval and make judgments
on the benefit or otherwise of an intervention at time points
which are intrinsically inappropriate and as a result bias
the assessment. The ease of access to care
6
Noted. The technical team will take
this into account when reviewing
evidence available.
Respiratory tract infection – antibiotic prescribing. Scope consultation: 30 July – 28 August 2007
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SH
SH
SH
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16.2
16.3
16.4
Stakeholder
British Society for Antimicrobial
Chemotherapy
British Society for Antimicrobial
Chemotherapy
British Society for Antimicrobial
Chemotherapy
Section
number
General
4.1.2
4.3.1(a)
Comments
can significantly affect the timing of supply and
administration of a medicine.
The scope does not address or make reference to the issue
of monitoring of implementation and compliance.
WE RECOMMEND THAT REFERENCE IS MADE TO
MONITORING OF IMPLEMENTATION AND
COMPLIANCE WITH LOCAL PROTOCOLS
Will the Guideline apply to the very elderly and nursing
home residents?
WE RECOMMEND THAT THE GUIDELINE CLEARLY
STATES WHETHER THE ABOVE ARE INCLUDED OR
EXCLUDED. OUR RECOMMENDATION WOULD BE TO
INCLUDE THESE GROUPS.
The scope includes 6 topics. Three of these (earache, sore
throat and acute cough) are single symptoms; the other
three are symptom complexes.
WE RECOMMEND THAT THE GUIDELINE GIVES VERY
CLEAR RECOMMENDATIONS ABOUT THE DEFINITION
OF THESE SYPTOM COMPLEXES AND THE TERM
“ACUTE”.
SH
16.5
British Society for Antimicrobial
Chemotherapy
4.3.1(c)
SH
16.6
British Society for Antimicrobial
Chemotherapy
4.3.1(e)
WE RECOMMEND THAT THE GUIDELINE
DEVELOPMENT TEAM CONSIDER THE FREQUENCY IN
WHICH, PARTICULARLY WHEN SYMPTOM
COMPLEXES ARE USED, THERE IS THE CHANCE TO
MIS-DIAGNOSE A CONDITION (EG PNEUMONIA) WHICH
REQUIRE IMMEDIATE ANTIBIOTIC THERAPY.
WE RECOMMEND THAT A CLEAR DEFINITION OF
WHAT SEPARATES “SELF LIMITING” FROM NON SELF
LIMITED BE INCLUDED IN THE GUIDELINES
WE RECOMMEND THAT PATIENTS NOT RECEIVING
ANTIBIOTICS ARE PROVIDED WITH AN ALTERNATIVE
7
Response
NICE clinical guidelines do come with
implementation tools and audit criteria
(as separate documents).
Yes. The guideline applies to all
adults (including the elderly) with no
co-mobidities that will affect the
decision to prescribe antibiotics as
outlined in section 4.3.2.
The guideline will address the
definition and basic aetiology of the 5
conditions – earache/sore
throat/acute cough/acute
rhinosinusitis/acute sinusitis
We will consider the evidence of the
symptom/sign clusters for each RTI to
predict benefit from antibiotics in a
primary care population
The definition of “self-limiting” will be
addressed in the guideline in line with
the National Prescribing Centre and
current available evidence.
The guideline will address the mode
of delivery such as brief verbal
Respiratory tract infection – antibiotic prescribing. Scope consultation: 30 July – 28 August 2007
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SUCH AS A DETAILED EXPLANATION, LEAFLET OR
ALTERNATIVE DRUG (potential for use of anti-tussives
should be included for acute cough).
SH
16.7
British Society for Antimicrobial
Chemotherapy
4.3.2
SH
16.8
British Society for Antimicrobial
Chemotherapy
4.3.2(b)
SH
SH
SH
17
18
19
British Thoracic Society
Calderdale PCT
CASPE Research
SH
SH
20
21
SH
SH
SH
SH
22
23
24
25
Cephalon
Commission for Social Care
Inspection
Connecting for Health
Cornwall & IoS PCT
Daiichi Sankyo UK
Department of Health
Gen
General
We are concerned that the exclusions are too broad, and
may lead to result in guidance that is not practical to use in
general practice and will not result in a change in practice if
required.
WE RECOMMEND THAT NICE GIVES FURTHER
CONSIDERATION TO DEVELOPING GUIDANCE THAT
INCLUDES THESE CONDITIONS.
Exclusion of patients with ‘co morbidities that affect antibiotic
prescription decision’ will significantly limit the usefulness of
the Guideline. Such conditions will need to be explicitly
stated in the Guideline.
This organisation was approached but did not respond
This organisation was approached but did not respond
On this occasion we have no comments on the proposed
scope.
This organisation was approached but did not respond
This organisation was approached but did not respond
This organisation was approached but did not respond
This organisation was approached but did not respond
This organisation was approached but did not respond
The scope for respiratory tract infections in children and
adults is from two years of age. A very large proportion of
children attend acute paediatric units, and the majority of
those admitted are under two years of age. We feel that
these do not necessarily need investigation, but need a
treatment decision. We are concerned that the guideline
proposes to exclude children under two years of age.
We accept that there may need to be a cut off in infancy.
8
Response
advice, information leaflet and the use
of analgesics.
We will review role of analgesics but
not the use of anti-tussives for acute
cough.
Given the short time frame of the
short clinical guideline process, it is
not possible to broaden the scope to
cover the reviewing of all evidence on
other conditions or co-mobidities
related to RTIs.
The exclusion of patients with ‘co
morbidities that affect antibiotic
prescription decision’ will be explicitly
stated in the guideline.
Noted.
Noted. After detailed consideration
and review of current available
literature, the technical team agree
the exclusion age should be lowered
to < 3 months so that it would be in
line with the NICE Febrile Illness in
Children Guideline.
Respiratory tract infection – antibiotic prescribing. Scope consultation: 30 July – 28 August 2007
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SH
26
SH
SH
27
28
SH
29.0
Stakeholder
Department of Health, Social
Security and Public Safety of
Northern Ireland
Derbyshire County PCT
Det Norske Veritas - NHSLA
Schemes
General Practice Airways Group
Section
number
Comments
Response
The NICE febrile child guideline has chosen “under three
months” as a group to be considered differently. In our
opinion, this guideline should also take into account the
febrile child guideline.
This organisation was approached but did not respond
This organisation was approached but did not respond
This organisation was approached but did not respond
General
GPIAG supports the overall emphasis and importance of
this topic and its relevance in primary care both at an adult
and paediatric level.
There is concern however that the title “self limiting
respiratory tract infections” is unhelpful. The term “selflimiting” suggests that the decision as to whether or not
antibiotics are needed is unproblematic. NICE guidelines
need to be clinically relevant. What primary care
professionals want to know is: ‘When faced with an
adult or child with a respiratory tract infection, will
antibiotics be of any use?’. At that point of first contact the
professional may not know whether the infection is selflimiting. For the guideline to be of value to primary care
professionals, it needs to help them answer this question,
and it is not clear that the guideline will do this.
The technical team has taken this
comment into consideration. The term
“self-limiting” is used in the full title so
that it would be in line with the
National Prescribing Centre and
current published literature. However,
the technical team will reword the
scope in relation to 4.1.1 and 4.1.2.
We agree that it is necessary to
address the question of which
symptom/sign clusters for each
condition predict likely benefit or not
from immediate prescription of
antibiotics in adults and children
presenting in primary care with RTIs.
The key issue is in section 4.1 : It seems to us that the
guideline ought to deal with how you tell the difference
between Groups 4.1.1 and 4.1.2
“Self limiting” implies that the condition will improve without
intervention, therefore rendering antibiotics unnecessary.
This may be true in many medical conditions. It is clear,
however, that many conditions have an improved outcome
with health care intervention in a variety of ways. (this may
9
We have re-worded section 3 e) and
4.1.1 to take account of this
Respiratory tract infection – antibiotic prescribing. Scope consultation: 30 July – 28 August 2007
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Response
be shortened illness – e.g. depression; less long term
morbidity or damage e.g. fractures; or improved
symptomatology and return to work)
There is also a negative implication in focussing on ‘where
not to prescribe’ rather than a more general focus on the
‘best or most appropriate’ use of antibiotics when diagnosing
and treating RTIs.
For these reasons we believe that the short title is more
useful than the full guideline title in its current form. The use
of ‘minor’ or ‘uncomplicated’ would be preferable to ‘selflimiting’ but these would also require detailed definition.
SH
29.1
General Practice Airways Group
3c
We believe that a quality review with appropriate
dissemination of results and educational packages will have
a significant impact on antibiotic prescribing and
management of RTI. We also believe that with a programme
linked to public health and patient education, the impact
could be even greater.
The concept of three strategies – none / delayed /
immediate is fine, but may be considered simplistic. All of
these require a safety net, no matter which strategy is used.
Similarly, the level of “sell” on delayed and several other
factors will impact on whether or not the patient is in
agreement with the shared management strategy. There is
considerable work that indicates that even with “immediate
treatment”, on many occasions the patient decides to ‘wait
and see’. It should also be borne in mind that some patients
may be asked to delay filling/starting their prescription, but
we have no way of knowing whether they follow these
instructions or not, without a detailed audit.
It would be good to look at actual practice observation as
well as RCT data (real world observational studies). The
complex world of communication skills in the consultation
10
Patient information package and
patient perspectives will be reviewed
as two of the key clinical questions.
Different strategies for the delayed
management will be reviewed in the
guideline i.e. prescription was given
immediately but asked to ‘cash in’
later vs. asked patients to come back
to the practice to collect the
prescription after defined period of
time.
Both patient and professional’s
perspectives and expectations in
relation to communication will be
addressed in the guideline.
An economic evaluation aims to
integrate all costs and benefits that
Respiratory tract infection – antibiotic prescribing. Scope consultation: 30 July – 28 August 2007
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Response
should not be ignored. It could be argued that the concept of
delayed prescription is merely a continuum of patient choice,
clinician decision and whether or not the prescription is
given at the first or subsequent consultation.
relate to the decision problem under
consideration. If modelling is
necessary and possible, the structure
of the model should be consistent
with coherent theories of the health
conditions under consideration and
the likely treatment pathways
individuals could follow for the
alternative management strategies
being evaluated.
It would be useful to review the place of telephone advice
and the role of NHS Direct on management strategies.
Similarly, it is appropriate to look not only at the cost of
prescription (albeit important, and a relevant link to
resistance) but also the cost of repeat consultations, time
lost from work, cost of other alternative prescriptions, if
antibiotics are NOT prescribed. Any evidence that the
incidence of serious infections such as pneumonia has risen
with the secular decline in antibiotic prescribing should be
reviewed.
Point c appears to indicate that NICE has decided which
infections are self-limiting before NICE has reviewed the
evidence to determine in which situations antibiotics will
NOT be useful, rather than assuring a comprehensive and
evidence based review using both RCT and other research
methodology.
As you correctly identified, any
analysis should consider more than
just the acquisition cost of antibiotics,
and include the cost of repeat
consultations and the costs of
managing adverse consequences that
might arise because antibiotics were
not prescribed immediately or not at
all. Clearly, the level of detail that can
be incorporated into a health
economic study will depend in part on
the quality and completeness of the
evidence available.
For the principal cost effectiveness
analysis, costs should relate to
resources that are under the control
of the NHS and Personal Social
Services (PSS) where differential
effects on costs between the
strategies under comparison are
possible. However, there will be
occasions when non-NHS/PSS costs
will be differentially affected by the
strategies under comparison. Under
11
Respiratory tract infection – antibiotic prescribing. Scope consultation: 30 July – 28 August 2007
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Comments
SH
29.2
General Practice Airways Group
3d
We agree that reduced variation is desirable. Consistency of
approach would encourage better public understanding and
better clinician adherence to guidelines
SH
29.3
General Practice Airways Group
3e
SH
29.4
General Practice Airways Group
4a
SH
29.5
General Practice Airways Group
4.1.1
The key to many changes in healthcare practice is the
influencing of opinion leaders and the general public. The
literature associated with influencing prescribing should be
considered. Standard treatment with antibiotics is not
uncommon with simple URTI when the patient is seen in
A&E or albeit briefly by secondary care colleagues and
discharged early in real clinical practice.
Attention should also be paid to the expectation that patients
have developed over time that an antibiotic will be given.
What is the evidence base for strategies to help to change
this expectation, if the expectation is inappropriate? Patient
expectation could be picked up in the context of guidelines
implementation at NICE. E.g the production of an
explanatory patient leaflet.
Hence if this is the exact definition of scope the programme
will miss many of the factors impacting on clinical care for
patients in primary care. The above issues need
consideration (telephone advice, previous practice,
influencing factors, methods of prospectively assessing “self
limiting illness.”
It is not clear why under 2s have been excluded.
Appropriate use of antibiotics in this group is just as
important as in other groups.
12
Response
these circumstances it may be
appropriate to consider the
implications of taking a broader
perspective on costs in a separate
analysis to the principal one.
Noted
Patient information package and
patient perspectives will be reviewed
as two of the key clinical questions.
Patient information package, patient
perspectives/expectations,
professional perspectives/views will
form part of the key clinical questions
to be reviewed.
After detailed consideration and
review of current available literature,
the technical team decided to lower
the exclusion age to < 3 months so
that it would be in line with the Febrile
Illness Guideline.
Respiratory tract infection – antibiotic prescribing. Scope consultation: 30 July – 28 August 2007
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number
SH
29.6
General Practice Airways Group
4.1.2
SH
29.7
General Practice Airways Group
4.3.1a
SH
29.8
General Practice Airways Group
4.3.1c
SH
29.9
General Practice Airways Group
4.3.1d
SH
29.10
General Practice Airways Group
4.3.1e
Comments
Identification of this group will need to be evidence based,
and this in itself is likely to be complex. Immediate antibiotic
prescribing (in A&E / Hospital / GP) does not always mean
that the condition is not “self limiting” and patients recover
despite our treatments.
The key issue in primary care is HOW to differentiate
between those in 4.1.1 and those in 4.1.2. It is difficult
to see how you can clearly eliminate a group when it is
the process of identifying who falls within that group
that is a key challenge.
A review of the symptoms of and evidence for antibiotic use
for each of these conditions would be very useful, and would
be more impactful for prescribers than guidance for the
vaguely defined ‘self-limiting infections’.
A common way of categorising RTIs is into upper respiratory
tract infections (URTI) and lower respiratory tract infections
(LRTI). Primary care practitioners will be looking for
guidance in line with these categories. If this distinction is
felt to be unhelpful based on the evidence, it should be
borne in mind that considerable communication and reeducation may be necessary.
Consideration of rhinosinusitis and hoarse voice should also
be considered.
Practices may be reluctant to take any course of action
which leads to the need for the patient to attend a further
consultation.
Written management plans tailored to the patient, and
advice from the pharmacist which reinforces the strategy
that the prescriber has advised would be useful.
This covers paracetamol / ibuprofen. It would be sensible to
consider pseudoephedrine, mucolytics and cough
preparations in the same section, along with steam
inhalation and other common current self treatments and
indeed advised.
Guidance on the use of advice about self-care that does not
involve prescribing would also be useful. E.g. signs of
13
Response
We agree that it is necessary to
address the question of which
symptom/sign clusters for each
condition predict likely benefit or not
from immediate prescription of
antibiotics in adults and children
presenting in primary care with RTIs.
The effectiveness of antibiotics for the
5 conditions in 4.3.1 will be reviewed.
The GDG will consider if it is useful to
differentiate RTI into upper and lower
RTI for the purposes of this guideline.
For LRTIs the focus is on the
management of acute cough, not on
other LRTIs.
Rhinosinusitis will be covered by the
revised scope.
This should be addressed by the
implementation tools and audit criteria
produced separately by NICE.
The mode of delivery of the three
management strategies will be
reviewed.
Due to the restricted timeframe for
short clinical guideline, it is not
possible to include the reviewing of all
other possible treatments/medicines
for individual RTIs.
Respiratory tract infection – antibiotic prescribing. Scope consultation: 30 July – 28 August 2007
Type
Orde
r No
Stakeholder
Section
number
SH
29.11
General Practice Airways Group
4.3.2a
SH
29.12
General Practice Airways Group
4.3.2b
SH
29.13
General Practice Airways Group
4.4
SH
30.0
Genzyme Diagnostics
4.3.2
Comments
worsening to look for, time off work, rest, advice on comorbidities – e.g. looking after self if have diabetes.
We have concerns about the value of the guidance if these
areas are excluded. They are central to the decision making
process when prescribing antibiotics.
To exclude the grey area of viral vs bacterial infections, and
not to define ‘self limiting’ in terms of what presents to
professionals will severely limit the value of the guideline.
Other key factors – agree that asthma / COPD should be
excluded. Many patients are smokers, many have diabetes
or heart disease; many have previous experiences that
influence their treatments. It should be explicit whether
smokers / patients with diabetes etc are both included in the
research and in the advice, as should the “consent to
randomisation rather than intention to treat” and the
previous experiences that may result in patients declining to
take part in trials.
This is excellent and very important.
An audit of delayed prescriptions would be useful - and why
this course of action was taken, and what the outcome was
It will be important to assess the impact (cost, patient
outcomes) of not prescribing immediately.
“Given the low incidence of streptococcal pharyngitis and
the minimal risk of acute rheumatic fever in persons over 20
years of age, it seems reasonable to rely on either a throat
culture or a high-sensitivity rapid antigen detection test
without confirmation by culture in adults. The high specificity
of the rapid tests (very few false positive results) should help
prevent the needless use of antimicrobial agents in adults
with pharyngitis.” (Bisno AL. N Engl J Med 2001;344:20511)
“..antibiotic treatment based only on positive rapid tests or
throat culture results can reduce unnecessary use of
antibiotics for treatment of pharyngitis.” (McIsaac WJ et al.
JAMA 2004;291:1597-95)
14
Response
Due to the restricted timeframe for
short clinical guideline, it is not
possible to include the reviewing of
various diagnostic testings for
individual RTIs.
The technical team will look at this
specifically when reviewing the
evidence.
Noted, thank you, however any
economic analysis should aim to
consider the full impact of not
prescribing antibiotics immediately.
Due to the restricted nature of a short
clinical guideline, it is not possible to
include a review of various rapid
diagnostic tests for individual RTIs.
It should also be noted that this is a
fast evolving area with currently
limited data from UK primary care
populations.
It would be appropriate to offer this
specific topic for consideration by the
NICE Topic Selection Process as a
potential future Technology Appraisal
Respiratory tract infection – antibiotic prescribing. Scope consultation: 30 July – 28 August 2007
Type
Orde
r No
Stakeholder
Section
number
Comments
Response
or Clinical Guideline.
“The GRAPH group evaluated whether guidelines for the
treatment of pharyngitis in adults (>25 years of age) based
on the use of Strep A (StA) rapid diagnostic tests (RDT)
were applicable in general practice.Methods - A pragmatic
''before-after'' study was made to evaluate changes in
practice after training. This was done over three periods:
period I ''before'' and III ''after'' in which data on GPs'
practice (about 100 general practitioners (GPs) from the
Bourgogne and Rhone Alpes regions) was collected; period
II when GPs underwent training including information on the
conclusions of the consensus conference and training to use
the Strep A RDT.Results - Data was collected on GPs'
practice in around 900 cases of pharyngitis in each period (I
et III) between October 1998 and March 1999. After just one
training course, RDTs were performed in 93% of cases, with
a positive rate of 20.2%. The overall use of antibiotics was
reduced by 48.4% (42.6% in period III vs. 82.6% in period I,
p<0.001). (Portier H et al. Assessing applicability of
guidelines on management of pharyngitis in adults in
general practice Medecine et Maladies Infectieuses
2001;31:388-395)
The last reference in particular shows that clinical guidelines
using rapid diagnostic tests can have a significant impact in
correct diagnosis and reduced antibiotic prescribing.
SH
31
Health Commission Wales
Other multi-country European studies are underway looking
at ways of reducing antibiotic prescribing and are including
evaluation of the role of rapid diagnostic testing. The
exclusion of the key piece of information to best target
antibiotics for patients with upper respiratory tract – namely
whether the condition caused by a virus or a bacterium –
means that clinicians will remain in the dark about whether
treatment is likely to work.
This organisation was approached but did not respond
15
Respiratory tract infection – antibiotic prescribing. Scope consultation: 30 July – 28 August 2007
Type
Orde
r No
SH
SH
SH
32
33
34
SH
SH
SH
SH
35
36
37
38
SH
SH
SH
SH
SH
39
40
41
42
43
SH
SH
44
45
SH
Stakeholder
Section
number
Comments
46.0
Health Protection Scotland
Healthcare Commission
Heatherwood & Wexham Park
Hospitals NHS Trust
Institute of biomedical Science
Kirklees Primary Care Trust
Launch Diagnostics
Medicines and Healthcare Products
Regulatory Agency (MHRA)
Menarini Diagnostics
Milton Keynes PCT
National Patient Safety Agency
National Pharmacy Association
National Public Health Service Wales
NCCHTA
NHS Clinical Knowledge
Summaries service
NHS Direct
4.3
Consider over the counter therapies and homely remedies,
e.g use of anaesthetic throat lozenges for a sore throat, use
of cold remedies.
SH
46.1
NHS Direct
4.3.1 d)
SH
46.2
NHS Direct
3.
Consider in relation to the DH Information Prescription
strategy due to be rolled out nationally 2008. Currently 20
pilots are exploring how information can be prescribed and
best delivered to meet patient’s needs as part of a care
pathway.
Would be helpful to look at the role of payment and self-care
to purchase analgesia and other OTC preparations. se
medicines OTC and will obtain medicines on prescription
too.
SH
SH
47
48
NHS Plus
NHS Quality Improvement Scotland
Response
This organisation was approached but did not respond
This organisation was approached but did not respond
This organisation was approached but did not respond
This organisation was approached but did not respond
This organisation was approached but did not respond
This organisation was approached but did not respond
This organisation was approached but did not respond
This organisation was approached but did not respond
This organisation was approached but did not respond
This organisation was approached but did not respond
This organisation was approached but did not respond
This organisation was approached but did not respond
This organisation was approached but did not respond
This organisation was approached but did not respond
This organisation was approached but did not respond
This organisation was approached but did not respond
16
Due to the restricted timeframe for
short clinical guideline, it is not
possible to include the reviewing of all
other possible treatments/medicines
for individual RTIs.
The technical team will look at this
strategy closely.
Due to the restricted timeframe for
short clinical guideline, it is not
possible to include the reviewing of all
other possible treatments/medicines
for individual RTIs.
Respiratory tract infection – antibiotic prescribing. Scope consultation: 30 July – 28 August 2007
Type
Orde
r No
SH
49
SH
SH
50
51.0
Stakeholder
North Cumbria Acute Hospitals
NHS Trust
North Tees PCT
PAGB
Section
number
Comments
Response
This organisation was approached but did not respond
General
This organisation was approached but did not respond
The scope of this guideline should be extended to include
consideration and use of people’s behaviour in dealing with
self limiting respiratory tract infections before they consult a
GP, so that the response in general practice can make more
and better use of self care in consultations for respiratory
tract infections.
PAGB has conducted consumer research over the last 20
years to find out more about the incidence of minor ailments
in the community and what people do about them. The latest
of these studies was carried out in 2005 by NOP World.
According to this study, 82.9% of the adult population
experienced respiratory conditions and 88.9% of children
had a cold in a 12 month period. This means that 41m
adults and 9m children suffered from colds, coughs, sore
throats, blocked nose, sinus problems and flu. It is
important therefore to examine what they did about these
symptoms.
The following shows the breakdown of the number of adults
experiencing these symptoms:
Cold - 34m people (82.3%)
Sore throat/cough - 28m people (67.2%)
Blocked nose/sinus problems (not related to a cold) - 14m
people (34.9%)
Flu - 10m people (24.1%).
Additionally, the study showed that the vast majority of
people either did nothing, waiting for the symptoms to clear
up, or used an OTC medicine. This is the type of behaviour
that should be encouraged further and before people
abandon it for a primary care consultation. Consequently,
17
Noted. While acknowledging that
health seeking behaviour prior to
consulting a health care practitioner is
extremely important with reference to
self-limiting RTIs a Clinical
Guideline’s remit is to address the
interaction between health care
practitioner and patient, not
antecedents of the consultation.
However, the guideline will address
the need to identify and address
patient’s ideas, concerns and
expectations with regard to need for
antibiotic prescription.
Respiratory tract infection – antibiotic prescribing. Scope consultation: 30 July – 28 August 2007
Type
SH
SH
Orde
r No
51.1
51.2
Stakeholder
PAGB
PAGB
Section
number
3 c)
4.3.1 b)
Comments
the guideline could provide valuable advice on the
management of RTIs at home and at work when this is
possible and reference to primary care when this is needed.
The scope of the guideline could be extended to cover the
use of community wide health campaigns that give people
information about looking after their symptoms and
signposting them to the relevant parts of the NHS such as
the community pharmacist, NHS Direct, walk in centre and
general practice in a step wise approach where the GP is
the final step when self care is no longer the optimal
solution.
We would argue that there is a fourth management strategy
which stands alone and is also cross cutting. The strategy
is referral to self care and the pharmacist. Since the main
response for non complex RTIs is self care and self
medication, patients’ pre-existing behaviour can be
endorsed and encouraged, even recommended further. In
addition, no matter which of the three different antibiotic
management strategies is employed, the self care strategy
can be added to it thereby making it a cross cutting strategy.
The scope could be extended to cover self care and referral
to the pharmacist and the means of communicating to
people that they should choose this option rather than going
to their GP. The long term benefit of reinforcing this kind of
behaviour would be to instil in people the action of first-line
self care in dealing with self limiting RTIs as the cultural
norm, thus ensuring the cultural shift from primary care
dependence to independent action.
Asking patients about their previous self care behaviour
needs to be included in the scope for this section as it
provides an understanding of the extent to which people are
prepared to try self care and why they abandon it for the
primary care consultation, particularly one with the GP,
resulting in nearly 8m consultations a year for self limiting
respiratory conditions among the adult population and 1m
consultations for children with colds. However, the majority
18
Response
Noted. While acknowledging that
health seeking behaviour prior to
consulting a health care practitioner is
extremely important with reference to
self-limiting RTIs a Clinical
Guideline’s remit is to address the
interaction between health care
practitioner and patient, not
antecedents of the consultation.
However, the guideline will address
the need to identify and address
patient’s ideas, concerns and
expectations with regard to need for
antibiotic prescription.
The guideline will address the need to
identify and address patient’s ideas,
concerns and expectations with
regard to need for antibiotic
prescription.
Respiratory tract infection – antibiotic prescribing. Scope consultation: 30 July – 28 August 2007
Type
Orde
r No
SH
SH
SH
52
53
54
SH
SH
SH
SH
Stakeholder
Section
number
Comments
Response
of people handle their respiratory tract symptoms either by
waiting till they get better or by treating them with OTC
medicines without needing to visit their GPs and at no cost
to the NHS. But those that do seek out the GP cost the NHS
£1.4b a year in GP time. Since two-thirds of consultations
result in prescriptions the dispensing cost is a further £60m.
The issuing of a prescription reinforces help seeking
behaviour and this becomes even more entrenched if the
prescription is for an antibiotic. Since most people will have
tried self care and self medication before presenting to the
surgery a few self care aware questions in history taking will
help in reinforcing self care behaviour rather than
dependency on the GP.
This organisation was approached but did not respond
This organisation was approached but did not respond
This organisation was approached but did not respond
55
56
57
58.0
PERIGON Healthcare Ltd
Powys Local Health Board
Primary Care Pharmacists
Association
PRIMIS+
Q-Med UK Ltd
Respironics UK
Rotherham PCT
1.
SH
58.1
Rotherham PCT
3a, 3b
SH
58.2
Rotherham PCT
3b
This organisation was approached but did not respond
This organisation was approached but did not respond
This organisation was approached but did not respond
The PCT feels that the title of the proposed guideline should
be “ Guidance on the appropriate use of antibiotics for selflimiting respiratory tract infections in adults & children in
primary care”
These paragraphs should be reversed in that the
introductory paragraph, 3a, supporting the clinical need for
the guideline should not focus on cost, but should focus on
the points currently in 3b, i.e. that inappropriate prescribing
has the potential to cause drug- related adverse events, to
increase the prevalence of antibiotic resistant organisms &
to increase primary care consultation rates for minor illness.
Should state the antibiotic prescribing costs, i.e. these
should be secondary to the patient & resistance factors
above.
19
This particular short clinical guideline
is part of the Optimal Practice Review
(OPR) programme, hence the title is
suitable for its purposes. For more
information on the OPR programme
please visit the NICE website.
This particular short clinical guideline
is part of the Optimal Practice Review
(OPR) programme, hence the content
of the scope is suitable for its
purposes. For more information on
the OPR programme please visit the
NICE website.
This particular short clinical guideline
is part of the Optimal Practice Review
(OPR) programme, hence the content
Respiratory tract infection – antibiotic prescribing. Scope consultation: 30 July – 28 August 2007
Type
Orde
r No
Stakeholder
Section
number
Comments
SH
58.3
Rotherham PCT
4.1.1.
The PCT suggests that the guideline should cover adults &
children, as defined in the guideline, but that there should be
no lower age limit.
SH
58.4
Rotherham PCT
4.1.2
Should dentists be included if sinusitis is covered in the
guideline?
SH
58.5
Rotherham PCT
4.3.1 d
SH
59
SH
60.0
Royal Brompton & Harefield NHS
Trust
Royal College of General
Practitioners
Easy access to appropriate patient leaflets is essential, for
successful implementation.
This organisation was approached but did not respond
4.3.1c
The text
‘For patients likely to have a self-limiting RTI,
and therefore not suitable for immediate
antibiotic treatment, the following antibiotic
management strategies will be considered’
Response
of the scope is suitable for its
purposes. For more information on
the OPR programme please visit the
NICE website.
After detailed consideration and
review of current available literature,
the technical team decided to lower
the exclusion age to < 3 months so
that it would be in line with the NICE
Febrile Illness Guideline.
The guideline addresses
rhinosinusitis which is managed by
primary medical care.
Patient information leaflet will be
addressed in the guideline.
The scope has been revised based
on this suggestion.
I think the reasoning should be clearer since defining
aninfections as self limiting is arguably an indication for no
offer of antibiotics. The following might be clearer:
‘For patients where antibiotics are not indicated
immediately the following management
strategies will be considered’
SH
60.1
Royal College of General
Practitioners
3 e)
Similar considerations apply to the text:
there is a need for guidance on
• ‘which RTIs can be treated as ‘selflimiting’ and are therefore not suitable
20
The scope has been revised based
on this suggestion.
Respiratory tract infection – antibiotic prescribing. Scope consultation: 30 July – 28 August 2007
Type
Orde
r No
Stakeholder
Section
number
Comments
•
Response
for immediate antibiotic treatment ‘
which antibiotic management strategies
could be offered once a decision has
been made that the patient is likely to
have ‘self-limiting’ RTI and ‘
The reasoning could perhaps be more definite:
there is a need for guidance on
• ‘which RTIs do not require immediate
antibiotic treatment ‘
• which antibiotic management strategies
could be offered once a decision has
been made that the patient does not
need immediate antibiotics
SH
61.0
Royal College of Midwives
General
SH
61.1
Royal College of Midwives
4.3.1 (d)
SH
62.0
Royal College of Nursing
General
SH
62.1
Royal College of Nursing
General
The Royal College of Midwives welcomes this guideline and
strongly supports the clinical need as stated in the scope.
If the mode of delivery strategy is by way of a patient
information leaflet, as opposed to brief verbal advice from
the practitioner, will the leaflet include advice on how the
patient will asses if the RTI is self-limiting?
Respiratory Tract Infection is commonly referred to as Upper
or Lower RTI. The guidance will need to indicate when it is
referring to upper, lower or both
Why is the cut off age two years as many one year olds
present with upper respiratory tract infections?
21
Noted
Evidence on brief verbal advice from
practitioners will also be reviewed in
the guideline.
The effectiveness of antibiotics for the
5 conditions will be reviewed, and as
the guideline does not address all
conditions within RTI, the
classification of URTI and LRTI is not
relevant within this guideline.
After detailed consideration and
review of current available literature,
the technical team decided to lower
the exclusion age to < 3 months so
that it would be in line with the Febrile
Illness Guideline.
Respiratory tract infection – antibiotic prescribing. Scope consultation: 30 July – 28 August 2007
Type
Orde
r No
Stakeholder
Section
number
SH
62.2
Royal College of Nursing
General
SH
62.3
Royal College of Nursing
SH
62.4
Royal College of Nursing
Section
4.2
Section
4.3
SH
62.5
Royal College of Nursing
SH
63
Royal College of Paediatrics and
Child Health
Section
4.4
Gen
Comments
This should prove a useful document. However it would be
useful to address what antibiotics should be prescribed in
terms of regimens as this is an area where there are
potential cost savings, and also an area where there is
inappropriate prescribing
Nurse-led community clinics should also be included
Perhaps it would be useful to also include guidance on what
‘worsening symptoms’ warrant the commencement of the
deferred antibiotic prescribing.
A useful key outcome measure would be the amount of
delayed prescriptions that were used
Overall this is a well thought through scope. My chief
concern relates to only including guidance for children aged
over 2 years. I can see no good rationale to the exclusion of
children aged under 2 years.
For 2005 the incidence of community antibiotic prescribing
for children in the UK was 643/1000 children for those aged
< 2 years, 690/1000 for the 2-5 year olds, 366/1000 for
those 6-10, and 325/1000 for those aged 11-15.
Therefore by excluding children aged under 2, the NICE
guidance would not cover approximately one third of all
community antibiotic prescribing in UK children.
The under 2s are in fact the key group to target for NICE
guidance. Concerns around potential harm following
delayed or non-prescribing are highest in this group,
although there is very limited evidence that complications
are increased. Influencing families and prescribers
behaviour at this young age is likely to considerably
influence prescribing for minor infections throughout
childhood. The recent introduction of conjugate
pneumococcal vaccination within the UK has significantly
reduced the risk of serious bacterial infections in the under 2
age group, but this is not widely appreciated by families or
GP’s who have seen this as a meningitis vaccination.
Viral infections are very common in this age group, and
22
Response
Due to the restricted timeframe for
short clinical guideline, it is impossible
to include the reviewing of antibiotic
regimens for individual RTIs.
Yes. This is included i.e. Walk-in
centres
Noted. The guideline will advise under
what situations the deferred
prescription should be started.
This will be one of the outcome
measures to be reviewed.
After detailed consideration and
review of current available literature,
the technical team decided to lower
the exclusion age to < 3 months so
that it would be in line with the NICE
Febrile Illness Guideline.
Respiratory tract infection – antibiotic prescribing. Scope consultation: 30 July – 28 August 2007
Type
Orde
r No
Stakeholder
Section
number
Comments
Response
there is good recent published data on the frequency of viral
isolates from young children with URTI.
NICE clinical guideline 47 on feverish illness in children
provides very limited guidance on antimicrobial prescribing
for the great majority of children presenting with a fever who
will have an URTI.
It is therefore very difficult to see why children aged under 2
should be excluded from this optimal practice guidance.
Failure to include this group runs the risk of seriously
reducing the impact of this potentially very important NICE
guidance for children. After many years of a consistent
reduction there is evidence of increased community
antibiotic prescribing rates for children. It is therefore illogical
to exclude guidance for possibly the most important group
within this Scope in terms of antimicrobial resistance.
Both the RCPCH and ARHAI would strongly encourage
NICE to reconsider the exclusion of children aged under 2
years from this Scope guidance. Both ARHAI and NICE very
much welcome the forthcoming guidance and are happy to
help in the process.
SH
64.0
Royal College of Pathologists
4.1.1
Although we appreciate that this initiative is directed towards
children over the age of 2yrs, there is also professional
concern amongst our paediatric microbiologists over the use
of antibiotics in younger children. Certainly there is a drive
within paediatric centres to recognise viral infections and not
to routinely prescribe antibiotics for these conditions.
After detailed consideration and
review of current available literature,
the technical team decided to lower
the exclusion age to < 3 months so
that it would be in line with the NICE
Febrile Illness Guideline.
SH
64.1
Royal College of Pathologists
4.3.1 (e)
Advice over the use of specific analgesics, together with
supporting evidence, would be most welcome
SH
64.2
Royal College of Pathologists
General
The AMM and RCPath are very happy to support this
initiative, and will actively contribute to further work on the
topic. The scope has been widely disseminated and
discussed amongst microbiologists, but at this stage we
The use of analgesics will be
addressed within this particular
guideline.
Noted, thank you
23
Respiratory tract infection – antibiotic prescribing. Scope consultation: 30 July – 28 August 2007
Type
SH
Orde
r No
65.0
Stakeholder
Royal College of Physicians of
London
Section
number
Point 3
Comments
have no further comments other than those made at the
Stakeholder meeting, and those outlined above.
The topic is appropriate since there is evidence that
antibiotics are prescribed inappropriately for these
conditions. Also that there is wide variation between
practices and individual GPs, which is not explained by
population variations and that harm (antibiotic resistance
and side effects in the individual) results from this.
Response
Noted.
Comparison to other European countries shows that there
are few with lower antibiotic prescription rates than the UK
and suggests that the margin for further reduction in
antibiotic prescription overall may not be that great. Harm
may ensue from inappropriate withholding of antibiotics,
especially if an incorrect initial diagnosis is made.
SH
65.1
Royal College of Physicians of
London
Point
4.1.2
Will the Guideline apply to the very elderly and nursing
home residents?
SH
65.2
Royal College of Physicians of
London
Point
4.3.1a
SH
65.3
Royal College of Physicians of
London
Point
4.3.1c
The scope includes 6 topics. Three of these (earache, sore
throat and acute cough) are single symptoms, the other
three are symptom complexes. The Guideline must give
very clear recommendations about the definitions of these
symptom complexes and the term ‘Acute’. It also will need to
consider the frequency in which, particularly when symptom
complexes are used, there is the chance to mis-diagnose a
condition (e.g. pneumonia) which requires immediate
antibiotic therapy.
What separates ‘self limiting’ from non self limiting must be
clearly defined.
SH
65.4
Royal College of Physicians of
London
Point
4.3.1e
Patients not receiving antibiotics must be provided with an
alternative such as detailed explanation, leaflet or alternative
drug - potential for use of anti-tussives should be included
24
Yes. The guideline applies to all
adults (including the elderly) with no
further co-mobidities that will affect
the decision to prescribe antibiotics.
The guideline will address the
definition and basic aetiology of the 4
conditions listed in 4.3.1
The definition of “self-limiting” will be
addressed in the guideline in line with
the National Prescribing Centre and
current available evidence.
This will be addressed within the
guideline under the section “the mode
of delivery” of antibiotic management
Respiratory tract infection – antibiotic prescribing. Scope consultation: 30 July – 28 August 2007
Type
Orde
r No
Stakeholder
Section
number
SH
65.5
Royal College of Physicians of
London
Point
4.3.2b
SH
SH
SH
SH
SH
SH
66
67
68
69
70
71
SH
72.0
Royal Society of Medicine
SACAR
Salford PCT
Sanofi-Aventis
Schering-Plough Ltd
Scottish Intercollegiate Guidelines
Network (SIGN)
Sedgefield PCT
4.3.1d
SH
SH
SH
73
74
75.0
SH
76
SH
SH
SH
77
78
79
SH
SH
80
81
SH
SH
SH
SH
82
83
84
85
SH
86
Sefton PCT
Sheffield PCT
Sheffield Teaching Hospitals NHS
Foundation Trust
Social Care Institute for Excellence
(SCIE)
Solihull PCT
South Staffordshire PCT
Specialist Advisory Committee on
Antimicrobial Resistance (SACAR)
Trafford Primary Care Trust
University Hospital of South
Manchester NHS Foundation Trust
University of Wales, Bangor
Warrington Primary Care Trust
Welsh Assembly Government
Welsh Scientific Advisory
Committee
West & East & North Hertfordshire
4.4c
Comments
Response
for acute cough
Exclusion of patients with ‘comorbidities that affect antibiotic
prescription decision’ will significantly limit the usefulness of
the Guideline. Such conditions will need to be explicitly
stated in the Guideline.
This organisation was approached but did not respond
This organisation was approached but did not respond
This organisation was approached but did not respond
This organisation was approached but did not respond
This organisation was approached but did not respond
This organisation was approached but did not respond
strategies.
The exclusion of patients with ‘co
morbidities that affect antibiotic
prescription decision’ will be explicitly
stated in the guideline.
This should also consider how the Rx is given (I hope to
publish soon on a non-URTI topic regarding different
methods of giving delayed Rxs- most doctors give the
prescriptions to patients and tell them to wait)
This organisation was approached but did not respond
This organisation was approached but did not respond
This section should have consideration of allergy status of
patient (adverse effects)
This organisation was approached but did not respond
Noted.
This organisation was approached but did not respond
This organisation was approached but did not respond
This organisation was approached but did not respond
This organisation was approached but did not respond
This organisation was approached but did not respond
This organisation was approached but did not respond
This organisation was approached but did not respond
This organisation was approached but did not respond
This organisation was approached but did not respond
This organisation was approached but did not respond
25
Yes. This will be addressed.
Respiratory tract infection – antibiotic prescribing. Scope consultation: 30 July – 28 August 2007
Type
Orde
r No
SH
87
SH
SH
SH
88
89
90
Stakeholder
PCTs
West Midlands Ambulance Service
NHS Trust
WhippsCross Hospital NHS Trust
Wyeth Pharmaceuticals
Yorkshire Ambulance Service
Section
number
Comments
This organisation was approached but did not respond
This organisation was approached but did not respond
This organisation was approached but did not respond
This organisation was approached but did not respond
26
Response