GPs should not prescribe antibiotics for suspected acute respiratory infection (ARI) based on remote consultation only, NICE has proposed in a new draft guideline.
It also says GPs can refer patients with pneumonia to virtual wards – i.e. to be cared for at home using digital tools to monitor their condition – including those with an intermediate CRB65 score.
The draft guideline on the initial assessment and management of suspected ARIs in over-16s covers pneumonia, respiratory viruses, and flu – but not Covid-19.
NICE is expecting the final guideline to be published ahead of winter, by 30 October, with the consultation closing 15 September.
The update follows draft guidance published in August recommending ARI hubs or ARI infection virtual wards as options for over-16s to be managed at home with the support of digital technologies.
Regarding face-to-face assessments, the new NICE guideline recommends that if any point during a remote consultation a person is suspected to have pneumonia – or if an adequate assessment cannot be made remotely – the person should be brought in for a face-to-face assessment.
And it says: ‘Do not prescribe antimicrobials for ARIs based on a remote consultation alone. If antimicrobials may be needed, refer the person for a face-to-face assessment.’
During an in-person appointment a clinical assessment should be carried out using the ‘CRB65 score’, which factors in the person’s age, blood pressure and respiratory rate to help make a judgement about managing pneumonia.
NICE said this will help determine whether the patient can be safely managed at home; the new option of care at home through a virtual ward; or if in-hospital assessment and treatment is needed.
‘Discuss the options with people with a score of 1 or 2 and make a shared decision about the best care pathways for them, for example supported home-based care such as a virtual ward,’ the draft guideline says.
The draft also includes new guidance on the use of testing to guide antibiotic prescribing to patients who present in-person at GP practices and walk-in centres.
It recommends not offering microbiological or influenza tests to determine whether to prescribe antibiotics, but instead to use a clinical assessment. However it does recommend considering a C-reactive protein (CRP) test – that can indicate the presence of infection – to help decide whether to prescribe antibiotics to people without suspected pneumonia.
According to NICE, ARIs have increased since the Covid pandemic, with around 220,000 people being diagnosed with pneumonia in England and Wales every year and causing significant winter pressures.
Professor Jonathan Benger, director of the Centre for Guidelines at NICE, said: ‘This useful and useable guidance focuses on what matters most and will help ensure busy healthcare professionals provide the right care, at the right time depending on the individual needs of their patients.
‘It will also help to support the additional capacity the NHS has created this winter and provide a richer urgent care pathway that meets the different needs of local populations.’
Professor Sir Stephen Powis, NHS England national medical director, said: ‘Acute respiratory infections are one of the most common reasons why patients seek a GP appointment or attend hospital as an emergency.
‘I am grateful to NICE for working with us on this new draft guidance which will help inform decisions on where a patient would be best treated while expanding the types of tests and other investigations used to determine the most appropriate treatment, which will be a real game-changer in the way we can deliver care for patients in the community.
‘This guidance will be hugely welcomed by local NHS teams, enhancing their ability to deliver the best possible care for patients, including in our innovative acute respiratory infection hubs and virtual wards – improving access to face-to-face appointments and helping prevent unnecessary hospital admissions for patients.’
The independent appraisal committee has also recommended research is conducted on people’s views and experiences of remote consultations ‘to help determine how effective they are’, NICE said.
It comes as the autumn Covid vaccination programme in England has been brought forward due to concerns over a new variant, and GPs will receive additional payments for each dose delivered.
Key highlights from the draft ARI guideline
1.1.5 If pneumonia is suspected, or if an adequate assessment cannot be made remotely, or if there is cause for concern (for example, co-morbidities that may be exacerbated by an ARI), refer the person for a face-to-face assessment. The decision about where to refer should be based on severity of symptoms, rate of deterioration and the presence of any serious co-morbidities (for example, chronic obstructive pulmonary disease).
1.1.6 Do not prescribe antimicrobials for ARIs based on a remote consultation alone. If antimicrobials may be needed, refer the person for a face-to-face assessment.
1.1.12 Use clinical judgement together with the CRB65 score to inform decisions about whether people with a clinical diagnosis of pneumonia need hospital assessment as follows:
• consider hospital assessment for people with a CRB65 score of 3 or more
• discuss the options with people with a score of 1 or 2 and make a shared decision about the best care pathways for them, for example supported home-based care such as a virtual ward
• consider home-based care for people with a CRB65 score of 0.
Source: NICE
Agree 100% – it only takes 30 seconds to look at a throat or listen to a chest – it really isn’t that onerous
More good news for Babylon😁
Please tell this to the patients !!
Is there any evidence that there is a problem that requires this solution?
It looks, at first glance, as more Ivory-Tower nonsense which ends up in the imposition of pointless scoring charts and processes and huge expense (and another inflation of hospital funding) which adds nothing to patient care whilst stripping out all clinical sense and compassion.
NICE – please stop increasing our workload without increasing our funding so we can increase our capacity and appointment length to deliver it. Otherwise you are setting up standards we will be unable to meet.
Does this apply to infective flares of copd? Are we now stopping leaving standby meds in case of flare?
This is actually a very good guideline.
Now don’t get me wrong, I’m usually as cynical about NICE guidelines as the next man, and the bit about f2f assessment will be controversial…
But for several years I’ve been saying to my trainees that it is crazy that there is no published algorithm to make a decision in primary care on which patients with cough should receive antibiotics. I have searched for algorithms before, and all the ones I found involved things like CXR or bloods which were not routinely available to us.
This one has a nice little list of features, the presence of any one of which is intended to result in issue of an antibiotic. (Tachypnoea >30, wheezing, o2 38, systolic 100, diarrhoea, impaired consciousness)
Some may prefer their own idiosyncratic “clinical judgement” but for me this algorithm is long long overdue.
Can I ‘refer’ the patient for a Face to Face with NICE? Cos I’m already filled up to the brim to fit in 20 arguments with clueless punters why they don’t need abx.
Liam please come locum for me, where I will give you a whole minute to assess a cough.
Look on the bright side————-no training
Most practice based GPs are doing this. Not sure how this ties in with online providers. Are doctors or clinicians who work for them placing themselves at risk by providing antibiotics with an online consultation?
Nice should be providing guidence fro the maximum number of consults a day as well/Patient contacts.
Sounds fantastic – now if only there was an acute respiratory hub, urgent care centre locally or even one planned. Genuinely this is not viable guidance without proper funding – we simply do not have capacity to do this. Agree it is gold standard but unfortunately Primary Care locally neither has the resources, staff or space to see the amount of patients to make this workable.
I never understood why you need remote consultation for some thing which has risk. Patients are not good in assessing their seriousness or triviality of symptoms. You may end up with perfect notes to defend your self but disastrous result for patients some time.
It takes much less time to see patient than triaging on phone.
Ask patient to count respiratory rate!! Take bp and asses if you are confused . CRB is for doctors not patients.
digital bp monitors are at times unpredictable.
Common sense. Have been concerned about remote over prescribing of antibiotics for a while (COPD aside)
G raj are you a gp ?
I agree with Darren. So many unnecessary charts like CRB65. Newas, etc etc. as if if respiratory rate was 29 instead of 30 we have different course of action.
Recently published PE exclusion criteria as another useless chart. We need to use common sense but when you talk to hospital they ask you about scores .
The most common ARI we see is the common cold. Based on these guidelines, if we cannot assess remotely with a resp rate, pulse rate, sats and blood pressure, we should assess f2f. Can’t recall the last time any patient or care home managed to give me these obs satisfactorily on a remote consultation. Also wheeze as a sign of pneumonia? Most common cause of wheeze in ARI is bronchitis which are 80% viral and our local anti-microbial guidance advocating no antibiotics. So on the one hand we are encouraging self care for “minor self limiting illness “but this risk averse guidance is now telling us to in essence to assess every ARI F2F? What an oxymoron. The capacity is not there in primary care and 10 minutes is not enough for this with more tick boxing test scores. Absurd expectations! What in earth is happening to to experience and clinical judgement in general practice.
Its leaving neo.
COugh = antibiotics, like in 90% of the non-western world.
Actually, just wait until you have one go sour on you. When I’d been a GP for about 5 years I saw a man of about 70 who had a cough. Not a COPD patient. Nice clear chest on exam and no tachypnoea. (We didn’t do sats then in the community.) I reassured him. The next day he was on a medical ward and was close to going to ITU.
After that I thought, “Whis is it to be? 50p worth of amoxicillin or my career on the line every time?”
PS I’m not advocating antibiotics for all coughs; just expressing that in most of the world, that’s the way it is.
Amoxicillin at that stage would likely have had minimal impact!
Sensible guidance.
Overwhelming majority of coughs don’t require antibiotics and often really not that taxing to do a quick assessment. Frequently prescribed remotely out of laziness or to simply keep people happy.
Hmm, coughing and spluttering in the waiting room ? I think the mode of consultation should be determined by mutual agreement between patient and clinician.
I work in Norfolk with higher than average elderly population. Limited option for F2F with this demographic and infection . It’s really not an efficient use of my time driving around the countryside.
Perhaps NICE could trust people a little more to do the right thing? Provide guidance but recognise it’s only an opinion, not divine truth.
Some will find algorithms helpful, others won’t.
As a patient I want to be seen, but maybe others can do things differently and still be safe?
This micromanagement is killing GP.
In the absence of evidence what is the justification for an uncosted guideline with significant implications for patients and for healthcare?
Is the aim to support successful complaints, or is it to reduce antibiotic use?
Is the intention to reduce the risk of serious illness going undiagnosed?
Is the intention to reduce over medicalisation?
Who is this PROPOSED guideline supposed to benefit?
Is it those who want to damage the health service?
Or is it to ‘protect’ the resources of the NHS to increase efficiency?
Will this change actually help the majority of patients with self limiting illness?
Will it improve detection of acute medical emergencies, which perhaps are not the remit of primary care anyway?
There are arguments available for each of these.
There is a great absence of evidence about all of them.
In particular there is little evidence from real world situations.
Not NICE, but National institute for Expensive Vague Guesses
@Steve McOne
Steve thanks for the offer but I am too busy trying to keep our practice above water!
you are right it takes more than 30 seconds but the point being it’s faster doing it face to face than over the phone
I wonder, when we are down to the last practicing Family Doctor, will NICE still be making recommendations on the basis of an ideal world and an ideal scenario? What we need at the moment is a “TRIAGE NICE” that gives advice on the most effective use of resources, be that human or technology, in an underfunded real world scenario- with the reciprocal advice that identifies what has been deprioritised to stop, whenever something new is begun.
As we are already so far behind on resources there will need to be at least 2 stops to one start for the foreseeable future.
NICE guidelines are for lawyers, lazy ‘expert’ GP witnesses, Noctors and medical students. I’m not against guidelines when used sensibly but reality isnt sensible. NICE is predominantly a text book for lawyers, stray from the guide if you like, but if things go wr
..wr
wrong (like my iphone just now ) you better have a detailed and nuanced excuse. Beware the guidance you were not aware of and well meaning advice that if followed will sometimes lead to disaster (e.g. J Glasspool above) Having recently been on the receiving end of a scatter gun negligence claim of almost zero merit, where a lazy GP ‘expert’ slavishly quoted NICE guidance ‘mandating’ an a&e visit (4-6 hours wait to be sent home with an out patient appointment) whilst the Hospital ‘expert’s opinion was that would have been of no benefit and made absolutely no difference to the outcome..well NICE guidance in use isn’t always helpful
NICE appears to be vulnerable to infiltration and excess influence from various groups pursuing their own agendas.
Hrt guidelines a good example, diabetes another; an organisation past it’s best-before date.
Hi
When the NICE team set up and work in my local respiratory hub, I will glad redirect all the coughs to see them face to face, freeing me up to do some real medicine.
Until then I will continue to do remote assessments and safety net by tresting the few with concerns over the low risk of possible bacteria infection or those with higher risk like COPD with antibiotic cover.
The 20 years of experience of doing my job trumps the ivory tower morons who give advice from their lofty position away from reality of front line GP work.
If I saw these patients face to face the waiting time would be weeks allowing them either natural recovery or an AE visit.
Take your pick, but you can’t have it both ways. Remote consulting is the genie you can’t shove back into the bottle now, pt demand is too high, not enough clinical resources/doctors to manage it all face to face now
This guidance is not helping, and still waiting for funded CRP testing to be delivered to my clinic.
Yes I am very happy to continue seeing sick/unwell patients to screen those who may require admission.
The smartest guy I’ve ever met in medicine was my old professor of Anaesthetics. Prior to his career in anaesthetics he was a GP for many years. He felt that no one should die of a respiratory illness without prescribing a 21p course of amoxicillin ( assuming no allergies ) he was right then and I think he might be still right now