Sarah Alton (pictured) and Professor Cliodna McNulty discuss the updated PHE guidance on managing and treating common infections and what it means for clinicians in primary care
Read this article to learn more about:
- how selective prescribing of antimicrobials can help to minimise the emergence of antimicrobial resistance in the community
- back-up and delayed antimicrobial strategies and when they are appropriate
- managing patient expectations regarding the prescribing of antimicrobials.
Antimicrobial resistance (AMR) is a major concern and a threat to future healthcare in the UK. One of the primary causes of AMR is the inappropriate prescribing of antimicrobials.1,2 The successful diagnosis, management, and treatment of common infections is one of the key components to mitigating this problem.
The importance of developing user-friendly guidance for primary care clinicians is ever growing to enable primary care staff to be aware of changing information, and to enhance patients’ experiences of the primary care system.3 The Primary Care Unit (PCU), Public Health England (PHE), first started to develop the Management and treatment of common infections guidance in 1999,4 well before evidence-based guidance was widespread and used reliably by primary care clinicians.
In 2013, the Department of Health issued the UK five year antimicrobial resistance strategy 2013 to 2018, emphasising the need for educating healthcare professionals about appropriate antimicrobial use, and to target antimicrobial prescribing.5 In 2015, NICE Guideline (NG) 15 on Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use6 was published, followed by NG63 Antimicrobial stewardship: changing risk-related behaviours in the general population,7 published in 2017. The guidelines are aimed at reducing antimicrobial resistance, and include information on interventions to reduce inappropriate antimicrobial use, and how to change the public’s behaviour regarding the use of antimicrobials.
Management and treatment of common infections
The PHE Management and treatment of common infections4 guidance, published in 2010 and updated in September 2017, is designed to be used and adapted by clinical commissioning groups (CCGs) and health boards across the UK. It is available as an editable table, to allow local clinicians and CCGs to adapt recommendations to suit local antimicrobial resistance rates, and to add contact details of local services. Following updates over the last 5 years, the guidance has seen increased emphasis on advice about self-care, non-antimicrobial treatments, and the use of point-of-care tests.
The main principles of the guidance are to:4
- provide up-to-date recommendations, aimed at primary care prescribers and healthcare providers (including those in general practice and out-of-hours settings, such as doctors, nurses, and pharmacists) giving first point of contact or symptomatic advice to people with common infections
- provide a simple, effective, economical, and empirical approach to the management and treatment of common infections, including the recommendation of non-antimicrobial treatments, where appropriate
- provide strategies that should lead to more targeted antimicrobial use
- suggest clinical scores or point-of-care testing to help target antimicrobials in those patients who will benefit most
- help minimise the emergence of antimicrobial resistance in the community
- provide guidance on patient risk factors that should be considered regarding antimicrobial resistance.
The 2017 update
Over 2016 and 2017, a full systematic review of the literature, and subsequent update of the current PHE guidance was conducted alongside the development of the NICE Clinical Knowledge Summaries (CKS).8 The categories of infection that were included in this review were:4
- upper respiratory tract infections
- lower respiratory tract infections
- urinary tract infections (UTIs)
- gastrointestinal tract infections
- genital tract infections
- skin and soft tissue infections
- eye infections.
Any updates made to the recommendations in the summary tables in the guidance are accompanied by references and rationales, to ensure that users understand why the changes have been made.
The section on UTIs was revised as a result of increasing antimicrobial resistance to Escherichia coli bacteraemias. Advice provided in the PHE common infections guidance is in line with the NHS England Quality premium (QP) 2017–19: reducing gram negative bloodstream infections (GNBSIs) and inappropriate antibiotic prescribing in at-risk groups.9 Due to increasing resistance of E. coli to trimethoprim, especially in the elderly, the guidance now emphasises nitrofurantoin as first-line treatment for lower UTI in adults, UTI in pregnancy, and UTI in children.10,11 The PHE guidance continues to advise considering back-up or delayed antimicrobials for women with mild urinary symptoms, and only using prophylactic antimicrobials for recurrent UTI, if severe and/or frequent.4 Prophylactic antimicrobials are only suggested after other strategies have been implemented, such as standby antimicrobials as soon as symptoms start.4
In addition, the information provided for Panton–Valentine leukocidin Staphylococcus aureus (PVL-SA) has changed following publication of a cross-sectional study at the Royal Free Hampstead NHS Trust Hospital, London.12 The sections on leg ulcers and Helicobacter pylori have both been updated, to ensure consistency between the Management and treatment of common infections guidance,4 and the relevant PHE quick reference diagnostic guides.13,14
As before, the guidance continues to give advice on when antimicrobials are recommended for suspected infections. The sinusitis (acute) section has been revised, so that phenoxymethylpenicillin is advised as the only first-line treatment (in the previous version phenoxymethylpenicillin or amoxicillin were options for first-line treatment). Recommendations for the treatment of sinusitis depend on the duration of symptoms, and what to do in cases of systemic illness or suspected complications.4,15 Emphasis is placed on self-care as first-line treatment, followed by a delayed antimicrobial strategy, with recommendations for immediate antimicrobial treatment considered for patients who are systemically very unwell, or have more serious signs and symptoms.4,15
A number of new conditions have been added to the guidance, following suggestions made in focus groups with microbiologists and primary care clinicians. These include scarlet fever (group A Streptococcus), genital herpes, acne, erysipelas, mastitis, and blepharitis.
Full literature searches were conducted for these conditions before any recommendations were added to the guidance.
Key priorities for implementation
The key priority for implementing the Management and treatment of common infections guidance4 is to make it readily available and known by all prescribers, including locums. Although implementing antimicrobial guidance is key to controlling antimicrobial resistance, the guidance should not be used in isolation and should be supported by:
- patient information about the usual duration of self-limiting conditions
- self-care (including the use of over-the-counter pain relief)
- safety-netting advice (to ensure awareness of more severe signs of infection)
- use of back-up or delayed antimicrobial prescriptions.
Emphasis is also placed on prescribing the appropriate antimicrobial and dosing regimen for each condition, considering local and national resistance rates, a patient’s individual complicating factors, and other potential risk factors (e.g. the development of Clostridium difficile or methicillin-resistant Staphylococcus aureus [MRSA]).
Share advice on self-limiting conditions, self-care, and safety-netting
It is important that clinicians discuss with patients the natural history or usual duration of their illness, and the usefulness of antimicrobials, depending on the severity of their infection. The guidance pays particular attention to this for upper respiratory tract infections, UTIs, and some skin and soft tissue infections, as most mild cases resolve without antimicrobials if the patient continues to practice self-care.16,17 The guidance also explicitly states that antimicrobials should only be prescribed for cases where there is likely to be clear clinical benefit, giving alternative, non-antimicrobial self-care advice where appropriate. Self-care, including over-the-counter pain relief, rest, and hydration is recommended as first-line treatment for:4
- most upper respiratory tract infections (including acute sinusitis)
- acute cough and bronchitis in healthy adults
- mild lower UTI in adults
- recurrent UTI in non-pregnant women
- mild to moderate acne
- eye infections
Safety-netting advice is a vital part of the consultation, to inform patients of signs and symptoms that their infection is getting worse, and red flags for systemic infection or signs of sepsis. The guidance recommends that safety-netting advice should be provided for all conditions, particularly UTIs, to prevent the development of acute pyelonephritis or bacteraemia. Materials to share with patients with UTIs or respiratory tract infections in consultations are available on the Royal College of General Practitioners’ (RCGP) TARGET website.18
Back-up or delayed antimicrobial prescriptions
Using a back-up or delayed antimicrobial prescription is thought to be associated with 40% fewer patients using antibiotics.19 Symptom control in most patients given a back-up or delayed prescription is similar to that seen in patients given an immediate antimicrobial prescription.19 The guidance recommends that a ‘no’ or ‘delayed/back-up’ antibiotic strategy should be considered for patients with acute self-limiting upper respiratory tract infections and mild UTI symptoms, based on number of symptoms, severity, and duration of symptoms. Patients should be given advice that they should start the antibiotic prescription if either their symptoms start to get worse, or if they do not start to feel a little better with self-care after 24 to 48 hours.16,20
Prescribing of appropriate antimicrobials
The Management and treatment of common infections guidance4 references all statements and gives rationales as to why each treatment strategy has been recommended for each clinical scenario. This draws on the most up-to-date robust evidence and guidance to ensure that the correct antimicrobials are prescribed, based on the most recent research. Clinicians should note current national and local antimicrobial resistance rates to the usual causative organism. In suspected UTI, taking urine samples for culture and antimicrobial sensitivities may be recommended to confirm diagnosis in milder cases, and to inform the most appropriate antimicrobial if there is increased risk of resistance. Factors that put patients at increased risk include:4
- being a care home resident
- having recurrent UTI
- hospitalisation for more than 7 days in the last 6 months
- unresolving urinary symptoms
- recent travel to a country with increased resistance
- previous UTI resistant to trimethoprim, cephalosporins, or quinolones.
The guidance emphasises that simple, generic antibiotics should be used where possible, and broad-spectrum antibiotics, such as ciprofloxacin, co-amoxiclav, and cephalosporins, should be avoided for infections where narrow spectrum antibiotics remain effective, due to the side-effects these can cause for patients and increased propensity for these antimicrobials to induce resistant gut flora. Particular attention should be paid to patients who are older, have been hospitalised recently, are immunocompromised, are pregnant, or have multiple morbidities, where clinicians should have a lower threshold for prescribing antibiotics. In these cases, antimicrobial resistance risk should be carefully considered, due to the possibility of more serious complications. Alternative antimicrobial recommendations are provided where appropriate throughout the guidance, alongside hyperlinks to the British national formulary for children for recommended child doses.21
The Management and treatment of common infections guidance,4 used alongside the PHE quick reference diagnostic guides,13,14 aims to optimise antimicrobial use by focusing not only on antimicrobial treatment, but also on the diagnosis and non-antimicrobial management of common infections. Clinicians may experience barriers in implementing this guidance, particularly when addressing the patient’s own expectations around their illness and prescribing of antimicrobials. It is therefore essential for clinicians to effectively address patient views about antimicrobials by discussing with patients the reasons why they have consulted, their expectations and concerns, and why they may or may not need an immediate antimicrobial prescription. Using back-up or delayed antimicrobial prescriptions can assist with these expectations, and is associated with 40% fewer patients using antibiotics.19
In summary, the implementation of this guidance by primary care clinicians can aid in tackling the public health threat of antimicrobial resistance. This, alongside the use of patient-facing materials, such as those available on the RCGP TARGET website, can also help in educating the public about antimicrobial resistance, and why antimicrobials may not always be the first-line treatment for managing and treating their common infections.18 All of the PHE antimicrobial diagnostic and treatment guides are available to view online (see: www.gov.uk/government/collections/primary-care-guidance-diagnosing-and-managing-infections). These guidelines are updated every 3 years, or more frequently if there are significant developments in the field.
Key points for clinicians
- Primary care clinicians should:
- implement the guidance, alongside sharing patient leaflets that provide advice and information to change behaviours, leading to more optimal antimicrobial prescribing
- discuss with patients their concerns and expectations, the severity of their suspected infection, management choices, and the natural history or usual duration of their illness
- provide safety-netting advice during a consultation, to inform the patient of signs and symptoms that their infection is getting worse, and red flags for systemic infection or signs of sepsis
- Back-up or delayed antibiotic strategies should be considered for acute self-limiting upper respiratory tract infections, and mild UTI symptoms. Patients should be given advice that they should start the antibiotic prescription if their symptoms either start to get worse, or if they do not start to feel a little better with self-care after 24 to 48 hours
- Simple, generic antibiotics should be used, where possible, and broad-spectrum antibiotics should be avoided for infections where narrow-spectrum antibiotics remain effective
- Particular attention should be paid to patients who are older, have been hospitalised recently, are immunocompromised, are pregnant, or have multiple morbidities
- The guidance should not be used in isolation. Supporting materials are available on the RCGP TARGET website: www.rcgp.org.uk/clinical-and-research/toolkits/target-antibiotics-toolkit.aspx
UTI=urinary tract infection; RCGP=Royal College of General Practioners; TARGET=Treat Antibiotics Responsibly, Guidance, Education, Tools
GP commissioning messages
written by Dr David Jenner, GP, Cullompton, Devon
- Commissioners should:
- ensure that the PHE Management and treatment of common infections guidance is immediately available to all prescribers and front-line clinical professionals, including pharmacists
- analyse local data to identify practices prescribing high quantities of antimicrobials and provide targeted educational events to reduce antimicrobial prescribing
- encourage promotion of the guidance to patients to adjust patient expectations—this could be achieved through publishing the guidance on practice websites and making it available through pharmacies, who are often the first contact point for patients
- Local formularies should be adapted to include the new recommendations and, if possible, the information should be made available in an electronic or app form
- Prompts or reminders for clinicians should be added or built in to clinical systems to allow for extra checks when certain items are prescribed (e.g. broad-spectrum antibiotics).
PHE=Public Health England
Read the Guidelines summary of PHE advice from Management and treatment of common infections—antibiotic guidance for primary care: for consultation and local adaptation for more recommendations on prescribing antimicrobials for common infections
- World Health Organization (WHO). Antimicrobial resistance—global report on surveillance. WHO, 2014. Available at: apps.who.int/iris/bitstream/10665/112642/1/9789241564748_eng.pdf?ua=1
- NICE. Urinary tract infections in adults. NICE Quality Standard 90. NICE, 2015. Available at: www.nice.org.uk/qs90
- Royal College of General Practitioners (RCGP). Essential knowledge updates: how the Royal College of GPs uses NICE guidance to deliver essential education to 16000 family doctors. NICE, 2011. www.nice.org.uk/sharedlearning/essential-knowledge-updates-how-the-royal-college-of-gps-uses-nice-guidance-to-deliver-essential-education-to-16000-family-doctors (accessed 11 September 2017)
- Public Health England (PHE). Management and treatment of common infections: antibiotic guidance for primary care—for consultation and local adaptation. PHE, 2010 (updated September 2017). Available at: www.gov.uk/government/publications/managing-common-infections-guidance-for-primary-care
- Department of Health. UK five year antimicrobial resistance strategy 2013 to 2018. DH, 2013. Available at: www.gov.uk/government/publications/uk-5-year-antimicrobial-resistance-strategy-2013-to-2018
- NICE. Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use. NICE Guideline 15. NICE, 2015. Available at: www.nice.org.uk/ng15
- NICE. Antimicrobial stewardship: changing risk-related behaviours in the general population. NICE Guideline 63. NICE, 2017. Available at: www.nice.org.uk/ng63
- NICE. Clinical Knowledge Summaries. Available at: cks.nice.org.uk (accessed 11 September 2017).
- NHS England. Technical guidance annex B—information on quality premium. NHS England, 2017. Available at: www.england.nhs.uk/wp-content/uploads/2016/09/annx-b-quality-premium-14-07-17.pdf
- Guneysel O, Onur O, Erdede M, Denizbasi A. Trimethoprim/sulfamethoxazole resistance in urinary tract infections. J Emerg Med 2009; 36 (4): 338–341.
- Gupta K, Hooton T, Naber K et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis 2011; 52 (5): 103–120.
- Shallcross L, Williams K, Hopkins S et al. Panton-Valentine leukocidin associated staphylococcal disease: a cross-sectional study at a London hospital, England. Clin Microbiol Infect 2010; 16 (11): 1644–1648.
- Public Health England (PHE). Venous leg ulcers: infection diagnosis and microbiological investigation guide for primary care. PHE, 2007 (updated March 2016). Available at: www.gov.uk/government/publications/venous-leg-ulcers-diagnosis-and-microbiology-investigation
- Public Health England (PHE). Test and treat for Helicobacter pylori (HP) in dyspepsia: quick reference guide for primary care—for consultation and local adaptation. PHE, 2004 (updated July 2017). Available at: www.gov.uk/government/publications/helicobacter-pylori-diagnosis-and-treatment
- NICE. Sinusitis (acute): antimicrobial prescribing. NICE guideline in development. NICE, 2017. Available at: www.nice.org.uk/guidance/gid-apg10002/documents/draft-guideline
- NICE. Respiratory tract infections (self-limiting): prescribing antibiotics. NICE Clinical Guideline 69. NICE, 2008. Available at: www.nice.org.uk/cg69
- Ferry S, Holm S, Stenlund H et al. The natural course of uncomplicated lower urinary tract infection in women illustrated by a randomized placebo controlled study. Scand J Infect Dis 2004; 36 (4): 296–301.
- Royal College of General Practitioners (RCGP). TARGET antibiotics toolkit. RCGP, 2012. Available at: www.rcgp.org.uk/TARGETantibiotics.
- Little P, Moore M, Kelly J et al. Delayed antibiotic prescribing strategies for respiratory tract infections in primary care: pragmatic, factorial, randomised controlled trial. BMJ 2014; 348 (7949): g1606.
- Little P, Turner S, Rumsby K et al. Dipsticks and diagnostic algorithms in urinary tract infection: development and validation, randomised trial, economic analysis, observational cohort and qualitative study. Health Technol Assess 2009; 13 (19): i–xi, 1–73.
- NICE. BNF for children. NICE, 2017. bnfc.nice.org.uk (accessed 11 September 2017).