Dr Rob Wicks welcomes the new guideline from SIGN on management of lower respiratory tract infection in adults
The most important thing about a new guideline, to my mind, is whether it is simple enough to be easily remembered in the clinical situation to which it relates.
Guidance on when to prescribe antibiotics is both timely and relevant for scientific and economic reasons, so it was with interest that I sat down to peruse the recent SIGN guideline on LRTIs.1
In essence, the guideline divides patients with chest infections into three clinical groups:
- No new chest signs, but pre-existing disease, breathlessness and/or increased sputum production
- New focal chest signs, possible community-acquired pneumonia
- No chest signs in previously fit individuals.
There are also seven indicators that help in assessing which category to put individual patients in:
- Raised respiratory rate
- Low blood pressure
- Confusion of recent onset
- Age over 50 years
- Preexisting disease
- High or low temperature
The groups are split logically into those who should be treated with antibiotics and those who should be given advice only. There are no surprises as to who qualifies for treatment. However, the section on the nontreatment group, namely previously fit patients without chest signs, I found the most educational.
GPs prescribe antibiotics 70% of the time if they think patients expect it, but our assessment of this expectation is only correct 47% of the time. Reconsultation for treatment failure is as common as for side-effects of antibiotics.
This was illustrated for me last weekend when I saw a young man in his 20s at our co-op°s base surgery. He described his cough and symptoms elaborately, and I was sure he wanted antibiotics. On most Saturdays he would have got them, but with the new guideline in mind I took a history and examined him. I then explained that he would probably improve without treatment and he went away quite content. Unfortunately, I didn°t have the advice sheet contained in the guideline to hand, but I intend to print some off for use in the surgery.
The patients who benefit from antibiotics are those with new chest signs, previous illness or signs of severe illness. The guideline recommends both antibiotic treatment and immunisation against influenza and pneumococcus for these individuals. In fact, it recommends pneumococcal vaccine for all the over-65s.
What I liked about this guideline was that it provides plenty of facts for the clinician to absorb. It is easy to understand as well as being easy to apply, and makes the decision as to whether to prescribe much easier. It is a good example of how evidence-based research can help in everyday practice.
Dr Farmer, a member of the guideline development group, states in his article (SIGN guideline aids GP management of respiratory infection) that he hopes the guideline will give GPs the confidence to apply the evidence to clinical practice. I think it may very well provide the basis for further reduction in unnecessary antibiotic prescribing and in the long run reduce reconsultation rates. The educational value for doctors and their patients should not be underestimated.
My only concern is that the people who ought to read it probably won°t! SIGN might find blowing its own trumpet a little difficult, but it should at least consider sending a copy to the prescribing lead in each of the new PCTs. We could save a fortune on our prescribing budgets.
I believe this guideline will succeed because it fulfils the criteria of being simple and easily remembered.
- SIGN 59: Community Management of Lower Respiratory Tract Infection in Adults. Edinburgh: Scottish Intercollegiate Guidelines Network, 2002. www.sign.ac.uk