Antibiotics should not be prescribed for a suspected acute respiratory infection (ARI) based on a remote consultation only, NICE has proposed in a new draft guideline.

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The update follows draft guidance published in August recommending ARI hubs or ARI infection virtual wards as options for over-16s to be managed at home with the support of digital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 vaccination providers will receive additional payments for each dose delivered.

This article fist appeared on our sister publication Pulse. 

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