Management Approaches

Consistent Approach to Management

Helping prescribers, pharmacists and patients adopt a consistent approach to managing respiratory tract infections was recommended. These should broadly divide into four areas:

Assessment of condition
Determining the seriousness of the condition
Communicating the correct and helpful messages
If not serious, then knowledge on how to manage through symptomatic relief and when to return for further investigation or alternative treatment.

Assessment

For prescribers, it is important to ensure that the condition is not trivialised and that a real interest is taken. “This needs to be mindful of cultural and personal diversity,” reminded Prof. Essack.

Patients’ primary symptomatic concern should be taken into account, such as throat pain, difficulty in swallowing and throat swelling in those with sore throats. Determining what action the patient has already taken and what they expect from a consultation is important in uncovering whether the desire for an antibiotic is the real driver. Research has shown that the primary concern for patients with sore throats is to establish the cause, receive pain relief and obtain information on the course of the condition. Hopes for an antibiotic ranked 11th out of 13 reasons.⁷Dr Noonan added that Irish research had found that less than a third of patients consulted for an antibiotic.

Identifying the main reason for consultation can help open up a discussion on whether antibiotics are appropriate, with prescribers referring/deferring to the pharmacist for symptomatic relief and advising patients to return if symptoms worsen or red flags appear.

For pharmacy staff the assessment should be similar, but less clinically focused. Their core role is to advise patients on symptomatic relief, that antibiotics are often not required and to suggest a course of action, including when or if to see the doctor.

For all healthcare professionals, there is a need for effective communications to achieve a balance in being informative, effective and empathetic.

Severity

Many respiratory tract infections are self-limiting in nature. Not only can this trivialise complaints, but it also undermines the key issue of deciding whether infection is severe. Therefore, a more in-depth assessment of symptoms, sometimes in combination with physical examination or testing, is required to eliminate the risk of serious infections.

Dr Noonan pointed out that the fear of missing serious infection was often a reason for antibiotic use.

“Liability and litigation are unfortunate drivers; until we have better ways of being sure something is not serious we will continue to see antibiotics being used” she said.

Furthermore, antibiotics are safe and cheap drugs with relatively low direct harm, which patients like to use, and therefore a prescription is easily given, Dr van der Velden added. Awareness of red flag symptoms and normal duration of illness should also be taken into account.

Knowledge

Communicating to patients effectively on how to manage a non-serious respiratory tract infection without an antibiotic requires skill. Effective communication skills are needed to help to promote a partnership approach between practitioner and patient, rather than a paternalistic, hierarchical relationship.

Encouraging self-management should be the focus of consultations, with both the patient and healthcare professional negotiating and agreeing on a treatment plan and discussing suitable symptomatic relief options.

Using a personalised patient leaflet during the consultation can be a valuable tool as it allows a dialogue around antibiotic expectations, establishes symptomatic treatment preferences and provides an advocacy opportunity for antibiotic stewardship. Advising patients that a condition such as sore throat can be treated with analgesics with little risk of serious problems also helps reinforce a self-management strategy.

Raising awareness of antibiotic resistance as a public health issue can also be covered. Patients oblivious to the impact of resistance on other people to be treated in the future, or that, by taking an antibiotic now, the likelihood of being infected themselves with resistant bugs is increased for up to a year.

For pharmacy staff and nurses it is important to match patient expectations. For example, in the pharmacy, patients are already choosing a self-management option, but they may need advice on suitable formulations to meet individual preferences and how to use them, as well as what course of action to follow. Where patient leaflets are used, these should be the same as those used by the doctor.

Factors to Consider in Managing Respiratory Tract Infections

Take patient concerns seriously and treat with respect in an empathetic, understanding manner.
Acknowledge the primary symptoms, likely course and duration of the infection.
Work in partnership to create an individualised selfmanagement plan.
Make patients aware of the normal duration of conditions and advise on red flag symptoms and when to re-consult.
Identify patient’s preferences and recommend symptomatic treatment that meets these.
Educate on antibiotic resistance and what it can mean to patients at a personal level and their family members.

Patient Participation

Tools to encourage patient participation in non-antibiotic strategies for respiratory tract infections would be valuable for healthcare professionals. These should be consistent for use across all healthcare disciplines; Dr van der Velden proposed that these should encompass all common respiratory tract infections, rather than having different tools and materials for each condition.

Educating healthcare professionals must be complemented by patient education. Manufacturers could play a role in providing funding for resources to meet healthcare professional and patient needs.

Underpinning everything, advised Prof. Oxford, was “the need for political action. This is the crux.”

A framework that brings all of these elements together will be the focus of future GRIP activities to help countries meet the challenge of antibiotic resistance.