Guidance

Recommendations

Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations and has information about prescribing medicines (including off‑label use), professional guidelines, standards, and laws (including on consent and mental capacity), and safeguarding.

This guideline should be read alongside NICE's antimicrobial prescribing guidelines on:

This guideline does not cover people with known COVID‑19. See NICE's guidelines on COVID for advice on managing COVID‑19 infection.

It does not cover the ongoing management of acute respiratory infection (ARI) after first assessment and initial management.

For advice on:

1.1 All first contact with NHS services

These recommendations cover all people with symptoms and signs of an ARI who contact NHS services whether remotely or in person.

1.1.2

Offer self-care advice to people whose symptoms can be managed at home. Ensure they know the likely duration of illness and when and how to seek medical help, for example, if symptoms worsen rapidly or significantly, do not improve over a specified time, or they become systemically very unwell.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on all first contact with NHS services.

Full details of the evidence and the committee's discussion are in:

1.2 Remote contact with NHS services at first presentation

These recommendations cover people with symptoms and signs of an ARI using remote means such as telephone, video call, online app, email or text message for initial assessment by NHS services, including NHS 111, 999 call centres and general practice.

1.2.1

Approach all remote assessments in a holistic, person-centred way, including checking that the person is able to use any digital technology being suggested and offering alternatives, when necessary.

1.2.2

Assess people to determine whether their symptoms can be safely managed at home or whether they have symptoms and signs that require further investigation; for example, symptoms and signs of concern for lower respiratory tract infection include breathlessness or confusion that is new or increased. If symptoms can be managed at home, offer self-care advice (see recommendation 1.1.2).

1.2.3

Arrange or refer the person for a face-to-face assessment if:

  • an adequate assessment cannot be made remotely (for example, because the person has difficulty communicating)

  • a serious illness is suspected (for example, pneumonia or non-infective causes of symptoms and signs)

  • they have a comorbidity that may be exacerbated by an ARI (for example, frailty or chronic obstructive pulmonary disease) or they are immunosuppressed.

    Any decision regarding the urgency of a face-to-face assessment, and where to refer (when appropriate), should be based on severity of symptoms and rate of deterioration.

1.2.4

Do not routinely prescribe antimicrobials based on a remote assessment alone unless the person knows when and how to seek further medical help and there is a sound reason to prescribe remotely, for example:

  • the person cannot or would find it very difficult to attend a face-to-face appointment and/or

  • the severity of illness can be adequately assessed remotely and the risk of an alternative diagnosis is low and

  • the prescriber is confident that antimicrobials are needed.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on remote contact with NHS services at first presentation.

Full details of the evidence and the committee's discussion are in:

1.3 In-person contact with NHS services at first presentation

These recommendations cover people with symptoms and signs of an ARI who present in‑person at sites that provide NHS services, including general practice and community pharmacies.

1.3.2

Consider the person's ARI symptoms and signs in the context of their overall health and social circumstances. The threshold for treatment or referral for further assessment may be lower for people who are more likely to have a poor outcome, for example, people with comorbidities or multimorbidity and people who are frail. [amended November 2023]

1.3.3

Do not offer rapid point-of-care microbiological tests or influenza (flu) tests to people with suspected ARI to determine whether to prescribe antimicrobials. Testing may be indicated for surveillance or infection control.

1.3.4

If, after clinical assessment, it is unclear if antibiotics are needed for someone with a lower respiratory tract infection, consider a point-of-care C‑reactive protein (CRP) test to support clinical decision making and:

  • offer immediate antibiotics if the CRP level is more than 100 mg/litre

  • consider a back‑up antibiotic prescription if the CRP level is between 20 mg/litre and 100 mg/litre

  • do not routinely offer antibiotics if the CRP level is less than 20 mg/litre.

1.3.5

Follow seasonal advice from the UK Health Security Agency (UKHSA) on managing influenza-like illness.

Clinical diagnosis of pneumonia

1.3.6

If a clinical diagnosis of pneumonia has been made, carry out a risk assessment using the CRB65 scoring system (see box 1).

1.3.7

Use clinical judgement together with the CRB65 score (bearing in mind this can be affected by other factors, for example, comorbidities or pregnancy) 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 2 or more

  • discuss the options with people with a score of 1 and make a shared decision about the best care pathways for them, for example, supported home-based care using a virtual ward or community intervention team

  • consider home-based care for people with a CRB65 score of 0.

See NICE's guidelines on pneumonia in adults: diagnosis and management and antimicrobial prescribing for community-acquired pneumonia for further details about the diagnosis and management of pneumonia.

Box 1: CRB65 score for risk assessment of pneumonia

CRB65 score is calculated by giving 1 point for each of the following prognostic features:

  • confusion (abbreviated mental test score of 8 or less, or new disorientation in person, place, or time); for guidance on delirium, see NICE's guideline on delirium

  • raised respiratory rate (30 breaths per minute or more)

  • low blood pressure (systolic less than 90 mmHg or diastolic 60 mmHg or less)

  • age 65 years or more.

People are stratified for risk of death (within 30 days) as follows:

  • 0: low risk (less than 1% mortality risk)

  • 1 or 2: intermediate risk (1 to 10% mortality risk)

  • 3 or 4: high risk (more than 10% mortality risk).

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on in-person contact with NHS services at first presentation.

Full details of the evidence and the committee's discussion are in:

Terms used in this guideline

This section defines terms that have been used in a particular way for this guideline.

Acute respiratory infection (ARI)

An acute illness (present for 21 days or less) affecting the respiratory tract with symptoms such as cough, sore throat, fever, sputum production, breathlessness, wheeze or chest discomfort or pain, and no alternative explanation.

Back-up prescription

A prescription for use at a later date if symptoms worsen.