Respiratory Tract Infections

Pharmacy is often the first stop for patients with suspected respiratory tract infections; presenting an opportunity to provide antibiotic stewardship and self-care advice

Respiratory tract infections (RTIs) are highly prevalent in Australia, accounting for an estimated 6–7 million visits to general practitioners each year.

The common cold, which is considered the most widespread RTI, is likely to infect adults approximately 2–4 times each year. Meanwhile, children can experience between 5–7 colds each year.

Of course, respiratory tract infections incorporate several infections of the throat, nose, airways or lungs and are characterised as being either upper or lower infections. Upper respiratory tract infections (URTIs) affect the sinuses, middle ear and throat and include the common cold, influenza, sinus infection, tonsillitis, laryngitis and acute otitis media. Lower respiratory tract infections (LRTIs) affect the airways and lungs and include croup, bronchitis, bronchiolitis and pneumonia.

Growing resistance

While RTIs are widespread, highly contagious ailments, they tend to be largely self-limiting. However, a major problem associated with RTIs, particularly among children, is antibiotic resistance and this is an area in which it’s believed pharmacists could play a greater role.

We know that antibiotic resistance is a growing problem in Australia and worldwide. In fact, the World Health Organisation (WHO) has described antibiotic resistance as one of the biggest global health threats of our time.

As new antibiotic-resistant strains of bacteria emerge, the fewer medicines we have available to treat these common infections, which poses a growing risk to people’s health.

The Antibiotic Use and Resistance in Australia (AURA) 2019 report found that despite a decline in antibiotic prescribing since 2016, antibiotics continue to be overprescribed compared with guideline recommendations. The indications for which antibiotics are most frequently inappropriately prescribed in the community are respiratory conditions.

AURA clinical director Dr Kathryn Daveson, says, “These latest AURA findings indicate that the levels of inappropriate prescribing of antibiotics in hospitals and the community are still too high and there is more work to be done.”

According to Antimicrobial Stewardship in Australian Health Care 2020, in 2017 alone, almost 42% of the Australian population had a least one antibiotic dispensed under the Pharmaceutical Benefits Scheme (PBS) and the Repatriation Pharmaceutical Benefits Scheme (RPBS).

The authors state that ‘antibiotics are being prescribed for acute respiratory infections in Australian general practice at rates four to nine times higher than current clinical practice guidelines recommend’.

They also say ‘antibiotics continue to be prescribed in general practice to patients with health problems for which there is no clinical benefit, including for influenza (52.2% of patients) and acute bronchitis (92.4% of patients).’

“The main concern is that when antibiotics are used inappropriately, they can alter the natural flora in the body and promote growth of antibiotic resistant organisms. This means that future infections could be harder to treat and there have already been numerous reports of patients dying from multi-resistant organisms, so we know this is a problem. This issue will only get worse if we don’t alter our prescribing habits,” says Dr Anna Samecki, GP and medical adviser at NPS MedicineWise.

3d set of orange lungs

Symptomatic management and self-care

The management of respiratory tract infections in the pharmacy setting mainly involves symptomatic relief for the primary symptoms. The most common symptoms include nasal congestion, rhinorrhoea, cough, sneezing, sore throat, headache, earache and fatigue.

It’s important to educate the general population on the fact that RTIs are generally viral in nature, often mild and self-limiting. While the symptoms will rarely cause serious harm, in some cases they can last quite a while.

“Pharmacists can provide guidance on how long symptoms typically last, as people often underestimate the duration of symptoms,” says Dr Samecki.

The following information has been taken from NICE Guidelines and NPS MedicineWise.

  • Sinusitis usually lasts 2–3 weeks.
  • Acute otitis media lasts about three days but can last up to one week. In seven days, nine out of 10 children will no longer have earache.
  • A sore throat/tonsilitis can last around one week. In three days, six out of 10 children will no longer have a sore throat. 
  • The usual course of an acute cough is up to three or four weeks. In 25 days, nine out of 10 children will no longer cough.
  • Flu can last up to two weeks.
  • Symptoms of the common cold typically last 7–10 days but can persist for up to three weeks. In 15 days, nine out of 10 children will no longer have a cold.

“While rest and plenty of fluids may be all that’s needed, simple analgesia, such as paracetamol or ibuprofen, may be helpful for relieving the pain associated with headache, sore throat and muscle aches.

“If cough is a major feature and interfering with sleep or day-to-day activities, a cough suppressant may be provided. Similarly, if congestion is interfering with sleep or daily activities and cannot be tolerated short-term nasal decongestants may be recommended,” says Dr Samecki.

Managing symptoms

To manage RTI symptoms in young children, parents and carers should be advised to ensure the child gets plenty of rest, stays warm, and is well hydrated. Paracetamol or ibuprofen can be administered where there is pain or fever. Saline nasal drops and vaporisers or steam inhalation can also be useful for managing nasal symptoms.

A study into the management of RTIs symptoms in young children also showed that pharmacists might consider natural and complementary medicine, such as Prospan for a chesty cough, Sambucol for cold and flu relief and Kaloba for bronchitis and sinusitis. This was often linked to parental pressure or anxiety about being able to give their child something to ease their symptoms.

“There is little evidence to support the use of supplements, vitamins and minerals in URTI management, so this is something to keep in mind,” advises Dr Samecki.

“If symptoms do not improve or worsen over a period of time, it’s important to refer the patient to their GP for review.

“Some parents may also see a ‘double sickening effect’ whereby the child comes down with a cold or flu-like illness, has a short period of recovery (e.g. a day or two), and then becomes sick again. Occasionally this could indicate a secondary bacterial infection after a viral illness, which needs assessment and proper management. Obviously if the child is very sick or unwell and needs immediate medical attention, the parents or carers should be advised to go to the nearest emergency department,” she adds.

According to NPS MedicineWise, additional alarm symptoms in children include:

  • Child becomes drowsy or irritable and does not improve after administering paracetamol or ibuprofen
  • Breathing problems, such as rapid breathing or shortness of breath
  • Cold or discoloured hands or feet
  • Changes in skin colour, such as pale or blue around the lips
  • Symptoms associated with meningitis such as severe headache, stiff neck, light sensitivity or rash that doesn’t fade when pressure is applied.

Certainly, studies have indicated that parental anxiety coupled with the need to ‘‘do something’’ for the sick child is one of the reasons why doctors sometimes inappropriately prescribe antibiotics.

However, says Dr Samecki says, “It’s important that we present a united front against the misuse of antibiotics, and pharmacists play a vital role in consistent and proactive messaging.

“We know many people seek health advice from their community pharmacists and often see them first, before the doctor. So pharmacists play a major role in health education and improving health literacy.

Also, if patients are getting the same message from their pharmacist and their doctor, they are probably more likely to listen and follow that advice.”

She says pharmacists can remind people that current evidence-based guidelines do not recommend antibiotics for simple URTIs and that most people will improve on their own with time and rest.

Patients who present with URIs can often benefit from reassurance, education, and instructions for symptomatic home treatment.

Dr Samecki refers to the Respiratory Tract Infections Action Plan, which can be downloaded from the NPS MedicineWise website; this is a useful resource that pharmacists can fill in with the patient. It helps them to understand what a RTI is and what treatment and self-care strategies they can use to help themselves feel better.

Self-care practices might include getting plenty of rest, increasing fluid intake, gargling warm salty water, steam inhalation and sucking on a lozenge.

Antibiotic stewardship

According to many government and independent bodies, pharmacists can play an important role in the fight against antibiotic resistance. The Global Respiratory Infection Partnership (GRIP), for example, states the pharmacy team is critical for antibiotic education.

It says pharmacists can advise patients that the majority of RTIs are viral infections that are self-limiting.

Pharmacists and their staff can play an essential role in explaining that antibiotics do not work but could pose a threat to the larger community. Key points to educate patients on include:

  • Most RTIs are caused by viruses, against which antibiotics do not work.
  • Antibiotics do not provide any pain-relieving effects.
  • Resistant bacteria can develop in any of us after antibiotic use, and can stay in our bodies for up to one year.
  • Misuse and overuse of antibiotics is reducing their ability to cure infections and save lives, now and in the future.
  • Increased use of antibiotics, including their misuse and overuse, results in higher risks of antibiotic resistance developing and spreading in the community.

GRIP’s framework, which is based on promoting behavioural change to prevent antimicrobial resistance, calls on pharmacists to help educate patients about responsible antibiotic use. The three-step approach developed for use in the pharmacy setting involves:

  1. Addressing patients’ concerns (offering reassurance)
  2. Being vigilant and addressing symptom severity
  3. Counselling on effective self-management.

In instances where it’s believed a patient has been inappropriately prescribed an antibiotic, Dr Samecki advises, “Contact the prescriber to clarify. It could be as simple as a miscommunication as to the indication of the antibiotics, an error or something else.”

Ultimately, pharmacists are considered well-placed to educate and advise on the issues surrounding antibiotic use and empower patients to self-manage their symptoms, practice good hand hygiene to stop the spread of infection, and safeguard antibiotics by avoiding inappropriate use.

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