2023+NICE指南：大于16岁人群疑似急性呼吸道感染的初次评估和初期管理英文版）.pdf

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1、S uspe c te d acu te r espir a tor y inf e c tion in o v er 16s:assessmen t a t fir st pr esen ta tion and ini tial manag emen t NICE guideline Published:31 October 2023 www.nice.org.uk/guidance/ng237 NICE 2023.All rights reserved.Subject to Notice of rights(https:/www.nice.org.uk/terms-and-conditio

2、ns#notice-of-rights).Y our r esponsi bili t y The recommendations in this guideline represent the view of NICE,arrived at after careful consideration of the evidence available.When exercising their judgement,professionals and practitioners are expected to take this guideline fully into account,along

3、side the individual needs,preferences and values of their patients or the people using their service.It is not mandatory to apply the recommendations,and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual,in consultation with them

4、and their families and carers or guardian.All problems(adverse events)related to a medicine or medical device used for treatment or in a procedure should be reported to the Medicines and Healthcare products Regulatory Agency using the Yellow Card Scheme.Local commissioners and providers of healthcar

5、e have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it.They should do so in the context of local and national priorities for funding and developing services,and in light of their duties to have due regard to the need to el

6、iminate unlawful discrimination,to advance equality of opportunity and to reduce health inequalities.Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.Commissioners and providers have a responsibility to promote an environmentally su

7、stainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.Suspected acute respiratory infection in over 16s:assessment at first presentation andinitial management(NG237)NICE 2023.All rights reserved.Subject to Notice

8、 of rights(https:/www.nice.org.uk/terms-and-conditions#notice-of-rights).Page 2 of20Con ten ts Overview.4 Who is it for?.4 Recommendations.5 1.1 All first contact with NHS services.5 1.2 Remote contact with NHS services at first presentation.6 1.3 In-person contact with NHS services at first present

9、ation.8 Terms used in this guideline.11 Recommendations for research.12 1 Early warning scores in different settings.12 2 Point-of-care microbiological tests.13 3 Costing antimicrobial stewardship.13 Rationale and impact.14 All first contact with NHS services.14 Remote contact with NHS services at f

10、irst presentation.14 In-person contact with NHS services at first presentation.16 Context.19 Finding more information and committee details.20 Suspected acute respiratory infection in over 16s:assessment at first presentation andinitial management(NG237)NICE 2023.All rights reserved.Subject to Notic

11、e of rights(https:/www.nice.org.uk/terms-and-conditions#notice-of-rights).Page 3 of20This guideline partially replaces CG191.This guideline is the basis of QS210.Ov er vie w This guideline covers assessment of people aged 16 and over with symptoms and signs of acute respiratory infection(bacterial o

12、r viral)at first remote or in-person contact with NHS services.It also covers the initial management of any infections.It aims to support healthcare practitioners in making sure that peoples treatment follows the best care pathway.It forms part of a suite of work on virtual wards being undertaken by

13、 NICE.This guideline replaces recommendation 1.1.1,and updates recommendations 1.2.1 and 1.2.2 from NICE guideline CG191(published December 2014).W ho is i t f or?Healthcare practitioners People aged 16 and over with suspected acute respiratory infection,their families and carers Suspected acute res

14、piratory infection in over 16s:assessment at first presentation andinitial management(NG237)NICE 2023.All rights reserved.Subject to Notice of rights(https:/www.nice.org.uk/terms-and-conditions#notice-of-rights).Page 4 of20R e c ommenda tions People have the right to be involved in discussions and m

15、ake informed decisions about their care,as described in NICEs 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

16、use),professional guidelines,standards,and laws(including on consent and mental capacity),and safeguarding.This guideline does not cover people with known COVID-19.See NICEs guidelines on COVID for advice on managing COVID-19 infection.It does not cover the ongoing management of acute respiratory in

17、fection(ARI)after first assessment and initial management,or management of exacerbations of underlying respiratory conditions.For advice on managing:cough(acute)associated with an upper respiratory tract infection or acute bronchitis,see NICEs guideline on antimicrobial prescribing for acute cough c

18、hronic obstructive pulmonary disease(acute exacerbation),see NICEs guideline on antimicrobial prescribing for acute exacerbation of chronic obstructive pulmonary disease sinusitis(acute),see NICEs guideline on antimicrobial prescribing for acute sinusitis sore throat(acute;including pharyngitis and

19、tonsillitis),see NICEs guideline on antimicrobial prescribing for acute sore throat.For advice on managing suspected tuberculosis,see NICEs guideline on tuberculosis.1.1 All fir st c on tac t wi th NHS ser vic es These recommendations cover all people with symptoms and signs of an ARI who contact NH

20、S services whether remotely or in person.Suspected acute respiratory infection in over 16s:assessment at first presentation andinitial management(NG237)NICE 2023.All rights reserved.Subject to Notice of rights(https:/www.nice.org.uk/terms-and-conditions#notice-of-rights).Page 5 of201.1.1 In people w

21、ith a suspected ARI,think could this be sepsis?and assess in line with the section on identifying people with suspected sepsis in NICEs guideline on sepsis.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

22、 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 a

23、ll first contact with NHS services.Full details of the evidence and the committees discussion are in:evidence review A:signs,symptoms and early warning scores for predicting severe illness evidence review B:rapid tests to inform triage and antibiotic prescribing decisions evidence review C:diagnosti

24、c accuracy of point-of-care tests for viral versus bacterial infection evidence summary D:acute respiratory infection.1.2 R emote c on tac t wi th NHS ser vic es a t fir st pr esen ta tion These recommendations cover people with symptoms and signs of an ARI using remote means such as telephone,video

25、 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 of

26、fering alternatives,when necessary.Suspected acute respiratory infection in over 16s:assessment at first presentation andinitial management(NG237)NICE 2023.All rights reserved.Subject to Notice of rights(https:/www.nice.org.uk/terms-and-conditions#notice-of-rights).Page 6 of201.2.2 Assess people to

27、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 ma

28、naged 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-inf

29、ective 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

30、 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 ver

31、y 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.Suspected acute respiratory infection in over 16s:assessment at first pre

32、sentation andinitial management(NG237)NICE 2023.All rights reserved.Subject to Notice of rights(https:/www.nice.org.uk/terms-and-conditions#notice-of-rights).Page 7 of20For a short explanation of why the committee made these recommendations and how they might affect practice,see the rationale and im

33、pact section on remote contact with NHS services at first presentation.Full details of the evidence and the committees discussion are in:evidence review A:signs,symptoms and early warning scores for predicting severe illness evidence review B:rapid tests to inform triage and antibiotic prescribing d

34、ecisions evidence review C:diagnostic accuracy of point-of-care tests for viral versus bacterial infection evidence summary D:acute respiratory infection.1.3 I n-per son c on tac t wi th NHS ser vic es a t fir st pr esen ta tion These recommendations cover people with symptoms and signs of an ARI wh

35、o present in-person at sites that provide NHS services,including general practice and community pharmacies.1.3.1 For people with symptoms and signs of an ARI,use clinical assessment to make a diagnosis and decide whether to prescribe antimicrobials,either immediately or with a back-up prescription,a

36、nd offer them self-care advice(see recommendation 1.1.2).If pneumonia is suspected,see also the section on clinical diagnosis of pneumonia.1.3.2 Consider the persons ARI symptoms and signs in the context of their overall health and social circumstances(for example,they may have comorbidities or mult

37、imorbidity,be frail,or have a learning disability or autism)when making decisions about treatment or referral for further assessment.1.3.3 Do not offer rapid point-of-care microbiological tests or influenza(flu)Suspected acute respiratory infection in over 16s:assessment at first presentation andini

38、tial management(NG237)NICE 2023.All rights reserved.Subject to Notice of rights(https:/www.nice.org.uk/terms-and-conditions#notice-of-rights).Page 8 of20tests to people with suspected ARI to determine whether to prescribe antimicrobials.Testing may be indicated for surveillance or infection control.

39、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

40、 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.Clinic al diagnosis o f pn

41、eumonia 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 dec

42、isions 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 exampl

43、e,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 NICEs guidelines on pneumonia in adults:diagnosis and management and antimicrobial prescribing for community-acquired pneumonia for further details about th

44、e diagnosis and management of pneumonia.Suspected acute respiratory infection in over 16s:assessment at first presentation andinitial management(NG237)NICE 2023.All rights reserved.Subject to Notice of rights(https:/www.nice.org.uk/terms-and-conditions#notice-of-rights).Page 9 of20Box 1:CRB65 score

45、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 NICEs guideline on delirium raised respiratory r

46、ate(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(m

47、ore 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 committees discussion are in:e

48、vidence review A:signs,symptoms and early warning scores for predicting severe illness evidence review B:rapid tests to inform triage and antibiotic prescribing decisions evidence review C:diagnostic accuracy of point-of-care tests for viral versus bacterial infection evidence summary D:acute respir

49、atory infection.Suspected acute respiratory infection in over 16s:assessment at first presentation andinitial management(NG237)NICE 2023.All rights reserved.Subject to Notice of rights(https:/www.nice.org.uk/terms-and-conditions#notice-of-rights).Page 10 of20T erms use d in this guideline This secti

50、on defines terms that have been used in a particular way for this guideline.A cu te r espir a tor y inf e c tion(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