11.1 Statement of intent

This guideline is not intended to be construed or to serve as a standard of medical care. Standards of care are determined on the basis of all clinical data available for an individual case and are subject to change as scientific knowledge and technology advance and patterns of care evolve. These parameters of practice should be considered guidelines only. Adherence to them will not ensure a successful outcome in every case, nor should they be construed as including all proper methods of care or excluding other acceptable methods of care aimed at the same results. The ultimate judgement regarding a particular clinical procedure or treatment plan must be made in light of the clinical data presented by the patient and the diagnostic and treatment options available. However, it is advised that significant departures from the national guideline or any local guidelines derived from it should be fully documented in the patient's case notes at the time the relevant decision is taken.

11.2 Local implementation

Implementation of national clinical guidelines is the responsibility of each NHS Trust and Health Board and is an essential part of clinical governance. It is acknowledged that every Trust cannot implement every guideline immediately on publication, but mechanisms should be in place to ensure that the care provided is reviewed against the guideline recommendations and the reasons for any differences assessed and, where appropriate, addressed. These discussions should involve both clinical staff and management. Local arrangements may then be made to implement the national guideline in individual hospitals, units and practices, and to monitor compliance. This may be done by a variety of means including patient-specific reminders, continuing education and training, and clinical audit.

11.3 Cost savings for NHSScotland

A preliminary economic analysis conducted by the Research Assistant to the SIGN Economic Advisor has estimated that substantial cost savings can ensue if the recommendations in this guideline are followed. Based on this analysis the number of antibacterial prescriptions for LRTI annually in Scotland is around 640 800, each costing between £3.19 and £5.18. A 40% reduction in the largely unnecessary antibiotic prescribing for LRTI is a reasonable target to aim for.¹⁷⁶ Achieving this target by implementing this guideline would save between £1-1.33 million annually for NHSScotland. These conservative estimates do not take into account further savings from reduced consultations with GPs due to antibiotic side effects or requests for repeat prescriptions.

11.4 Key points for audit

• Proportion of previously well patients with LRTI without focal chest signs receiving antibiotic treatment.
• Proportion of previously well patients with LRTI without focal chest signs receiving an information leaflet.
• Any increase in deaths among patients with community acquired pneumonia.
• Proportion of patients with COPD and an increase in purulent sputum having sputum cultured.
• Proportion of smokers with LRTI receiving smoking cessation advice.
• Proportion of patients presenting with LRTI fitting into recommended groups for influenza and pneumococcal vaccination who receive such vaccination.
• Proportion of patients previously well presenting with LRTI who have spirometry performed.
• Proportion of patients with LRTI referred for secondary care, investigation and advice.
• Number of LRTI consultations in the two years before establishment of a diagnosis of chronic lung disease.
• Monetary savings obtained as a result of reduced antibiotic prescribing.

11.5 Recommendations for research

• Identification of the aetiology of LRTI "in the community".
• Development of a better understanding of reasons for consultation and reconsultation of those with LRTI.
• Development of a workable definition and nomenclature of LRTI.
• Assessment of the role of nurse led clinics and NHS Direct / NHS 24 in dealing with LRTI.
• Assessing the value of sputum culture in patients with underlying lung disease in the community.
• Assessing the value of pulse oximetry in patients presenting with LRTI in the community.
• Assessing the value of education and other modalities to effect behavioural change in the reduction of antibiotic prescribing and reconsultation.
• Identifying the value of spirometry in patients presenting with LRTI.
• Identifying the cause of breathlessness in patients presenting with LRTI.
• Assessing the need for antibiotic treatment in patients with non respiratory co-morbidity and no focal signs in the chest who present with LRTI.
• Assessing the effect of delayed prescribing and/or awaiting sputum culture results on the rates of antibiotic prescribing and reconsultation.
• Assessing the efficacy of pharmacological agents for the treatment of cough.