Int J Clin Pract Suppl. 2013 Nov; (180):4–9.

A framework for the non-antibiotic management of upper respiratory tract infections: towards a global change in antibiotic resistance

Essack S and Pignatari AC



Antibiotic resistance has become a critical health issue on a global scale, with much of the problem resulting from inappropriate use of antibiotics in primary care. To change this practice, the global respiratory infection partnership has formulated a pentagonal (five P) framework for the non-antibiotic management of upper respiratory tract infections (URTIs) – one of the most common conditions in primary care for which antibiotics are prescribed. The framework presents the rationale for focusing on URTIs to promote antibiotic stewardship in primary care and elaborates on five key areas to focus on to bring about change: policy, prevention, prescribers, pharmacy and patients. The ultimate aim is to adopt a patient-centred symptomatic management strategy using a flexible framework that can be adapted across countries to create a consistent global approach to change behaviour.

PMID: 24238424



Antibiotic resistance is an unprecedented and escalating global health issue against which global interventions are imperative.   (WHO 2013, WEF 2013). Increasing resistance rates are largely a result of inappropriate antibiotic use, in particular overuse in primary care. Upper respiratory tract infections (URTIs) such as sore throat, the common cold and cough, account for a large proportion of antibiotic prescriptions in primary care, yet the majority of these conditions do not require antibiotics because most URTIs are viral in origin and generally self-limiting (Costelloe 2010, van der Velden 2013). Minimizing further antibiotic resistance requires a consistent and coordinated approach towards symptomatic treatment for common, self-limiting infections, such as URTIs, where inappropriate antibiotic use is prevalent.

To facilitate change towards the prudent use of antibiotics for the treatment of URTIs, members of the Global Respiratory Infection Partnership (GRIP) have developed a framework for the non-antibiotic management of such infections. The framework presents the rationale for focusing on URTIs to promote antibiotic stewardship in primary care and elaborates on five key areas of change: policy, prevention, prescribers, pharmacy and patients as outlined below.

Policy: National guidelines and national surveillance programmes help monitor antibiotic use and identify existing and emerging resistance patterns which can be used to alter and/or influence clinical practice, prescribing behaviour and marketing activities (Michie 2011, Oxford 2013). Health education policy considerations also include the education and continuing professional development of relevant healthcare providers within primary care (Oxford J 2013, Forsetlund 2003). The implementation of national policies by primary care providers should be further enhanced by advocacy and endorsement from local experts.

Prevention: Any clinical decision in terms of URTI management must consider the prevention of antibiotic resistance, in order to preserve the efficacy of existing antibiotics (Boucher 2013). Antibiotics should thus be restricted to essential use with improving patient outcomes on an individual and community level as a core principle. Healthcare professionals should inform patients of the signs and symptoms of more serious disease, to ensure that secondary infections or deteriorating conditions receive adequate and appropriate attention (NICE CG69 2008).

Prescribers: Based on a full symptoms assessment and a comprehensive differential diagnosis and after providing reassurance of the self-limiting nature of a URTI, prescribers have a key role in guiding patients towards seeking symptomatic relief, as opposed to antibiotic treatment.  Strategies to encourage appropriate prescribing in primary care include the development of evidence-based treatment guidelines/algorithms in collaboration with local experts which  incorporate the exclusion of serious infections from the diagnosis as well as how to handle patient demand for an antibiotic.  Both these strategies should be complemented by information on the full range of symptomatic treatments available over-the-counter. Physicians should also be made aware of the problems arising from over-prescription of antibiotics and their lack of efficacy in relieving patient symptoms (Oxford 2013). Communication strategies and formal training that focus on the doctorpatient dialogue and patient empowerment are also important when changing behaviours (Altiner 2007, Maguire 2002). Guidelines on how to engage with patients and involve them in treatment decisions should be implemented.

Pharmacy: The pharmacy is often the first place patients visit when seeking advice on a common health conditions. Pharmacy staff are therefore able to make a substantial contribution towards antibiotic stewardship and self-management of common self-limiting conditions, in particular URTIs. Pharmacy personnel are pivotal in establishing protocols for treatment and referral that support the non-antibiotic management of URTIs by advising on symptomatic relief options and realistic durations of illness. Education within the pharmacy setting is important for enhancing patients understanding. To achieve this, guidance and training on patient communication is necessary for members of the pharmacy team, while providing information leaflets for patients can further support such work.

Patients: To move towards a culture where non-antibiotic management of URTIs is standard, it is important to mobilize the public and patients as proponents of non-antibiotic treatment for self-limiting conditions (van Driel 2006). Initiating education for the public to nurture change is key (Michie 2011), such as through the use of media campaigns and educational projects in schools and universities (Oxford 2013).

It is important to address misconceptions that antibiotics will shorten the illness via a patient-centered approach (Altiner 2007, Altiner 2004). When patients describe severe symptoms, it is important to show empathy and reassurance that a serious illness has been excluded (Altiner 2007). Reasons for explicit requests for antibiotics should be explored in terms of the patient’s concerns and expectations, followed by education on the appropriate use of antibiotics and the natural course of the patient’s condition, reassuring patients that serious infection has been ruled out, discussing symptomatic treatment options and clarifying when a return visit is warranted (NPS 2009). Any advice needs to be tailored to the specific needs and preferences of the individual patient.

Sabiha Essack-fig1Figure 1. The pentagonal framework for change encompasses five key focus areas (the five ‘P’s)


In conclusion, a consistent and collaborative effort that encompasses policymakers, healthcare providers and patients is critical to help minimize the effects of antibiotic resistance and conserve antibiotics for the future. URTIs are a key area for concern, given their prevalence and the widespread use of antibiotics in treatment. It is also paramount that patient concerns and needs are considered and acknowledged in consultations. Healthcare providers should work in partnership with their patients to develop an individualized treatment plan and empower patients to self-manage URTIs with non-antibiotic treatment options for symptomatic relief. Adopting these recommendations will reinforce the recognition that antibiotic resistance is a serious global health issue, for which a change in daily clinical practice within primary care is essential.



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RB Group PLC supported publication of this supplement article as part of an unrestricted educational grant. Editorial assistance during the development and revision of this manuscript was provided by Cello Health Communications and supported by RB Group PLC.



Professor Sabiha Essack

School of Health Sciences, University of KwaZulu-Natal

Private Bag X54001, Durban, 4000, South Africa

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