Suspected acute respiratory infection in over 16s: assessment at first presentation and initial management

In people with a suspected ARI, think 'could this be sepsis?' and assess in line with the section on identifying people with suspected sepsis in NICE's guideline on sepsis.

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.

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.

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).

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.

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 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, and offer them self-care advice (see recommendation 1.1.2). If pneumonia is suspected, see also NICE's guideline on pneumonia: diagnosis and management.

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]

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.

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.

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