Managing acute cough: a summary of recommendations

  • NICE

  • curated by Pavankumar Kamat
  • Clinical Guidance Summaries
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Guideline name: Cough (acute): antimicrobial prescribing [NG120]

Update type: New guideline

Published: Feb 2019

Takehome

  • Most cases resolve within 3 to 4 weeks without antibiotics. A viral upper respiratory tract infection is the most common cause of acute cough.

Assessment

  • Clinicians should be aware that acute cough is a self-limiting infection which usually resolves within 3 to 4 weeks without the need for antibiotics.
  • It is typically caused by a viral upper respiratory tract infection (RTI), such as a cold or flu. Other causes include acute bronchitis, a lower RTI (viral or bacterial), other infective or non-infective causes.
  • Evaluate and manage children aged
  • Evaluate and manage adults with suspected pneumonia according to the NICE guideline.

Referral

  • If there are symptoms or signs suggesting a more serious illness or condition, refer to a hospital, or seek specialist advice.

Treatment

  • If there is rapid or significant worsening of symptoms, there is no improvement after 3 to 4 weeks, or the person becomes systemically very unwell (as per prescriber's clinical judgement), advise patients to seek prompt medical help.
  • Do not offer oral/inhaled bronchodilator or corticosteroid to patients with cough associated with an upper RTI or acute bronchitis unless there is an underlying respiratory disease, such as asthma.
  • Mucolytics are not routinely recommended for cough associated with an upper RTI or acute bronchitis.
  • Do not offer antibiotics to patients with cough associated with an upper RTI or acute bronchitis unless they are systemically very unwell (as per prescriber's clinical judgement) or have a high risk of complications.
  • Antibiotics are not known to improve overall clinical condition and symptom duration of people with acute bronchitis
  • When antibiotics are not prescribed, give advice about why an antibiotic is not needed. When antibiotics are prescribed, give advice about their possible adverse effects, especially diarrhoea and nausea.
  • Individuals with an acute cough found to be systemically very unwell (as per prescriber's clinical judgement) on face-to-face clinical examination should be offered immediate antibiotic prescription.
  • Individuals with an acute cough found have a high risk for complications on face-to-face clinical examination should be offered immediate antibiotic prescription or a back-up antibiotic prescription. Conditions predisposing to complications include:
    • Pre-existing comorbidity,
    • Young children born prematurely,
    • >65 years with ≥2 criteria listed below, or >80 years with ≥1 criteria listed below:
      • Hospitalisation in the past year
      • Type 1 or type 2 diabetes
      • History of congestive heart failure
      • Currently using oral corticosteroids.

Self-care

  • Patients may consider honey (children aged >1 year), pelargonium (people aged ≥12) and over-the-counter cough medicines containing expectorant guaifenesin (people aged ≥12), or cough suppressants, except codeine (people aged ≥12 without persistent cough or excessive secretions) as all these have limited evidence of some benefit of symptomatic relief from cough.
  • Antihistamines, decongestants and codeine-containing cough medicines are not recommended.

Antibiotic prescribing

  • In adults aged ≥18 years, the first choice of antibiotic is doxycycline, and alternative first choices include amoxicillin, clarithromycin, and erythromycin.
  • In children and young people aged
  • Doxycycline is contraindicated in pregnant women. Amoxicillin or erythromycin are the preferred options for pregnant women.

This summary is reviewed by Prof.  Rishabh Prasad  MBBS, MA, MSC, FRCGP, FFCI, FRSA

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