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Clinical Summary

Managing acute cough: a summary of recommendations

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 <5 years presenting with fever according to the NICE guideline.
  • 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 <18 years, the first choice of antibiotic is amoxicillin, and alternative first choices include clarithromycin, erythromycin, and doxycycline.
  • 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


References


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