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algorithm on antimicrobial prescribing for acute cough

Cough (acute): antimicrobial prescribing. Download a PDF of this algorithm. 

Managing acute cough

  • Be aware that an acute cough:
    • is usually self-limiting and gets better within 3 to 4 weeks without antibiotics
    • is most commonly caused by a viral upper respiratory tract infection, such as a cold or flu
    • can also be caused by acute bronchitis, a lower respiratory tract infection, which is usually a viral infection but can be bacterial
    • can also have other infective or non-infective causes
  • For children under 5 with an acute cough and fever, follow the NICE guideline on fever in under 5s: assessment and initial management
  • For adults with an acute cough and suspected pneumonia, follow the NICE guideline on pneumonia in adults: diagnosis and management

Referral and seeking specialist advice

  • Refer people with an acute cough to hospital, or seek specialist advice on further investigation and management, if they have any symptoms or signs suggesting a more serious illness or condition (for example, sepsis, a pulmonary embolism or lung cancer)

Treatment

  • Give general advice to people about:
    • the usual course of acute cough (lasts up to 3 or 4 weeks)
    • how to manage their symptoms with self-care (see the recommendations on self-care)
    • when to seek medical help, for example if symptoms worsen rapidly or significantly, do not improve after 3 to 4 weeks, or the person becomes systemically very unwell
  • Do not offer the following treatments to people for an acute cough associated
    • with an upper respiratory tract infection or acute bronchitis unless the person has an underlying airways disease, such as asthma:
    • an oral or inhaled bronchodilator (for example, salbutamol) or
    • an oral or inhaled corticosteroid
  • Do not offer a mucolytic (for example acetylcysteine or carbocisteine) to treat an acute cough associated with an upper respiratory tract infection or acute bronchitis

Acute cough associated with an upper respiratory tract infection

  • Do not offer an antibiotic to treat an acute cough associated with an upper respiratory tract infection in people who are not systemically very unwell or at higher risk of complications (see above). Give advice about why an antibiotic is not needed

Acute cough associated with acute bronchitis

  • Do not routinely offer an antibiotic to treat an acute cough associated with acute bronchitis in people who are not systemically very unwell or at higher risk of complications (see above)
  • Be aware that:
    • antibiotics do not improve the overall clinical condition of people with acute bronchitis
    • antibiotics make little difference to how long symptoms of acute bronchitis last (on average they shorten cough duration by about half a day)
    • antibiotics have possible adverse effects, particularly diarrhoea and nausea
  • For adults with an acute cough associated with acute bronchitis who have had a point of care C-reactive protein test after a clinical diagnosis of pneumonia has been ruled out, follow the NICE guideline on pneumonia in adults: diagnosis and management for recommendations on prescribing antibiotics according to C-reactive protein results
  • When no antibiotic prescription is given, give advice about why an antibiotic is not needed
  • If an antibiotic prescription is given, give advice about possible adverse effects of the antibiotic, particularly diarrhoea and nausea

Acute cough in people who are systemically very unwell or at higher risk of complications

  • For people with an acute cough who are identified at a face-to-face clinical examination as systemically very unwell, offer an immediate antibiotic prescription (see choice of antibiotic)
  • Be aware that people with an acute cough may be at higher risk of complications if they:
    • have a pre-existing comorbidity, such as significant heart, lung, renal, liver or neuromuscular disease, immunosuppression or cystic fibrosis
    • are young children who were born prematurely
    • are older than 65 years with two or more of the following criteria, or older than 80 years with 1 or more of the following criteria:
      • hospitalisation in previous year
      • type 1 or type 2 diabetes
      • history of congestive heart failure
      • current use of oral corticosteroids
  • For people with an acute cough who are identified at a face-to-face clinical examination as at higher risk of complications, consider:
    • an immediate antibiotic prescription (see choice of antibiotic) or
    • a back-up antibiotic prescription
  • When an immediate antibiotic prescription is given, give advice about possible adverse effects of the antibiotic, particularly diarrhoea and nausea
  • When a back-up antibiotic prescription is given, give advice about:
    • an antibiotic not being needed immediately
    • using the back-up prescription if symptoms worsen rapidly or significantly at any time

Reassessment

  • Reassess people with an acute cough if their symptoms worsen rapidly or significantly, taking account of:
    • alternative diagnoses, such as pneumonia
    • any symptoms or signs suggesting a more serious illness or condition, such as cardiorespiratory failure or sepsis
    • previous antibiotic use, which may have led to resistant bacteria

Self-care

  • Be aware that some people may wish to try the following self-care treatments, which have limited evidence of some benefit for the relief of cough symptoms:
    • honey (in people aged over 1 year)
    • pelargonium (a herbal medicine; in people aged 12 and over)
    • over-the-counter cough medicines containing the expectorant guaifenesin (in people aged 12 and over)
    • over-the-counter cough medicines containing cough suppressants, except codeine, (in people aged 12 and over who do not have a persistent cough, such as in asthma, or excessive secretions)
  • Be aware that limited evidence suggests that antihistamines, decongestants and codeine-containing cough medicines do not help cough symptoms

Choice of antibiotic

  • When prescribing antibiotics for an acute cough follow:
    • table 1 for adults aged 18 years and over
    • table 2 for children and young people under 18 years
Table 1: Antibiotics for adults aged 18 years and over
Antibiotic[A]Dosage and course length[B]

First choice

Doxycycline[C]

200 mg on first day, then 100 mg once a day for 4 days (5-day course in total)

Alternative first choices[D]

Amoxicillin

500 mg three times a day for 5 days

Clarithromycin

250 mg to 500 mg twice a day for 5 days

Erythromycin

250 mg to 500 mg four times a day or 500 mg to 1,000 mg twice a day for 5 days

[A] See BNF for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment, pregnancy and breast-feeding

[B] Doses given are by mouth using immediate-release medicines, unless otherwise stated

[C]  Doxycycline should not be given to pregnant women, and the possibility of pregnancy should be considered in women of childbearing age (BNF, December 2018)

[D]  Amoxicillin or erythromycin are preferred in women who are pregnant.

Table 2: Antibiotics for children and young people under 18 years
Antibiotic[A]Dosage and course length[B]

First choice

Amoxicillin

1 to 11 months, 125 mg three times a day for 5 days

1 to 4 years, 250 mg three times a day for 5 days

5 to 17 years, 500 mg three times a day for 5 days

Alternative first choices[C]

Clarithromycin

1 month to 11 years:

Under 8 kg, 7.5 mg/kg twice a day for 5 days 8 to 11 kg, 62.5 mg twice a day for 5 days

12 to 19 kg, 125 mg twice a day for 5 days

20 to 29 kg, 187.5 mg twice a day for 5 days

30 to 40 kg, 250 mg twice a day for 5 days

12 to 17 years, 250 mg to 500 mg twice a day for 5 days

Erythromycin

1 month to 1 year, 125 mg four times a day or 250 mg twice a day for 5 days 2 to 7 years, 250 mg four times a day or 500 mg twice a day for 5 days

8 to 17 years, 250 mg to 500 mg four times a day or 500 mg to 1,000 mg twice a day for 5 days

Doxycycline[D]

 

12 to 17 years, 200 mg on first day, then 100 mg once a day for 4 days (5-day course in total)

[A] See BNF for children for appropriate use and dosing in specific populations, for example, hepatic impairment and renal impairment

[B] The age bands apply to children of average size and, in practice, the prescriber will use the age bands in conjunction with other factors such as the severity of the condition and the child’s size in relation to the average size of children of the same age. Doses given are by mouth using immediate-release medicines, unless otherwise stated

[C] Amoxicillin or erythromycin are preferred in young women who are pregnant

[D] Doxycycline should not be given to young women who are pregnant, and the possibility of pregnancy should be considered in young women of childbearing age (BNF for children, December 2018).

Terms used in the guideline

Acute cough

Acute cough is commonly defined as a cough that lasts less than 21 days (3 weeks). The average duration is 18 days, although it can sometimes last for up to 29 days (over 4 weeks). It is most commonly caused by an upper respiratory tract infection, such as a cold or flu, which are viral infections. It can also be caused by acute bronchitis, a lower respiratory tract infection, which is usually a viral infection but can be bacterial

Other infective causes of cough include pneumonia, acute exacerbations of asthma, chronic obstructive pulmonary disease or bronchiectasis (which may also be non-infective exacerbations), and viral-induced wheeze, bronchiolitis, croup or whooping cough. Non-infective causes may include lung cancer, a foreign body, interstitial lung disease, pneumothorax, pulmonary embolism, heart failure, use of certain medicines (for example, an angiotensin-converting enzyme inhibitor), upper airway cough syndrome (post-nasal drip), or gastro-oesophageal reflux disease

Acute bronchitis

Acute bronchitis is a lower respiratory tract infection with temporary inflammation of the airways (the trachea and major bronchi) that causes cough and mucus production lasting for up to 3 weeks. It is usually caused by a viral infection, but may be caused by a bacterial infection. (NICE clinical knowledge summary on chest infections—adult)

Self-care treatments

Self-care treatments available for acute cough include honey, herbal medicines and over-the-counter cough medicines (for example, expectorants and cough suppressants [also called antitussives])

© NICE 2018. Cough (acute): antimicrobial prescribing.  Available from: www.nice.org.uk/guidance/NG120. All rights reserved. Subject to Notice of rights.

NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.

First included: February 2019.