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Overview

This Guidelines summary includes recommendations for primary healthcare professionals on the management and treatment of people with acute cough. It includes a useful treatment flowchart for reference.

Recommendations cover:

  • the management and treatment of acute cough
  • acute cough in people:
    • with an upper respiratory tract infection
    • with acute bronchitis
    • who are systemically very unwell or at higher risk of complications
  • self-care treatments
  • prescribing antibiotics.

For the complete set of recommendations on managing acute cough, refer to the full guideline. 

Managing acute cough

Algorithm 1: Cough (acute): antimicrobial prescribing

NICE Cough (acute) antimicrobial prescribing

For guidance on managing acute cough in people with suspected or confirmed COVID-19, follow the NICE rapid guideline on managing COVID-19.

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 the section, Acute cough in people who are systemically very unwell or at higher risk of complications). 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 the section, Acute cough in people who are systemically very unwell or at higher risk of complications).
  • 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.
  • 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 as systemically very unwell (ideally at a face-to-face clinical examination), offer an immediate antibiotic prescription (see the section, 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 2 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 identigied as at higher risk of complications (ideally at a face-to-face clinical examination), consider:
    • an immediate antibiotic prescription (see the section, 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
AntibioticDosage and course length

First choice

Doxycycline:

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

Alternative first choices

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

See the BNF  for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment, pregnancy and breast-feeding.

Amoxicillin and erythromycin are preferred in women who are pregnant. Doxycycline should not be given to young women who are pregnant, and the possibility of pregnancy should be considered in women of childbearing age (BNF, December 2018).

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

First choice

Amoxicillin:

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

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

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

Alternative first choices

Clarithromycin:

1 month to 11 years:

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

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

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

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

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

12 years 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 years to 7 years, 250 mg four times a day or 500 mg twice a day for 5 days

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

Doxycycline:

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

See the BNF for children  for appropriate use and dosing in specific populations, for example, hepatic impairment and renal impairment.

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.

Amoxicillin and erythromycin are preferred in young women who are pregnant. 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).

 

© NICE 2021. 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.

Published date: 07 February 2019 (amended May 2021).

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