NICE and PHE publish antimicrobial prescribing guidance for acute cough

As part of their series on antimicrobial prescribing for common infections, NICE and Public Health England (PHE) have published guidance on the management of acute cough (NG120) The principal aim of the guideline series is to limit antibiotic use and reduce antimicrobial resistance.

In the new guidance, NICE points out that acute cough is usually self-limiting and gets better within three to four weeks without antibiotics. It is most commonly caused by a viral upper respiratory tract infection, although it can also be caused by acute bronchitis (a lower respiratory tract infection that is usually viral but can also be bacterial).

The guidance states that an antibiotic should not be offered to treat acute cough associated with upper respiratory tract infection in people who are not systemically very unwell or at higher risk of complications. Instead, these patients should be advised on the usual course of acute cough and how to manage their symptoms with self-care. They should be told to seek medical help if symptoms worsen rapidly or significantly, do not improve after three or four weeks or if they become systemically very unwell. Antibiotics should also not routinely be offered to those with acute cough associated with acute bronchitis, unless they are systemically unwell or at higher risk of complications.

However, an immediate antibiotic prescription should be offered to patients with acute cough identified as being systemically very unwell at a face-to-face examination. For those identified as being at higher risk of complications (eg those with a pre-existing co-morbidity), either an immediate or a back-up antibiotic prescription should be considered. They should be told to use the back-up prescription if symptoms worsen rapidly or significantly at any time. Patients given an antibiotic should be advised of the possible adverse effects, including diarrhoea and nausea.

All patients should be reassessed if symptoms worsen rapidly or significantly, taking into consideration more serious conditions such as pneumonia, cardiorespiratory failure or sepsis, as well as the possibility of antimicrobial resistance.

NICE provides a useful flowchart to guide treatment decisions, as well as tables listing antibiotics choices and dosage regimens. A five-day course of antibiotics is recommended. In their advice on self-care, NICE suggests that there is limited evidence for the benefit of honey (in those aged >12 months) and, for people aged ≥12 years, pelargonium and OTC medicines containing guaifenesin or cough suppressants (except those containing codeine) for the relief of cough symptoms.


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