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Low doses of penicillins are more likely to select out resistance, amoxicillin doses of 500mg or above are recommended. Do not use early generation quinolones for pneumonia e.g. ciprofloxacin, ofloxacin due to poor pneumococcal activity. Reserve levofloxacin for proven resistant organisms.
The information below is based on NICE NG120 Cough (acute): antimicrobial prescribing (February 2019).
Acute cough is self-limiting, and symptoms can resolve within 3 to 4 weeks. It is commonly caused by a viral upper respiratory tract infection, but it can also be caused by acute bronchitis, a lower respiratory tract infection, which is usually a viral infection but can be bacterial.
For children under 5 years who present with an acute cough and fever refer to NICE NG143: Fever in under 5s: assessment and initial management (November 2019)
NHS England (NHSE) has published new prescribing guidance for various common conditions for which over the counter (OTC) items should not be routinely prescribed in primary care (quick reference guide). These conditions include coughs, colds, and nasal congestion.
Many of these products are cheap to buy and are readily available OTC along with advice from pharmacies. Some self-care medicines are available from shops and supermarkets. Please click here for further information, exceptions, and a patient leaflet.
Self-care advice:
Limited evidence suggests that antihistamines, decongestants and codeine-containing cough medicine do not help cough symptoms.
Do not offer oral or inhaled bronchodilators or corticosteroids to people for an acute cough associated with an upper respiratory tract infection or acute bronchitis unless the person has underlying airways disease such as asthma.
Do not offer mucolytics to treat acute cough.
Do not offer an antibiotic to treat an acute cough associated with an upper respiratory tract infection or acute bronchitis in people who are not systemically very unwell or at higher risk of complications.
Antibiotics do not improve overall clinical condition of people with acute bronchitis and make little difference to how long symptoms last.
Immediate prescription of antibiotics is recommended in patients who:
Consider immediate prescription of antibiotics or a 5-day prescription (delayed for 7 days) in patients who:
Doxycycline is contraindicated in pregnancy, and the possibility of pregnancy should be considered in young women of childbearing age.
Amoxicillin or erythromycin are preferred in women who are pregnant
MHRA Drug Safety Update (December 2020): Erythromycin: update on known risk of infantile hypertrophic pyloric stenosis
See section: 5.1.1 Penicillins, 5.1.3 Tetracyclines, and 5.1.5 Macrolides
Reassess at any time if symptoms worsen rapidly or significantly, taking account of:
The following Referral Guidelines are available locally:
Click here for guidance on COPD and for further information on the management of acute exacerbations (including prescription of corticosteroids), rescue packs and self-management plans.
If clinical evidence of pneumonia, follow community-acquired pneumonia advice (see below).
The information below is based on NICE Guideline 114: Chronic obstructive pulmonary disease (acute exacerbation): antimicrobial prescribing (Dec 2018), unless otherwise stated.
Many exacerbations (including some severe exacerbations) are not caused by bacterial infections so will not respond to antibiotics. Symptoms usually last between 7 – 10 days, but some events may last longer.
The severity of the exacerbation and severity of the underlying disease will determine if it is managed in the inpatient or outpatient setting.
Consider an antibiotic for people with an acute exacerbation of COPD, after taking into account:
The GOLD 2019 Report for the Global Strategy for the Diagnosis, Management, and Prevention of COPD states that antibiotics should be used in patients who have three cardinal symptoms: increased dyspnoea, sputum volume and sputum purulence.
GOLD 2019 recommends that antibiotics may also be considered if only two of the above symptoms are present, if sputum purulence is one of the symptoms.
GOLD 2019 also recommends that antibiotics should be given if patients require mechanical ventilation (invasive or non-invasive).
If a sputum sample has been sent for culture and susceptibility testing and an antibiotic has been given, review the choice of antibiotic when results are available and only change the antibiotic according to susceptibility results if bacteria are resistant and symptoms are not already improving (using a narrow-spectrum antibiotic wherever possible).
NICE Guideline 115 recommends that for patients who have their exacerbation managed in primary care – sending sputum samples for culture is not recommended in routine practice however NICE Guideline 114 states that sputum samples should be sent if symptoms have not improved following antibiotic treatment.
Advise the patient:
Reassess at any time if symptoms worsen rapidly or significantly, taking account of:
Refer patients with an acute exacerbation of COPD to hospital if they have any symptoms or signs suggesting a more serious illness or condition.
If patient is unable to take oral antibiotics, or is severely unwell, consider intravenous treatment (see below).
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Seek specialist advice
If patient is unable to take oral antibiotics, or is severely unwell, admit to secondary care for consideration of intravenous antibiotics, via outpatient or home parenteral antibiotic therapy service where available.
Review intravenous antibiotics by 48 hours and consider stepping down to oral antibiotics when patients are stabilised.
For suspected or confirmed pneumonia in patients with COVID-19, refer to NICE COVID-19 rapid guideline: managing COVID-19 (NG191) – identifying and managing co-infections section can be found here.
For guidance on managing bacterial pneumonia not secondary to COVID-19, see NICE guidance Pneumonia (community-acquired): antimicrobial prescribing (NG138)