Lower respiratory tract infections

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.

Acute cough, bronchitis

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:

  • Patients may wish to try self-care treatments, which have limited evidence of some benefit for the relief of cough symptoms; e.g. honey (in people aged over 1 year), over-the-counter cough suppressants or expectorants.

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.

Acute cough associated with an upper respiratory tract infection or acute bronchitis

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:

  • Are systemically very unwell, as identified at a face-to-face clinical examination

Consider immediate prescription of antibiotics or a 5-day prescription (delayed for 7 days) in patients who:

  • Are at risk of developing complications because of pre-existing co-morbidity, including significant heart, lung, renal, liver or neuromuscular disease, immunosuppression, cystic fibrosis and young children born prematurely
  • Are older than 65 years with two or more of the following criteria; or older than 80 years with one of 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

Where antibiotics are indicated

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

Adults aged 18 years and over
Doxycycline
  • 200 mg on first day, then 100 mg once a day for 4 days (5‑day course in total)
Amoxicillin
  • 500mg three times a day for 5 days
Clarithromycin
  • 250mg to 500mg twice a day for 5 days
Erythromycin
  • 250mg to 500mg four times a day or 500mg to 1,000mg twice a day for 5 days
Children and young people under 18 years
Amoxicillin
  • 1 month to 11 months: 125mg three times a day for 5 days
  • 1 to 4 years: 250mg three times a day for 5 days
  • 5 to 17 years: 500mg three times a day for 5 days
Clarithromycin
  • Children 1 month to 11 years of age (doses given twice daily for 5 days):
    • Body-weight under 8 kg: 7.5mg/kg
    • Body-weight 8–11 kg: 62.5mg
    • Body-weight 12–19 kg: 125mg
    • Body-weight 20–29 kg: 187.5mg
    • Body-weight 30–40 kg: 250mg
    Children and young people 12 to 17 years of age:
    • 250mg to 500mg twice daily for 5 days
Erythromycin
  • Children 1 month to 17 years of age (doses given for 5 days)
    • 1 month to 23 months: 125mg four times a day or 250mg twice a day
    • 2 to 7 years: 250mg four times a day or 500mg twice a day
    • 8 to 17 years: 250mg to 500mg four times day or 500mg to 1,000mg twice a day
Doxycycline
  • Children and young people 12 to 17 years of age:
    • 200 mg on first day, then 100 mg once a day for 4 days (5‑day course in total)

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:

  • Alternative diagnoses, such as pneumonia (community-acquired) (see below)
  • Any symptoms or signs suggesting a more serious illness or condition, such as cardiorespiratory failure or sepsis
  • Previous antibiotic use, which may lead to resistant organisms

The following Referral Guidelines are available locally:

Acute exacerbation of COPD

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 severity of symptoms, particularly sputum colour changes and increases in volume or thickness beyond the person's normal day-to-day variation
  • whether they may need to go into hospital for treatment
  • previous exacerbation and hospital admission history, and the risk of developing complications
  • previous sputum culture and susceptibility results
  • the risk of antimicrobial resistance with repeated courses of antibiotics.

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:

  • about possible adverse effects of antibiotics, particularly diarrhoea
  • that symptoms may not be fully resolved when the antibiotic course has been completed
  • to seek medical help without delay if:
    • symptoms worsen rapidly or significantly, or
    • symptoms do not start to improve within 2–3 days (or other agreed time), or
    • the person becomes systemically very unwell (with or without antibiotics)

Reassess at any time if symptoms worsen rapidly or significantly, taking account of:

  • other possible 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

Refer patients with an acute exacerbation of COPD to hospital if they have any symptoms or signs suggesting a more serious illness or condition.

Oral antibiotics

If patient is unable to take oral antibiotics, or is severely unwell, consider intravenous treatment (see below).

First line
  • Empirical treatment or guided by most recent sputum sample results
  • If patient is taking prophylactic antibiotic then ensure treatment is with an antibiotic from a different class
Amoxicillin
  • 500mg three times a day for 5 days (1g three times a day if severe)
  • See section 5.1.1 Penicillins

OR

Doxycycline
  • 200mg single dose on day one, then 100mg once daily, for a total of 5 days (200mg once daily if severe)
  • See section 5.1.3 Tetracyclines

OR

Clarithromycin
  • 500mg twice a day for 5 days
  • Use with caution if predisposition to QT prolongation
  • See section 5.1.5 Macrolides
Second line
  • If no improvement in symptoms on first choice taken for at least 2-3 days, send a sputum sample for culture and susceptibility testing if this has not been done already.
  • Try alternative first line choice but from a different class.
  • Seek microbiology advice if symptoms are not improving with repeated courses of antibiotics or if bacteria are resistant to oral antibiotics.
Patients at high risk of treatment failure
  • E.g. Repeat courses of antibiotics; previous or current sputum culture with resistant bacteria; patients at high risk of complication
  • To be guided by susceptibilities when available
Co-amoxiclav

OR

Seek specialist advice

Intravenous antibiotics

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.

Community-acquired pneumonia (CAP) - management in the community

Start antibiotic treatment as soon as possible and certainly within 4 hours

Use CRB65 score to help to assess severity and to guide treatment

Each feature scores 1:

  • Confusion (AMT 8 or less, or new disorientation in person, place or time)
  • Respiratory rate 30 breaths per min or more
  • BP (systolic BP less than 90mmHg or diastolic BP 60mmHg or less)
  • Age 65 years or more

Determine the risk of death as follows:

  • CRB65 0 = low risk (less than 1% mortality risk)
  • CRB65 1 or 2 = intermediate risk (1-10% mortality risk)
  • CRB65 3 or 4 = high risk (more than 10% mortality risk)

CRB65 score is NOT a substitute for good clinical judgement; clinicians should take into account other prognostic factors. Care should be taken with younger fit adults, as it is possible that the score may be low in patients who nevertheless have severe illness.

  • Consider home‑based care for patients with a CRB65 score of 0
  • Consider hospital assessment for patients with a CRB65 score of 1, and particularly those with a CRB65 score of 2
  • Urgent hospital admission for all patients with a CRB65 score of 3 or 4 (unless hospital admission is inappropriate according to patient treatment escalation plans)

The formulary gives dose and duration of treatment for adults unless stated otherwise

Low or moderate severity CAP (based on clinical judgement and guided by CRB65 score of 0, 1 or 2) - oral antibiotics

Amoxicillin
  • 500mg three times a day for 5 days, review at 3 days and extend to 7-10 days if poor response
  • See section 5.1.1 Penicillins
Alternative oral antibiotics if penicillin allergy or if amoxicillin is unsuitable (for example, atypical pathogens suspected)
Doxycycline
  • 200mg single dose on the first day, then 100mg once daily for 4 days (5 day course in total), review at 3 days and extend to 7-10 days if poor response
  • See section 5.1.3 Tetracyclines

Notes

  1. Doxycycline is contraindicated in pregnancy

OR

Erythromycin (in pregnancy)
  • 500mg four times a day for 5 days, review at 3 days and extend to 7-10 days if poor response
  • See section 5.1.5 Macrolides

OR

Clarithromycin (3rd line)
  • 500mg twice a day for 5 days, review at 3 days and extend to 7-10 days if poor response
  • See section 5.1.5 Macrolides

Patient information (NICE CG191 Pneumonia in adults: diagnosis and management; NICE NG138: Pneumonia (community-acquired): antimicrobial prescribing)

Explain to patients with community‑acquired pneumonia that after starting treatment their symptoms should steadily improve, although the rate of improvement will vary with the severity of the pneumonia, and most people can expect that by:

  • 1 week: fever should have resolved
  • 4 weeks: chest pain and sputum production should have substantially reduced
  • 6 weeks: cough and breathlessness should have substantially reduced
  • 3 months: most symptoms should have resolved but fatigue may still be present
  • 6 months: most people will feel back to normal
Last updated: 13-02-2020

 

Home > Formulary > Chapters > 5. Infections > Lower respiratory tract infections

 

  • First line
  • Second line
  • Specialist
  • Hospital