Acute Cough/Bronchitis - Management of Infection Guidance for Primary Care

Publication: 30/09/2010  
Last review: 01/02/2016  
Next review: 05/12/2019  
Clinical Guideline
CURRENT 
ID: 2230 
Approved By:  
Copyright© Leeds Teaching Hospitals NHS Trust 2016  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Acute Cough/Bronchitis

Illness

Comments

Preferred option

Alternative

Acute cough/ bronchitis
CKS
NICE 69

Antibiotics have little benefit if no co-morbidityA+2 ,3,4
If antibiotics are indicated, consider delayed prescription with symptomatic advice/leaflet A-2,6( leaflet)
Symptom can take 3 weeks to resolve

Amoxicillin electronic Medicines Compendium information on Amoxicillin
500mg TDS
5 days

Doxycycline electronic Medicines Compendium information on Doxycycline
200mg OD
5 days
(reduce to 100mg if adverse effects)

Principles of Treatment

  1. This guidance is based on the best available evidence but its application must be modified by professional judgement.
  2. A dose and duration of treatment is suggested. In severe or recurrent cases consider a larger dose or longer course
  3. Choices are given as Preferred option or Alternative for patients intolerant of the preferred option and 2nd Line for when an alternative is required because of treatment failure
  4. Only send microbiology specimens if there is a clinical suspicion of infection. Inappropriate specimens (e.g. routine ulcer swab or routine catheter specimen of urine) lead to inappropriate antibiotic prescribing.
  5. Prescribe an antibiotic only when there is likely to be a clear clinical benefit.
  6. Consider a no, or delayed, antibiotic strategy for acute self-limiting upper respiratory tract infections 1,A+
  7. Limit prescribing over the telephone to exceptional cases.
  8. Use simple generic antibiotics if possible. Avoid broad spectrum antibiotics (e.g. Co-Amoxiclav (Amoxicillin-Clavulanate), quinolones and cephalosporins) when narrow spectrum antibiotics remain effective, as they increase risk of Clostridium difficile, MRSA and resistant UTI's.
  9. In pregnancy AVOID tetracyclines, aminoglycosides, quinolones, and high dose metronidazole. Short-term use of trimethoprim (unless low folate status or taking another folate antagonist such as antiepileptic or proguanil) or nitrofurantoin (at term, theoretical risk of neonatal haemolysis) is unlikely to cause problems to the foetus.
  10. Where a ‘best guess’ therapy has failed or special circumstances exist, microbiological advice can be obtained from LTHT Microbiology (Mon-Fri 9am-5pm and Sat and Sun 9am-1pm: 0113 39 23962/28580; Otherwise via LTHT switchboard - ask for the On call Microbiology Registrar)

Note
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Letters indicate strength of evidence:
A+ = systematic review: D = informal opinion

Provenance

Record: 2230
Objective:
  • to provide a simple, empirical approach to the treatment of common infections
  • to promote the safe, effective and economic use of antibiotics
  • to minimise the emergence of bacterial resistance and reduce the incidence of Healthcare Associated Infections in the community
Clinical condition:

Acute Cough/Bronchitis

Target patient group:
Target professional group(s): Primary Care Doctors
Pharmacists
Adapted from:

This guidance was initially developed in 1999 by practitioners in South Devon, as part of the S&W Devon Joint Formulary Initiative, and Cheltenham & Tewkesbury Prescribing Group and modified by the PHLS South West Antibiotic Guidelines Project Team, PHLS Primary Care Co-ordinators and members of the Clinical Prescribing Sub-group of the Standing Medical Advisory Committee on Antibiotic Resistance. It was further modified following comments from Internet users. The guidance has been updated annually as significant research papers, systematic reviews and guidance have been published. The Health Protection Agency works closely with the authors of the Clinical Knowledge Summaries.


Evidence base

Grading of guidance recommendations
The strength of each recommendation is qualified by a letter in parenthesis.


Study design

Recommendation
grade

Good recent systematic review of studies

A+

One or more rigorous studies, not combined

A-

One or more prospective studies

B+

One or more retrospective studies

B-

Formal combination of expert opinion

C

Informal opinion, other information

D

Acute bronchitis

  1. NICE Clinical Guideline 69. Respiratory Tract Infections - antibiotic prescribing for self-limiting respiratory tract infections in adults and children in primary care. July 2008. RATIONALE: Describes strategies for limiting antibiotic prescribing in self-limiting infections and advises in which circumstances antibiotics should be considered. A no antibiotic or a delayed antibiotic prescribing strategy should be agreed for patients with acute cough/chronic bronchitis. In the 2 RCTs included in the review, the delay was 7-14 days from symptom onset and antibiotic therapy. Patients should be advised that resolution of symptoms can take up to 3 weeks and that antibiotic therapy will make little difference to their symptoms and may result in side effects. Patients should also be advised to seek a clinical review if condition worsens or becomes prolonged. The evidence behind these statements is primarily from the studies referred to below. There has been no systematic review of the evidence of length of antibiotic treatment for acute cough or bronchitis when antibiotics are prescribed. However the NICE pneumonia guidance group found evidence for the efficacy of 5 days’ antibiotic to treat pneumonia; therefore it is reasonable to consider that 5 days would also be effective in bronchitis.
  2. Fahey T, Smucny J, Becker L, Glazier R. Antibiotics for acute bronchitis. In: The Cochrane Library, 2006, Issue 4. Chichester, UK: John Wiley & Sons, Ltd link . Accessed 23.09.14. RATIONALE: Systematic review of nine studies (4 in primary care). Studies in primary care showed antibiotics reduced symptoms of cough and feeling ill by less than one day in an illness lasting several weeks in total.
  3. Chronic cough due to acute bronchitis. Chest. 2006;129:95S-103S. RATIONALE: Clinical guidelines on managing cough associated with acute bronchitis. Large body of evidence including meta-analyses and systematic reviews does not support routine antibiotic use.
  4. Wark P. Bronchitis (acute). In: Clinical Evidence. London. BMJ Publishing Group. 2008;07:1508-1534. RATIONALE: Discusses the evidence to support self care and limiting antibiotic prescriptions. Systematic review of 13 RCTs found that antibiotics only modestly improved outcomes compared with placebo
  5.  Francis N et al. Effect of using an interactive booklet about childhood respiratory tract infections in primary care consultations on reconsulting and antibiotic prescribing: a cluster randomised controlled trial. BMJ 2009;339:2885. RATIONALE: Utilising an information booklet during primary care consultations for children with RTIs significantly decreased antibiotic use (absolute risk reduction 21.3% (95%CI, 13.7-28.9 p<0.001). Reconsultation occurred in 12.9% of children in intervention group and 16.2% in control group (absolute risk reduction 3.3%, no statistical difference). There was no detriment noted to patient satisfaction in the intervention group.
  6.  Treatment of acute bronchitis available in Clinical Knowledge Summaries website: CKS Accessed 23.09.14.

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