Printed on: January 15th, 2025

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Acute cough and pneumonia

Acute cough and pneumonia

This article was updated in December 2023.

Here, we combine a number of different NICE guidelines: from symptom-based guidance (acute cough) to disease-based guidance (e.g. pneumonia). In particular, NICE talks about pneumonia and acute bronchitis as sub-diagnoses of lower respiratory tract infections, but NICE does not use the term ‘chest infections’ – which we suspect is the diagnosis we use most often! If we were to try and summarise NICE’s terms and definitions in a Venn diagram (of sorts!), we think it would look something like this:

NICE has 3 relevant guidelines:

• Triaging adults with respiratory tract infections (NICE 2023, NG237).
• Cough (acute): antimicrobial prescribing (NICE 2019, NG120).
• Pneumonia in adults (NICE 2023, CG191).

There are 2 key questions for primary care:

1. Does this patient need to be in hospital? (Can we make this decision on the phone?)
2. If not sick enough for hospital, is the patient sick enough to need antibiotics?

The answer to question 1 may be quite objective, helped by measurements such as oxygen saturation, temperature and clinical scores (CRB65/NEWS/PEWS). The answer to question 2 is a more subjective issue, and guidelines help steer (guide) us rather than provide an easy yes/no answer.

When thinking about prescribing in respiratory tract infections, it may be helpful to think about it in this way:

For those well enough to be managed at home, there may be mismatches between the patient’s and clinician’s view of whether antibiotics are needed, and this needs to be addressed sensitively. At Red Whale, we are aware that the prescribing decision (despite guidelines!) may be affected by:

• Clinician skills/experience/time available and whether the patient is being assessed remotely/face to face.
• Degree of continuity of care/whether the consultation is taking place in or out of hours.
• Population demographics, including deprivation.

Hold these dilemmas in your head as you consider the 3 NICE guidelines, summarised in this GEMS (there is a separate article on Pneumonia in children):

Please follow the link for a PDF version of the GEMS for download/printing: Acute cough and pneumonia: GEMS

Data from almost 10 000 primary care consultations for acute cough associated with respiratory tract infection was analysed to describe symptom trajectory and time to recovery (BJGP 2023;73(728):e196).

• Half of patients will recover within 6 days.
• The rest will recover by 28 days.

Slower recovery (>10 days) was associated with:

• Increasing age.
• Increasing severity of illness.
• Prior duration of illness >7 days at presentation.
• Pre-existing lung disease.

A small trial of adults in France looked at this. Interestingly, it managed to recruit only 310 suitable patients in 5 years! Patients admitted to hospital with community-acquired pneumonia but without significant complications (e.g. not needing intensive care, no large effusion) were randomised to a 3d or 8d course of antibiotic (co-amoxiclav) (Lancet 2021; 397:1195).

• The main outcome was cure on day 15, and there were no differences between the two groups for this outcome.
• Incidence of side-effects were similar between the 2 groups.

I’d suggest we need more data before we deviate away from the NICE guidance.

A Dutch study showed that the use of point-of-care CRP tests in people in nursing homes with suspected lower respiratory tract infections reduced antibiotic use (BMJ 2021;374:n2198).

It was a pragmatic trial: clinicians could enrol patients if they suspected the person had a lower respiratory tract infection.

• In those who did NOT have a point-of-care CRP test, 82% were prescribed antibiotics.
• In those who had a point-of-care test, only 53% were given antibiotics.
• There was no difference in rates of full recovery at 3 weeks, hospital admissions or deaths between the 2 groups, although this was a small trial (241 participants).

If you have access to point-of-care CRP tests, they may be worth considering for those in a nursing home with LRTI not requiring admission.

Cough and cold remedies containing pholcodeine have been withdrawn from the UK market (MHRA safety update April 2023;16:1).

Pholcodeine use in the preceding 12 months is associated with increased risk of subsequent anaphylaxis with use of neuromuscular-blocking agents in general anaesthetics.

We should no longer prescribe or dispense these items.

Acute cough and pneumonia There are many causes of acute cough. Start by assessing severity and considering those at higher risk of complications (ideally face to face): consider immediate antibiotics in these groups. For everyone else with acute cough associated with URTI or bronchitis, do not offer antibiotics due to lack of evidence of benefit. Consider OTC self-care, including honey, pelargonium and cough mixtures. In pneumonia, use clinical judgement and CRB65 score to assess clinical risk and define management. CRB65 ≥1: consider admission (especially if ≥2). CRB65 = 0: offer 5d course of single antibiotic. CXR and sputum culture not routinely needed. Review if symptoms not improving after 3d, and consider extending duration of antibiotics. Recovery from pneumonia is long. After 3m, most symptoms will have resolved, but fatigue may continue.

Useful resources: Websites (all resources are hyperlinked for ease of use in Red Whale Knowledge) NHS – cough NHS - antibiotic resistance Royal College of Paediatrics/Healthier Together: Coughs in under 1y Coughs in those ≥1y