Clinical Topic A-Z Clinical Speciality

Chest infections - adult

Chest infections - adult
D012140Respiratory Tract Diseases
Infections and infestationsRespiratory
2012-08-01Last revised in August 2012

Chest infections - adult - Summary

Acute bronchitis is a transient inflammation of the trachea and major bronchi caused by viral infection. Inflammation, associated with oedema and mucus production leads to cough (usually lasting 7-10 days) and phlegm production that can persist for up to 3 weeks. It is usually a mild, self-limiting illness.

Differentiating features:

Cough is the predominant symptom.

There may or may not be sputum, wheeze, or dyspnoea.

There may be systemic features with or without a raised temperature.

Smoking cessation should be encouraged and adequate analgesia and hydration advised.

Antibiotics are not routinely indicated but should be considered if the person is immunocompromised or an existing condition is likely to significantly worsen.

Amoxicillin is first-line treatment, or doxycycline is an alternative. If these are unsuitable, a macrolide can be considered.

A delayed antibiotic prescribing strategy may be considered.

Routine follow up is unnecessary. People who have deteriorated should be re-examined to exclude pneumonia.

For people with a pre-existing condition that has deteriorated on treatment, admission to hospital or a second-line antibiotic (co-amoxiclav or doxycycline) should be considered. Advice from a microbiologist may be necessary if these are unsuitable.

Community-acquired pneumonia

Community-acquired pneumonia is an acute infection of the lung parenchyma acquired in the community:

In 45% people: no pathogens are identified.

In 36% of people: Streptococcus pneumoniae.

In 10% of people: Haemophilus influenzae.

Mycoplasma pneumonia occurs in outbreaks every 4 to 7 years.

Differentiating features:

Cough is the predominant symptom.

At least one other symptom of sputum, wheeze, dyspnoea, or pleuritic pain.

Focal chest signs including dullness to percussion, coarse crepitations, vocal fremitus.

At least one systemic feature is present (sweats, fevers, myalgia) with or without a temperature above 38°C.

Chest X-ray is not usually necessary, but diagnostic.

The CRB-65 score helps with making referral decisions. The score is determined by awarding one point for each of the following features: Confusion — recent; Respiratory rate of 30 breaths/min or greater; Blood pressure — systolic of 90 mmHg or less or diastolic of 60 mmHg or less; and 65 years old or older.

CRB-65 score of 3 or more — urgent admission to hospital.

CRB-65 score of 2 — same-day assessment in secondary care.

CRB-65 score of 1 — same-day assessment in secondary care should be considered.

CRB-65 score of 0 — treatment at home is usually appropriate, depending on clinical judgement and available social support.

When oxygen saturation is less than 92% (as measured by pulse oximetry) admission is advised.

Treatment involves the use of antibiotics.

Amoxicillin is first-line.

A macrolide is indicated if amoxicillin is contraindicated.

Doxycycline should be considered if infection with Mycoplasma pneumoniae is suspected.

All cases of pneumonia should be followed up.

For people not requiring admission, consider a second-line antibiotic.

For people over 50 that smoke, or with persistent symptoms or signs of pneumonia, a chest X-ray should be arranged after 6 weeks.

Have I got the right topic?

144months3060monthsBoth

This CKS topic covers the management of acute bronchitis and community-acquired pneumonia in adults.

The CKS topic does not cover acute exacerbations of chronic obstructive pulmonary disease or asthma, upper respiratory tract infections, bronchiolitis, hospital-acquired or rare forms of pneumonia, or infections in people who are immunocompromised.

There are separate CKS topics on Asthma, Chronic obstructive pulmonary disease, Cough - acute with chest signs in children, and Common cold.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary health care.

How up-to-date is this topic?

How up-to-date is this topic?

Changes

Last revised in August 2012

February 2013 — minor update. The 2013 QIPP options for local implementation have been added to this topic [NICE, 2013].

October 2012 — minor update. The 2012 QIPP options for local implementation have been added to this topic [NPC, 2012].

May–July 2012 — reviewed. A literature search was conducted in April 2012 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of the topic. No major changes to clinical recommendations have been made.

Previous changes

May 2011 — minor update. The 2010/2011 QIPP options for local implementation have been added to this topic [NPC, 2011]. Issued in June 2011.

October 2010 — technical update. The management section of this topic has been simplified to improve clarity and navigation. There have been no changes to the clinical content or meaning of the recommendations.

September 2010 — minor update. The Supporting evidence on a delayed antibiotic prescribing strategy compared with a no antibiotic prescribing strategy has been updated. Issued in September 2010.

October 2009 — updated to include the BTS guidelines for the management of community acquired pneumonia in adults: update 2009 [British Thoracic Society, 2009]. Issued in November 2009.

April 2009 — minor update. Dose of erythromycin in the Prescriptions in the scenario Acute bronchitis has been corrected. Issued in May 2009.

January 2009 — minor update. Minor change in wording regarding when to prescribe doxycycline, erythromycin, and clarithromycin, in line with updated advice from the Health Protection Agency [HPA and Association of Medical Microbiologists, 2008]. Issued in February 2009.

May to August 2007 — converted from CKS guidance to CKS topic structure. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence.

This CKS topic replaces the CKS guidance on Chest infections, together with the CKS topic on Cough - acute with chest signs in children. Advice on the management of acute exacerbations in chronic obstructive pulmonary disease has been removed and can now be found in the CKS topic on Chronic obstructive pulmonary disease. Prescriptions for oxytetracycline and for flucloxacillin have been removed.

October 2006 — minor update. Analgesia prescriptions updated because new doses of ibuprofen for children are recommend by the British National Formulary. Issued in October 2006.

October 2005 — minor update. Volumatic® spacer device discontinued and prescriptions removed; advice for using alternative spacer devices included. Issued in November 2005.

July 2005 — updated to incorporate the Referral guidelines for suspected cancer published by the National Institute for Health and Care Excellence. Issued in July 2005.

March 2004 — reviewed. Validated in May 2004 and issued in July 2004.

March 2001 — reviewed. Validated in July 2001 and issued in October 2001.

June 1998 — written.

Update

New evidence

Evidence-based guidelines

Guidelines published since the last revision of this topic:

González-Castillo, J., Martín-Sánchez, F.J., Llinares P., et al. (2014) Guidelines for the management of community-acquired pneumonia in the elderly patient. Revista espanola de quimioterapia 27(1), 69-86. [Abstract]

HTAs (Health Technology Assessments)

No new HTAs since 1 April 2012.

Economic appraisals

No new economic appraisals relevant to England since 1 April 2012.

Systematic reviews and meta-analyses

Systematic reviews published since the last revision of this topic:

Khan, A.R., Riaz, M., Bin Abdulhak, A.A., et al. (2013) The role of statins in prevention and treatment of community-acquired pneumonia: a systematic review and meta-analysis. PLoS One 8(1), e52929. [Abstract] [Free Full-text]

Nie, W., Zhang, Y., Cheng, J., and Xiu, Q. (2012) Corticosteroids in the treatment of community-acquired pneumonia in adults: a meta-analysis. PLoS One 7(10), e47926. [Abstract] [Free Full-text]

Rozenbaum, M.H., Pechlivanoglou, P., van der Werf, T.S., et al. (2013) The role of Streptococcus pneumoniae in community-acquired pneumonia among adults in Europe: a meta-analysis. European Journal of Clinical Microbiology and Infectious Diseases 32(3), 305-316. [Abstract]

Shafiq, M., Mansoor, M.S., Khan, A.A., et al. (2013) Adjuvant steroid therapy in community-acquired pneumonia: a systematic review and meta-analysis. Journal of Hospital Medicine 8(2), 68-75. [Abstract]

Yuan, X., Liang, B.B., Wang, R., et al. (2012) Treatment of community-acquired pneumonia with moxifloxacin: a meta-analysis of randomized controlled trials. Journal of Chemotherapy 24(5), 257-267. [Abstract]

Primary evidence

Randomized controlled trials published since the last revision of this topic:

Gonzales, R., Anderer, T., McCulloch, C.E., et al. (2013) A cluster randomized trial of decision support strategies for reducing antibiotic use in acute bronchitis. JAMA Internal Medicine 173(4), 267-73. [Abstract]

New policies

No new national policies or guidelines since 1 April 2012.

New safety alerts

No new safety alerts since 1 April 2012.

Changes in product availability

No changes in product availability since 1 April 2012.

Goals and outcome measures

Goals

To support primary healthcare professionals:

To alleviate symptoms

To prescribe antibiotics appropriately

To refer people needing secondary care appropriately

QIPP - Options for local implementation

QIPP - Options for local implementation

Non-steroidal anti-inflammatory drugs (NSAIDs)

Review the appropriateness of NSAID prescribing widely and on a routine basis, especially in people who are at higher risk of both gastrointestinal (GI) and cardiovascular (CV) morbidity and mortality (e.g. older patients).

If initiating an NSAID is obligatory, use ibuprofen (1200 mg per day or less) or naproxen (1000 mg per day or less).

Review patients currently prescribed NSAIDs. If continued use is necessary, consider changing to ibuprofen (1200 mg per day or less) or naproxen (1000 mg per day or less).

Review and, where appropriate, revise prescribing of etoricoxib to ensure it is in line with MHRA advice and the NICE clinical guideline on osteoarthritis [CSM, 2005; NICE, 2008b].

Co-prescribe a proton pump inhibitor (PPI) with NSAIDs for people with osteoarthritis, rheumatoid arthritis, or low back pain (for people over 45 years) in accordance with NICE guidance [NICE, 2008b; NICE, 2009a; NICE, 2009b].

Take account of drug interactions when co-prescribing NSAIDs with other medicines (see Summaries of Product Characteristics). For example, co-prescribing NSAIDs with ACE inhibitors or angiotensin receptor blockers (ARBs) may pose particular risks to renal function; this combination should be especially carefully considered and regularly monitored if continued.

Antibiotic prescribing — especially quinolones and cephalosporins

Review and, where appropriate, revise current prescribing practice and use implementation techniques to ensure prescribing is in line with Health Protection Agency (HPA) guidance.

Review the total volume of antibiotic prescribing against local and national data.

Review the use of quinolones and cephalosporin prescribing against local and national data.

[NICE, 2013]

Background information

Definition

What is it?

Chest infections in the primary care setting can be broadly split into acute bronchitis, pneumonia, and infective exacerbations of chronic obstructive pulmonary disease (COPD). Further information about infective exacerbations of COPD is available in the CKS topic on Chronic obstructive pulmonary disease.

Acute bronchitis is an acute inflammation of the bronchial tree [Alberta Medical Association, 2008]. Inflammation, associated with oedema and mucus production leads to cough and phlegm production that last for up to 3 weeks [Braman, 2006].

Community-acquired pneumonia is an acute infection of the lung parenchyma caused by any organism found regularly outside hospital [Pugh, 2000]

Usual pathogens

What are the usual pathogens?

There is uncertainty about what proportion of chest infections are caused by specific pathogens because:

Microbiological investigations cannot accurately identify the underlying cause of a chest infection in many cases, because investigations:

Often fail to identify any viral or bacterial pathogen.

May isolate commensal bacteria that play no pathological role.

May only identify pathogens causing secondary infection.

Different studies commonly report quite different findings for the proportion of chest infections caused by a specific organism. This may be due to seasonal variation, patient characteristics, definitions of chest infection, and different diagnostic techniques.

Acute bronchitis

Viral infection is widely reported to account for most cases of acute bronchitis [Braman, 2006; Alberta Medical Association, 2008]. However, the proportions of viral and bacterial causes of acute bronchitis are unclear from the limited available evidence. This uncertainty results from:

The high proportion of people in whom no viral or bacterial pathogen can be identified, despite thorough investigation.

The presence of commensal bacteria isolated from the upper respiratory tract that may not or may not have a pathogenic role in a particular infection.

Two small prospective studies (n = 316 and n = 80) examined the pathological causes of acute bronchitis in people who had no co–morbid conditions [Macfarlane et al, 2001; Creer et al, 2006]. In both studies no pathogen was identified in a significant proportion of people. There were significant differences in the proportion of different pathogens reported in each study but overall, it can be concluded that:

Viral infections are the most commonly identified cause of acute bronchitis.

A significant minority of identified causes are bacterial.

Of the bacterial causes Streptococcus pneumoniae and Haemophilus influenzae were the most commonly identified.

The atypical bacteria Mycoplasma pneumoniae and Chlamydia pneumoniae were identified in a small proportion of people.

Community-acquired pneumonia

Although there are a large number of microbes that can cause pneumonia, there are only a relatively small number that are frequent pathogens.

In studies examining which pathogens cause community-acquired pneumonia (CAP), the likelihood of a specific pathogen being isolated depends on the clinical setting of the study. Thus, the results are different in patients studied in the community compared with those admitted to hospital and those receiving treatment in intensive care units. The identified pathogens for CAP in people treated in the community, reported by the British Thoracic Society, is summarized in Table 1.

Mycoplasma pneumonia occurs in outbreaks every 4 to 7 years and is much more common in school age children and young adults [Taylor-Robinson, 2003].

Table 1 . Pathogens isolated in people with community-acquired pneumonia treated in the community.
Microbial agent Percentage of people with pathogen
None identified 45.3%
Streptococcus pneumoniae 36.0%
Haemophilus influenzae 10.2%
Staphlococcus aureus 0.8%
Legionella pneumophilia 0.4%
Mycoplasma pneumoniae 1.3%
All viruses 13.1%
Data from: [British Thoracic Society, 2009]

Prevalence

How common is it?

Acute respiratory infections present commonly in general practice, and account for 17% of all consultations [DTB, 1998].

The annual incidence of acute bronchitis is 44 per 1000 adult population. Most episodes occur during autumn or winter [Wark, 2006].

The annual incidence of community-acquired pneumonia is 5–11 per 1000 adult population [British Thoracic Society, 2009].

The illness results in about 83,000 hospital admissions each year, and is the fifth leading cause of death in the UK [Guest and Morris, 1997].

It accounts for 5–12% of all lower respiratory tract infections managed by GPs in the community [British Thoracic Society, 2009] .

The incidence is higher in the elderly [British Thoracic Society, 2009].

Most episodes occur during autumn or winter [Loeb, 2006].

Pneumonia is likely to be present in no more than 5% of people presenting with acute respiratory symptoms [Metlay et al, 1997; DTB, 1998; Macfarlane et al, 2001].

Complications and prognosis

Acute bronchitis

Acute bronchitis is usually a mild, self-limiting illness. The cough usually lasts 7–10 days, but 45% of people will still have a cough after 2 weeks, and 25% of people will still have a cough after 3 weeks [Alberta Medical Association, 2008].

Community-acquired pneumonia

Complications of community-acquired pneumonia include:

Pleural effusion and empyema.

Lung abscess.

Septicaemia and metastatic infection such as meningitis, septic arthritis, endocarditis, and peritonitis.

The mortality of adults with pneumonia:

Is less than 1% of those who are well enough to be managed in the community.

Ranges from 6–12% of those requiring admission to hospital.

Rises to more than 50% of those requiring intensive care.

[British Thoracic Society, 2009]

Diagnosis

Diagnosis of adult chest infections

Diagnosis

How do I know my patient has acute bronchitis or community-acquired pneumonia?

Symptoms and signs of acute bronchitis and community-acquired pneumonia (CAP):

Cough is the predominant symptom present in both acute bronchitis and CAP.

A combination of symptoms and signs have been shown to have a high sensitivity for diagnosing CAP.

The British Thoracic Society recommend using differentiating clinical features as an aid to diagnosing CAP and distinguishing it from acute bronchitis. Clinical judgement must always be used in combination with these recommendations because:

No combination of symptoms or signs are clearly diagnostic for CAP.

Elderly people with CAP present more frequently with non-specific symptoms, and are less likely to have a fever compared with younger people.

Differentiating features

Features of acute bronchitis and community-acquired pneumonia

The differentiating clinical features of acute bronchitis and community-acquired pneumonia are shown in Table 1.

Table 1 . Symptoms and signs of acute bronchitis and community-acquired pneumonia.
Factor Acute bronchitis Community acquired pneumonia
History Cough Cough
May or may not have sputum, wheeze, or dyspnoea At least one other symptom of sputum, wheeze, dyspnoea, or pleuritic pain
Examination Wheeze often present, but no other focal chest signs Focal chest signs present Includes dullness to percussion, course crepitations, vocal fremitus
May have systemic features with or without a raised temperature Features include sweats, fevers, myalgia At least one systemic feature present with or without a temperature above 38°C Features include sweats, fevers, myalgia
Investigations (not usually considered necessary in general practice) Chest X–ray clear Chest X–ray diagnostic
Data from: [Braman, 2006; British Thoracic Society, 2009]

Basis for recommendation

Basis for recommendation

Recommendations on the diagnosis of bronchitis or community-acquired pneumonia are based on expert opinion from the British Thoracic Society in the guideline Recommendations for the management of cough in adults [Morice et al, 2006] and expert opinion from a review article [Metlay et al, 1997].

Investigations

When should I investigate a chest infection?

A chest X-ray is diagnostic of pneumonia, but is not considered necessary for most people with suspected community-acquired pneumonia (CAP) who are managed in the community.

Microbiological investigations are not usually considered necessary to diagnose community-acquired pneumonia or acute bronchitis in most people with suspected acute bronchitis or CAP managed in the community. Sputum samples for culture and/or sensitivity may be useful in people with recurrent episodes of acute bronchitis who may have become colonized with bacteria resistant to first-line antibiotics.

Basis for recommendation

Basis for recommendation

Recommendations on investigations are based on expert opinion from the British Thoracic Society in the guideline Recommendations for the management of cough in adults [Morice et al, 2006], and the British Thoracic Society Guidelines for the management of community-acquired pneumonia in adults: update 2009 [British Thoracic Society, 2009].

Differential diagnosis

What else might it be?

For people diagnosed with acute bronchitis in whom symptoms persist for longer than 3 weeks, other conditions to be ruled out include:

Asthma/chronic obstructive pulmonary disease.

Post-infectious cough.

Whooping cough.

Post-nasal drip.

Gastro-oesophageal reflux.

Tuberculosis.

An underlying malignancy in people who smoke.

For people with chest signs, other conditions to be ruled out include:

Pneumonia with underlying malignancy.

Heart failure.

Pulmonary embolism.

Asthma.

Basis for recommendation

Basis for recommendation

Information on the differential diagnosis of chest infection is based on expert opinion from American clinical guidelines [Braman, 2006].

Management

Management

Scenario: Acute bronchitis : covers the management of adults presenting with symptoms of acute bronchitis and their follow up.

Scenario: Community-acquired pneumonia : covers the management of adults presenting in primary care with pneumonia, including advice on admission, treatment with antibiotics, and follow up.

Scenario: Acute bronchitis

Scenario: Acute bronchitis

144months3060monthsBoth

Overview

Overview of management

Provide self-care advice. For most people, adequate hydration, analgesia, and comfort measures are adequate. People who smoke should be encouraged to quit and given the necessary support and treatment to do so.

Antibiotics are not routinely indicated.

Consider prescribing an antibiotic if the person has a significantly impaired ability to fight infection (e.g. immunocompromised status, cancer, or physical frailty) or if acute bronchitis is likely to significantly worsen a pre-existing condition (e.g. heart failure, angina, or diabetes).

If an antibiotic is necessary, prescribe amoxicillin first-line, or doxycycline as an alternative. Consider a macrolide (erythromycin or clarithromycin) if amoxicillin or doxycycline are unsuitable.

A delayed antibiotic prescribing strategy may be considered for people with acute bronchitis where it is felt safe not to prescribe antibiotics immediately.

Routine follow up is unnecessary. Re-examine people who have deteriorated to exclude pneumonia. For people with a pre-existing condition that has deteriorated on treatment, consider admission or a second-line antibiotic depending on clinical judgement:

Co-amoxiclav or doxycycline are options in people who have already received amoxicillin.

If these are unsuitable, seek specialist advice from a microbiologist.

Self-care advice

What self-care advice should I give in a person with acute bronchitis?

Advise the person to:

Use paracetamol or ibuprofen as required to reduce pain or temperature (see the section on Analgesia in Prescribing information).

Drink sufficient fluids to prevent dehydration.

Stop smoking. Offer support and treatment to achieve this (see the CKS topic on Smoking cessation).

Cough medicines are not recommended, although they are unlikely to do harm. Some people may find simple remedies like honey and lemon soothing.

Self-care interventions

Self-care interventions

Preventing dehydration in people with acute bronchitis:

Advise people to observe the frequency and colour of their urine. Fluid intake should be increased if urine is passed infrequently and is dark in colour.

Many cough medicines are available to buy over the counter, and may have already been tried by the person presenting with acute bronchitis. Products available for cough may contain dextromethorphan, menthol, sedating antihistamines, codeine, or pholcodine.

Some people may find cough medicines soothing, although this is likely to be a placebo response. If a person is already taking a cough medicine they believe is relieving symptoms, then there is probably no harm in them continuing with that product.

If the person enquires about other chest treatments, advise them that they are probably not effective. This includes the use of beta-agonists and Chinese herbal medicines.

Basis for recommendation

Basis for recommendation

The recommendations are consistent with those made by the British Thoracic Society in Recommendations for the management of cough in adults [Morice et al, 2006].

Analgesics: there is limited evidence from controlled trials that both paracetamol and ibuprofen reduce some symptoms of cold such as pain and temperature. However, they have no effect on the specific symptoms of acute bronchitis such as cough. Ibuprofen has more contraindications than paracetamol, but has the advantage of probably being more effective at reducing temperature and requiring less frequent dosing.

Aspirin and other nonsteroidal anti-inflammatory drugs (other than ibuprofen) are not recommended, as they are more likely to cause serious adverse effects.

In particular, aspirin should be avoided in older people who are more prone to its adverse effects, or who are taking concomitant nonsteroidal anti-inflammatory drugs or aspirin for cardiovascular purposes.

Preventing dehydration:

In clinical practice dehydration is a commonly observed problem for people that are unwell with a chest infection.

It occurs because they have increased fluid losses from sweating and/or a reduced fluid intake due to general malaise.

It may not be recognized by someone who is unwell because many of the symptoms of dehydration such as headache, dry mouth, and general malaise may be wrongly attributed to their infective illness rather than dehydration.

For someone who is unwell dehydration may be most easily recognized by observing urine colour and output, and may be relieved by increasing fluid intake appropriately.

Cough medicines to suppress a productive cough are not recommended because they suppress the natural mechanism that keeps the airway clear. In principle, suppression of an unproductive cough is unlikely to cause harm [SIGN, 2002]. However:

Cough medicines that are available over the counter are largely ineffective, and may have associated adverse effects [Morice et al, 2006].

They may have a useful placebo effect. Because they have little effect at suppressing cough, there is probably no harm in someone continuing to use them even for a productive cough if they have already bought them.

Opioids in doses higher than recommended in over-the-counter preparations may suppress cough but also have significant adverse effects and are therefore not recommended.

Smoking cessation is widely advocated because:

Smoking cessation reduces irritation to the bronchial tree already inflamed due to infection, and theoretically may reduce coughing.

Smoking is a risk factor for acute bronchitis. Smoking cessation reduces the risk of further episodes of acute bronchitis, in addition to conferring many other health benefits.

Beta2-agonists are not routinely recommended for the treatment of acute bronchitis. A Cochrane review (search date: February 2011) found that beta2-agonists may benefit adults with evidence of airway obstruction, but that overall the evidence did not support the use of these drugs in people with acute bronchitis [Becker et al, 2011].

Chinese medicinal herbs are not recommended in people with acute bronchitis. A Cochrane review (search date: September 2011) found none of the 74 studies identified met the inclusion criteria for the review. Although some studies did suggest benefit, these were open to study bias and methodological flaws, and therefore overall Chinese medicinal herbs cannot be recommended. The safety of Chinese medicinal herbs is also unknown [Jiang et al, 2012].

When to prescribe an antibiotic

When should I prescribe an antibiotic in a person with acute bronchitis?

Antibiotics are not indicated in people who are otherwise well. Explain why antibiotics are not necessary, giving written information if necessary.

Consider prescribing antibiotics for people who have a pre-existing condition that impairs their ability to deal with infection or is likely to deteriorate with acute bronchitis. This includes people:

Who are over 75 years of age, with fever.

With chronic obstructive pulmonary disease (COPD).

With heart failure.

Who are immunocompromised, including people with cancer or insulin dependant diabetes.

A delayed antibiotic prescribing strategy for people with acute bronchitis can be considered where it is felt safe not to prescribe antibiotics immediately.

Reassure the person that antibiotics are not needed immediately as they will make little difference to symptoms, and may have adverse effects.

Advise the person to use the delayed prescription if symptoms do not settle or get significantly worse.

Advise the person about the need for review if symptoms get significantly worse despite using the delayed prescription.

Information on antibiotics

Information on why antibiotics are not necessary

For a person with acute bronchitis who has no pre-existing conditions, it may be helpful to cover the following issues when discussing the role of antibiotics:

Acute bronchitis is a self-limiting condition that will usually resolve without treatment within 3 weeks.

Antibiotics are unlikely to significantly increase their rate of recovery.

Antibiotics are almost as likely to give them an adverse effect as any benefit.

Antibiotics interact with certain medications, such as the contraceptive pill and warfarin.

Widespread use of antibiotics for self-limiting conditions contributes to increased antibiotic resistance, reducing antibiotic effectiveness against more serious conditions.

Basis for recommendation

Basis for recommendation

Basis for not recommending antibiotics for people with acute bronchitis who are otherwise well

Antibiotics should be reserved for people where there is a risk of serious harm from even a modest deterioration in their chronic condition, or for people who are at risk of a more severe infection because their ability to deal with infection is impaired.

For people with acute bronchitis who do not have pre-existing pulmonary disease, there is evidence from a Cochrane systematic review that antibiotics have a modest effect in reducing the duration of cough in some individuals.

Although there is evidence of benefit, the magnitude of this benefit needs to be balanced against the probability of harm from antibiotics for the individual. Some studies have estimated that adverse effects of antibiotics are as frequent as any beneficial effects [SIGN, 2002].

Current evidence suggests that resistance to the main pathogens implicated in acute bronchitis is not yet widespread in the UK, but increased prescribing of antibiotics is a known mechanism of bacterial resistance, and countries with widespread prescribing of antibiotics in primary care also tend to exhibit greater levels of resistance. Therefore it is prudent not to prescribe antibiotics for self-limiting illnesses whenever possible.

Based upon considerations of benefit, harms, and increased antibiotic resistance, there is widespread agreement amongst experts that antibiotics are not recommended for people with acute bronchitis who do not have any significant pre-existing conditions.

[Fahey et al, 2004; Braman, 2006]

Basis for considering a delayed prescription strategy for people with acute bronchitis who are otherwise well

There is evidence that delayed antibiotic prescribing is an effective strategy for managing acute bronchitis. There is no difference in antibiotic consumption between the delayed and no prescribing strategies, and people given delayed prescriptions do not develop diarrhoea significantly more than people offered a no antibiotic prescribing strategy.

A potential advantage of the delayed prescribing strategy is that it offers a safety net for the small proportion of people with acute bronchitis who develop complications or whose symptoms worsen significantly. A person with acute bronchitis may also prefer to have a delayed prescription rather than no prescription at all, and this could help to maintain the doctor-patient relationship [NICE, 2008a].

Basis for considering antibiotics for people with acute bronchitis who are unwell with other conditions

With the exception of people with COPD, CKS found no direct evidence to support the use of antibiotics for people with acute bronchitis and other conditions.

Recommendations for when to prescribe an antibiotic in people with a pre-existing condition are therefore based upon:

Extrapolation from the evidence of the benefit of antibiotics for people who do not have a pre-existing condition, and the assumption that people with pre-existing conditions who are at greater risk of harm from acute bronchitis would gain greater benefit from treatment.

Evidence of benefit of antibiotics for people with acute bronchitis and COPD. For further information, see the CKS topic on Chronic obstructive pulmonary disease.

Expert opinion issued in guidelines for the management of adult respiratory tract infections by the European Respiratory Society [Woodhead et al, 2005]. This recommends prescribing antibiotics for people with certain co-existing conditions and people over 75 years of age with fever.

Additional advice to treat people who are immunocompromised is a pragmatic recommendation from CKS.

Antibiotics should be reserved for people where:

There is a risk of serious harm from even a modest deterioration in their chronic condition caused by acute bronchitis.

They are at risk of a more severe infection because their ability to deal with infection is impaired.

Which antibiotic to prescribe

Which antibiotic should I prescribe in a person with acute bronchitis?

If antibiotics are indicated for acute bronchitis, use empirical treatment:

Amoxicillin is recommended for first-line use.

Doxycycline is an alternative, or consider clarithromycin if amoxicillin or doxycycline is unsuitable.

For details of dosing regimens, contraindications, and adverse effects of these antibiotics, see individual sections on Amoxicillin and co-amoxiclav, Doxycycline, and Clarithromycin in Prescribing information.

Basis for recommendation

Basis for recommendation

This recommendation is consistent with those of the Health Protection Agency [HPA and Association of Medical Microbiologists, 2010], with the exception that CKS also recommends the use of macrolides in the event that amoxicillin or doxycyline is unsuitable for the person to be treated.

Empirical treatment is necessary as sputum samples are impractical for identifying a causative pathogen in primary care [SIGN, 2002].

There is no evidence from controlled trials to support the use of one antibiotic over another in the treatment of acute bronchitis. Therefore the choice of antibiotic should reflect their in vitro efficacy against the pathogens most likely to be involved, especially Streptococcus pneumoniae and Haemophilus influenzae.

Amoxicillin provides coverage against most of the bacteria involved in acute bronchitis, including penicillin-intermediate resistant S. pneumoniae (bacteria in an intermediate stage of developing full penicillin resistance), when used at adequate doses [Bush, 2003]. It has a favourable risk/benefit ratio, with few adverse effects.

Doxycycline is active against most of the bacteria that cause bronchitis, including H. influenzae and, less commonly encountered, Mycoplasma pneumoniae [Chopra, 2003]. Oxytetracycline is another option, but requires more frequent dosing.

Clarithromycin is a suitable alternative to amoxicillin in people allergic to penicillin. It is active against most of the bacterial pathogens involved in acute bronchitis [Bryskier and Butzler, 2003], although resistance to them is increasing, especially in H. influenzae.

Clarithromycin is recommended in preference to erythromycin by the BTS guidelines for the management of community acquired pneumonia, on the basis of improved gastrointestinal tolerance and an easier dosing schedule [British Thoracic Society, 2009].

Follow up

How should I follow up a person with acute bronchitis?

Routine follow up is not necessary. However, advise the person to seek advice if their condition deteriorates significantly or symptoms persist for longer than 3 weeks.

At follow up, consider other diagnoses and rule out serious causes of symptoms (including developing pneumonia). If the person has already received a course of antibiotics (due to a pre-existing condition), consider watchful waiting (especially if the condition has not deteriorated), or treat with a second-line antibiotic.

Co-amoxiclav gives cover against beta-lactamase-producing organisms. Doxycycline gives cover against some atypical pathogens (e.g. Mycoplasma pneumoniae and Chlamydia pneumoniae).

If these antibiotics are unsuitable, seek advice from a microbiologist (a macrolide or fluoroquinolone may be recommended).

Consider admission if the person significantly deteriorates whilst taking oral antibiotics.

After the person has recovered from acute bronchitis, consider whether pneumococcal or influenza immunization is necessary. See the CKS topics on Immunizations - pneumococcal and Immunizations - seasonal influenza.

Basis for recommendation

Basis for recommendation

Basis for advising re-consultation if the person's condition deteriorates

A significant deterioration may be caused by pneumonia that was not previously clinically apparent.

Basis for management options for people that do not improve, or who worsen, on antibiotics

Based upon the known pathogens causing acute bronchitis, people that do not improve whilst receiving antibiotics are likely to have one of the following [Macfarlane et al, 2001]:

An underlying viral infection.

A streptococcal infection resistant to amoxicillin.

An atypical bacterial infection not susceptible to any penicillin antibiotics.

The majority of people who do not improve on antibiotics will have a viral infection and discontinuing the antibiotic will not cause any deterioration in their condition.

In a minority of people, prescribing a second antibiotic may result in improvement when there is an underlying bacterial cause that was not susceptible to the first-line choice. This may be a reasonable option for people who are seriously ill with a pre-existing condition, when any further deterioration is likely to have serious consequences.

Co-amoxiclav or doxycycline are suitable second-line antibiotics in people who have previously taken amoxicillin.

Co-amoxiclav is a combination product containing amoxicillin and clavulanic acid. This is an inhibitor of beta-lactamase, an enzyme that is present in many penicillin-resistant bacteria, and helps amoxicillin retain its efficacy. In particular, co-amoxiclav should be effective against penicillin-resistant strains of Streptococcus pneumoniae, Moraxella catarrhalis, and Haemophilus influenzae.

Doxycycline has a different spectrum of activity to amoxicillin, and should be considered if previous amoxicillin failure was suspected to be due to Mycoplasma pneumoniae or Chlamydia pneumoniae (although this will not be known for certain in practice).

If amoxicillin was not previously used due to allergy or other contraindications, it is reasonable to seek advice on second-line treatment from a microbiologist. A macrolide may be suitable, although this may not provide adequate coverage. Fluoroquinolones tend to be effective with few adverse effects, but prescribing these drugs in primary care should be restricted because of fears of growing resistance.

Basis for recommending pneumococcal vaccination

S. pneumoniae is one of the pathogens known to cause acute bronchitis [Macfarlane et al, 2001].

The effectiveness of pneumococcal vaccination in preventing morbidity and mortality from S. pneumoniae has been demonstrated in a meta-analysis of 14 randomized controlled trials (n = 48,837) [Cornu et al, 2001].

Basis for recommending influenza vaccine

The influenza virus is one of the pathogens known to cause acute bronchitis [Macfarlane et al, 2001].

A number of randomized controlled trials and cohort studies have demonstrated that influenza immunization is effective for:

Reducing the incidence of influenza.

Reducing morbidity and mortality from secondary bacterial infections following influenza, particularly in at-risk groups.

Scenario: Community-acquired pneumonia

Scenario: Community-acquired pneumonia

144months3060monthsBoth

Overview

Overview of management

Assess the person's need for admission by determining respiratory rate, blood pressure, age (65 years of age and older), and whether they are confused (the 'CRB-65' scale).

If admission is not indicated, arrange a chest X-ray for people over 50 years of age that smoke, and give advice on self-care such as using analgesia and keeping hydrated. People who smoke should be encouraged to quit and given the necessary support and treatment to do so. Treat with an antibiotic.

Amoxicillin is first-line.

A macrolide (erythromycin, clarithromycin, or azithromycin) is indicated if amoxicillin is contraindicated.

Doxycycline can be used if there is an epidemic of Mycoplasma pneumoniae.

Follow up all people with pneumonia. If they have not clinically improved or are worsening on treatment, reconsider the need for admission.

For people not requiring admission consider a second-line antibiotic:

For people who have received amoxicillin previously, switch to, or add on, a macrolide (erythromycin or clarithromycin).

If these are not suitable seek expert advice from a microbiologist.

Arrange a chest X-ray after 6 weeks for people over 50 years of age that smoke, and for people with persistent symptoms or signs of pneumonia.

Admission and referral

When should I admit or refer a person with pneumonia to secondary care?

Assess the CRB-65 score for all people diagnosed with pneumonia. One point is awarded for each of the following features: Confusion — recent; Respiratory rate of 30 breaths/min or greater; Blood pressure — systolic of 90 mmHg or less or diastolic of 60 mmHg or less; and 65 years old or older. (However, other factors should also be considered when making the decision to admit).

For people with a CRB-65 score of 3 or more, arrange urgent admission to hospital.

For people with a CRB-65 score of 2, arrange same-day assessment in secondary care. Secondary care options include short-stay inpatient treatment or hospital-supervised outpatient treatment.

For people with a CRB-65 score of 1, consider arranging same-day assessment in secondary care.

For people with a CRB-65 score of 0, treatment at home is usually appropriate, depending on clinical judgement (for example the stability of any comorbid illness) and available social support.

If available, use pulse oximetry to assess the severity of people with suspected pneumonia and other acute respiratory illnesses.

People with oxygen saturation less than 92% require admission to hospital.

For people over the age of 50 years who smoke and do not require admission to hospital, check for possible underlying lung cancer by:

Assessing for clinical features of underlying lung cancer.

Arranging a chest X-ray at the time of presentation.

Arranging a follow-up chest X-ray at 6 weeks if the initial X-ray does not detect an underlying malignancy (see Follow up).

Refer urgently (within 2 weeks) if there are any clinical or radiographic features of lung cancer.

Factors indicating admission

Other factors that indicate admission

The CRB-65 system should not be used to replace clinical judgement in deciding if a person should be admitted. Other factors should also be considered in making the decision. These include:

The person's wishes.

Their social support.

Pre-existing conditions.

Pregnancy.

General frailty.

Clinical features of underlying lung cancer include:

Hemoptysis.

Weight loss.

Voice hoarseness.

Finger clubbing.

Cervical and/or supraclavicular lymphadenopathy.

Features suggestive of metastasis.

For further information on assessment and management of people with suspected lung cancer, see the CKS topic on Lung cancer - suspected.

Basis for recommendation

Basis for recommendation

Basis for recommendation to assess the CRB-65 score of a person diagnosed with pneumonia:

The CRB-65 scoring system, recommended by the British Thoracic Society, uses key clinical features to predict the individual's risk of death from pneumonia [British Thoracic Society, 2009].

The evidence for the relationship between these clinical features and the risk of death has been determined by a cohort study that prospectively followed 1000 people with community-acquired pneumonia (CAP) who had been admitted to hospital with a primary diagnosis of CAP [Lim et al, 2003]. It found that the risk of death for people with:

A score of 0 was 1.2%.

A score of 1 was 5.3%.

A score of 2 was 12.2%.

A score of 3 was 18.2%.

A score of 4 was 32.9%.

The British Thoracic Society recommends using this system to assess the need for hospital treatment based upon:

Consideration of this evidence of risk.

Expert opinion as to what level of risk is considered acceptable for people being managed less intensively at home.

Basis for pulse oximetry recommendations

The BTS guidelines for the management of community acquired pneumonia in adults: update 2009 recommend that pulse oximetry should be available to general practitioners who are responsible for the assessment of patients in the out-of-hours setting for the assessment of severity and oxygen requirement in patients with CAP and other acute respiratory illnesses [British Thoracic Society, 2009].

The SIGN and BTS guideline on the management of Asthma recommend that anyone with asthma and oxygen saturation of < 92% should be admitted to hospital [SIGN and BTS, 2008].

Basis for assessing all people over the age of 50 years that smoke for clinical features of underlying lung cancer:

There is good evidence from a number of prospective studies that people diagnosed with pneumonia who smoke are at high risk of having underlying lung cancer.

In one study 17% of smokers over the age of 60 years with pneumonia had underlying lung cancer [Woodhead et al, 1987].

In another study 11% of smokers over the age of 50 years with pneumonia had lung cancer [Gibson et al, 1993].

Basis for arranging a chest X-ray for people over the age of 50 years who smoke presenting with pneumonia:

There is evidence from two prospective studies of people with pneumonia that a chest X-ray taken at the time of presentation can detect up to approximately 60% of people with underlying lung cancer.

In one prospective study of 236 people with community-acquired pneumonia, ten people were diagnosed with lung cancer [Woodhead et al, 1987]. Of these, 60% were detected on the initial chest X-ray.

In another prospective study of 1011 people hospitalized with community-acquired pneumonia, an initial chest X-ray detected 61% of people with underlying lung cancer [Holmberg and Kragsbjerg, 1993].

When to prescribe an antibiotic

When should I prescribe an antibiotic in a person with community-acquired pneumonia?

Antibiotics are always indicated for people with suspected community-acquired pneumonia (with the possible exception of people in the terminal phase of life).

Basis for recommendation

Basis for recommendation

This recommendation is consistent with guidelines produced by the British Thoracic Society [British Thoracic Society, 2009]:

Immediate empirical treatment with antibiotics is considered essential to reduce mortality, length of illness, severity of symptoms, and the likelihood of complications.

Although the evidence from randomized controlled trials to support antibiotic use is limited, this is likely to be because the benefit of antibiotics is beyond doubt in this group. This would make placebo controlled trials unethical.

Antibiotics may not be appropriate during the terminal phase of life, see the CKS topic on Palliative cancer care - cough.

Which antibiotic to prescribe

Which antibiotic should I prescribe for a person with community-acquired pneumonia?

Amoxicillin is the first-line antibiotic for most people.

Doxycycline or clarithromycin if the person is allergic to penicillin.

Consider doxycycline, alone or combined with amoxicillin, if infection with Mycoplasma pneumoniae is suspected (most likely in school age children and young adults with non-severe symptoms if there is a known epidemic).

If the person has severe pneumonia that would normally be treated in hospital, consider prescribing one of the following:

Amoxicillin combined with clarithromycin.

Doxycyline.

For details of dosing regimens, contraindications, and adverse effects of these antibiotics, see the sections on Amoxicillin and co-amoxiclav, Doxycycline, and Clarithromycin in Prescribing information.

Basis for recommendation

Basis for recommendation

These recommendations are based on those of the British Thoracic Society (BTS) [British Thoracic Society, 2009] and the Scottish Intercollegiate Guidelines Network (SIGN) [SIGN, 2002].

Empirical treatment is necessary, as sputum samples take too long to process to identify a causative pathogen of community-acquired pneumonia and practically influence initial management.

CKS found no evidence from randomized controlled trials to support the use of one antibiotic over another in the treatment of pneumonia. The choice of antibiotic used is therefore dependent on the known susceptibility of the causative pathogens of bacterial pneumonia, taking into account resistance patterns.

Amoxicillin is the preferred first-line choice in most cases [British Thoracic Society, 2009], as it has a broad spectrum of activity and most of the common pathogens involved are still susceptible to it [Bush, 2003].

The majority of cases of community-acquired pneumonia are caused by Streptococcus pneumoniae or Haemophilus influenzae, which are still susceptible to amoxicillin if a large enough dose is given (see Dosing regimen of amoxicillin).

Other atypical pathogens may not be sensitive to amoxicillin. However, in reality, these tend to be rare causes of community-acquired pneumonia, and will often elicit symptoms severe enough for referral or admission.

Clarithromycin has a similar spectrum of activity to amoxicillin and is an appropriate alternative if the person has an allergy to penicillin.

Clarithromycin is recommended as the macrolide of choice (instead of erythromycin) by the BTS guidelines, on the basis of improved gastrointestinal tolerance and an easier dosing schedule [British Thoracic Society, 2009].

In exceptional cases where a person has severe pneumonia but is not admitted, the addition of clarithromycin to amoxicillin should be considered to maximize effectiveness and provide a broad range of cover. This recommendation is based on clinical experience rather than published studies [SIGN, 2002].

Doxycycline is recommended as an alternative to amoxicillin and amoxicillin plus clarithromycin by the BTS guidelines because pneumococci have less resistance to it, and it has greater activity against atypical pathogens, including M. pneumoniae [British Thoracic Society, 2009]. SIGN recommend that a tetracycline should be used first-line when M. pneumoniae infection is suspected because tetracyclines have more activity against this pathogen than amoxicillin [SIGN, 2002].

Fluoroquinolones, such as levofloxacin and, more recently, moxifloxacin, have greater activity than amoxicillin against some of the pathogens involved in pneumonia, including S. pneumoniae. They are not generally recommended for use in primary care because of rising levels of resistance to fluoroquinolones observed in countries with widespread prescribing of these antibiotics in the community. However, they may be recommended by a specialist if the person has contraindications to penicillins and macrolides.

Self-care advice

What self-care advice should I give to a person with community-acquired pneumonia?

Use paracetamol or ibuprofen as required to reduce temperature and symptoms of malaise (see the section on Analgesia in Prescribing information).

Rest and drink sufficient fluids to prevent dehydration.

Advise people to observe the frequency and colour of their urine. Fluid intake should be increased if urine is passed infrequently and is dark in colour.

Cough medicines are not recommended.

People who smoke should be advised to quit. Offer support and treatment in stopping smoking (see the CKS topic on Smoking cessation).

Basis for recommendation

Basis for recommendation

The recommendations are consistent with those made by the British Thoracic Society Guidelines for the management of community-acquired pneumonia in adults [British Thoracic Society, 2009].

Analgesics: there is limited evidence from controlled trials that both paracetamol and ibuprofen reduce some symptoms of cold, such as pain and temperature. However, they have no effect on symptoms such as cough. Ibuprofen has more contraindications than paracetamol (which may be especially relevant to older people with severe infection), but has the advantage of probably being more effective at reducing temperature and requiring less frequent dosing.

Aspirin and other nonsteroidal anti-inflammatory drugs are not recommended, as they are more likely to cause serious adverse effects.

In particular, aspirin should be avoided in older people who are more prone to its adverse effects, or who are taking concomitant nonsteroidal anti-inflammatory drugs, or aspirin for cardiovascular purposes.

Preventing dehydration:

In clinical practice dehydration is a commonly observed problem for people who are unwell with a chest infection.

It occurs because they have increased fluid losses from sweating, and/or a reduced fluid intake due to general malaise.

It may not be recognized by someone who is unwell because many of the symptoms of dehydration such as headache, dry mouth, and general malaise, may be wrongly attributed to their infective illness rather than dehydration.

For someone who is unwell dehydration may be most easily recognized by observing urine colour and output, and may be relieved by increasing fluid intake appropriately.

Cough medicines to suppress a productive cough are not recommended because they suppress the natural mechanism that keeps the airway clear. In principle, suppression of an unproductive cough is unlikely to cause harm [SIGN, 2002]. However:

Cough medicines that are available over the counter are largely ineffective, and may have associated adverse effects [Morice et al, 2006].

They may have a useful placebo effect. Because they have little effect at suppressing cough, there is probably no harm in someone continuing to use them even for a productive cough if they have already bought them.

Opioids in doses higher than recommended in over-the-counter preparations may suppress cough, but also have significant adverse effects and are therefore not recommended.

Smoking cessation is widely advocated because:

Smoking cessation reduces irritation to the bronchial tree already inflamed due to infection, and theoretically may reduce coughing.

Smoking is a risk factor for chest infections [Gutzwiller et al, 1989]. Smoking cessation reduces the risk of further episodes of chest infections, in addition to conferring many other health benefits.

Follow up

How should I follow up a person with pneumonia?

Regularly reassess the key clinical features used in the CRB-65 system and the person's ability to cope at home. Follow up until clinical features of the pneumonia have resolved.

For people having difficulty coping at home — offer admission.

For people whose CRB-65 score deteriorates on treatment — arrange admission.

For people whose CRB-65 score does not improve despite antibiotic treatment — further management will depend on clinical judgement. The options are either arrange admission, or add in or switch to a second antibiotic.

For people prescribed amoxicillin, switch to, or add in, a macrolide.

If amoxicillin was not initially used, seek advice from a microbiologist or respiratory physician.

Arrange a chest X-ray after 6 weeks for all people:

With symptoms and signs that are slow to resolve or persist despite treatment.

Who smoke and are over 50 years of age.

Advise people that smoke to quit and offer them support to do so. See the CKS topic on Smoking cessation.

Following recovery from pneumonia, consider whether pneumococcal or influenza immunization is necessary. See the CKS topics on Immunizations - seasonal influenza and Immunizations - pneumococcal.

Basis for recommendation

Basis for recommendation

Basis for arranging admission for people that deteriorate on treatment

People that deteriorate on treatment are at an increased risk of death from pneumonia.

They require alteration to their treatment and close observation to ensure that these alterations are effective.

For most people hospital admission is the appropriate way to deliver this care.

Basis for management options for people that are not improving on treatment

In people who have not responded to an initial course of amoxicillin, switching to, or adding on a macrolide, is recommended by the British Thoracic Society [British Thoracic Society, 2009].

Empirical treatment with a macrolide and/or amoxicillin is based on clinical experience rather than published studies [SIGN, 2002].

The rationale is to provide antibiotic coverage for as many pathogens involved in the infection as possible. Up to 10% of community-acquired pneumonia may be caused by two organisms.

If the person was not initially taking amoxicillin because it was contraindicated, CKS recommends getting expert advice from a microbiologist. Other antibiotics such as fluoroquinolones may be recommended.

The British Thoracic Society recommends a follow-up X-ray at 6 weeks based upon evidence that [British Thoracic Society, 2009]:

People with pneumonia who smoke are at high risk of having lung cancer.

People with pneumonia and persistent or slowly resolving symptoms and signs of pneumonia are at high risk of having an underlying malignancy.

Chest X-rays taken at presentation will not detect all people with an underlying malignancy.

A chest X-ray will detect an underlying malignancy in most people after 6 weeks of treatment for pneumonia.

Basis for recommending smoking cessation

Smoking cessation is widely advocated because:

Cross-sectional studies show that smoking is a risk factor for chest infections [Gutzwiller et al, 1989]. Smoking cessation reduces the risk of further episodes of chest infections, in addition to conferring many other health benefits.

Advice and treatment to stop smoking have been shown to have a small but significant effect in reducing smoking.

Basis for recommending pneumococcal vaccination

Streptococcus pneumoniae is one of the pathogens known to cause acute bronchitis [Macfarlane et al, 2001].

The effectiveness of pneumococcal vaccination in preventing morbidity and mortality from S. pneumoniae has been demonstrated in a meta-analysis of 14 randomized controlled trials (n = 48,837) [Cornu et al, 2001].

Basis for recommending influenza vaccine

The influenza virus is one of the pathogens known to cause acute bronchitis [Macfarlane et al, 2001].

A number of randomized controlled trials and cohort studies have demonstrated that influenza immunization is effective for:

Reducing the incidence of influenza.

Reducing morbidity and mortality from secondary bacterial infections following influenza, particularly in at-risk groups.

Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://medicines.org.uk/emc), or the British National Formulary (BNF) (www.bnf.org).

Amoxicillin and co-amoxiclav

Dosing regimen of amoxicillin

What dosing regimen of amoxicillin should I prescribe?

Amoxicillin: there is little evidence on the optimal duration of amoxicillin treatment for chest infections. The following recommendations are based on established guidelines and formularies:

Acute bronchitis: if antibiotics are required, a short 5-day course at a dose of 500 mg three times a day, is recommended [HPA and Association of Medical Microbiologists, 2010].

Community-acquired pneumonia: a 7-day course at a dose of 500 mg three times a day is warranted for uncomplicated infection [British Thoracic Society, 2009; HPA and Association of Medical Microbiologists, 2010]. A dose of 500 mg three times a day (in combination with clarithromycin 500 mg twice daily) is recommended (for 7–10 days) if the person has severe pneumonia that would normally be treated in hospital (CRB-65 = 1) but admission is not possible [British Thoracic Society, 2009; HPA and Association of Medical Microbiologists, 2010].

Co-amoxiclav: CKS recommends the higher British National Formulary dose of co-amoxiclav (500 mg amoxicillin component three times a day) [BNF 63, 2012], when it is used as second-line treatment for acute bronchitis. This dose should be optimal in eradicating resistant strains of Streptococcus pneumoniae and other pathogens.

Contraindications and cautions

Who should avoid using amoxicillin or co-amoxiclav?

Amoxicillin or co-amoxiclav should not be taken by people who have true penicillin allergy.

Gastrointestinal adverse effects alone (nausea, vomiting, or diarrhoea) do not constitute an allergy to penicillin.

Co-amoxiclav should be used with caution in people with hepatic disease. If used, monitor liver function.

Basis for recommendation

These recommendations are based on the British National Formulary [BNF 63, 2012].

Hypersensitivity reactions with penicillins

Although rare, penicillin hypersensitivity reactions are potentially fatal.

Hypersensitivity reactions are different from allergic reactions to penicillins.

Allergic reactions are more common and occur in 1–10% of people treated with penicillins.

Hypersensitivity reactions occur in fewer than 0.05% of people treated with penicillins. People with a history of atopic allergy (for example asthma, eczema and hay fever) are more likely to have a hypersensitivity reaction to penicillins.

If a person has a history of anaphylaxis, urticaria, or rash immediately after taking penicillin, they are at risk of immediate hypersensitivity to penicillins and should not receive a penicillin.

The following do not constitute a hypersensitivity to penicillin and if they occur in a person taking a penicillin, treatment can be continued cautiously:

Gastrointestinal adverse effects alone (for example nausea, vomiting, or diarrhoea).

A minor rash (a non-confluent, non-pruritic rash restricted to a small area of the body).

A rash that occurs more than 72 hours after penicillin administration.

Adverse effects

What are the adverse effects of amoxicillin and co-amoxiclav?

The most common adverse effects of penicillins include diarrhoea (consider pseudomembranous colitis if a person develops severe diarrhoea during or after treatment), nausea, vomiting, and skin rash.

Anaphylaxis is rare and can be immediate or delayed.

Co-amoxiclav may rarely cause cholestatic jaundice during or shortly after its use. This is more common in men, in people over the age of 65 years, and with long courses of treatment (over 14 days).

Oral hormonal contraception — additional contraceptive precautions are not required during or after courses of amoxicillin or co–amoxiclav.

However, women should be advised about the importance of correct contraceptive practice if they experience vomiting or diarrhoea. For further information, see the section on Antibiotics in the CKS topic on Contraception - assessment.

Basis for recommendation

Pseudomembranous colitis

Severe diarrhoea during or after treatment with antibiotics may be a sign of pseudomembranous colitis (PMC).

PMC is an acute, exudative colitis caused by Clostridium difficile, a Gram-positive toxin-releasing bacillus. It often follows antibiotic treatment and is usually of acute onset, but may become chronic.

PMC is a particular hazard of ampicillin, amoxicillin, co-amoxiclav, second- and third-generation cephalosporins, clindamycin, and quinolones, but few antibiotics are free of this adverse effect.

For more information, see the CKS topic on Diarrhoea - antibiotic associated.

[Bartlett, 2002; Aronson, 2006; BNF 63, 2012].

Cholestatic jaundice with co-amoxiclav

This information is based on Revised indications for co-amoxiclav (Augmentin) published by the Medicines and Healthcare products Regulatory Agency (MHRA), formerly the Committee on Safety of Medicines [CSM, 1997].

Oral contraceptives

The information on oral contraceptives is based on the guidance Drug interactions with hormonal contraception issued by the Faculty of Sexual and Reproductive Healthcare [FSRH, 2011].

Doxycycline

Dosing regimen of doxycycline

What dosing regimen of doxycycline should I prescribe?

Give 200 mg of doxycyline on the first day, followed by a maintenance dose of 100 mg once a day. The duration of treatment will depend on the type and severity of infection:

Acute bronchitis: 5 days is recommended.

Community-acquired pneumonia: doxycycline is indicated as a first-line treatment if the person cannot taken amoxicillin, or when an atypical pathogen (principally Mycoplasma pneumoniae) is suspected (most likely in school age children and young adults with non-severe symptoms if there is a known epidemic). A course of 7 days is usually sufficient, but consider extending up to 10 days if the person is slow to respond.

Basis for recommendation

These recommendations are based on the guidance Management of infection guidance for primary care for consultation and local adaptation issued by the Health Protection Agency (HPA) [HPA and Association of Medical Microbiologists, 2010], the British Thoracic Society guidelines for the management of community acquired pneumonia in adults: update 2009 [British Thoracic Society, 2009], Community management of lower respiratory tract infection in adults: a national clinical guideline issued by the Scottish Intercollegiate Guidelines Network [SIGN, 2002], and the British National Formulary [BNF 63, 2012].

Contraindications and cautions

Who should avoid taking doxycyline?

Contraindications

Do not prescribe doxycyline to:

Pregnant or breastfeeding women and children under 12 years of age as it is deposited in the teeth and bones of unborn or developing children.

People with:

Known hypersensitivity to any of the tetracyclines.

Acute porphyria.

Systemic lupus erythematous.

Caution

Prescribe doxycyline with caution in:

People with myasthenia gravis or hepatic impairment.

People exposed to or likely to be exposed to excessive sunlight (for example working outdoors or on holiday in a sunny climate) or ultraviolet light.

Basis for recommendation

Contraindication

These are based on the manufacturer's Summary of Product Characteristics [ABPI Medicines Compendium, 2012] and the British National Formulary [BNF 63, 2012].

Young children — tetracyclines are deposited in the growing bone and teeth (by binding to calcium) of young children, causing staining and occasionally dental hypoplasia. They are therefore contraindicated in children under 12 years, and in pregnant or breast-feeding women [BNF 63, 2012].

Systemic lupus erythematosus — tetracyclines may exacerbate systemic lupus erythematosus [BNF 63, 2012].

Caution

Abnormal hepatic function has been reported rarely with tetracyclines, and doxycycline should be given with caution to people with hepatic impairment or receiving other potentially hepatotoxic drugs [ABPI Medicines Compendium, 2012].

Tetracyclines may increase muscle weakness in patients with myasthenia gravis [BNF 63, 2012].

Photosensitivity reactions may occur in hypersensitive people and such people should be warned to avoid direct exposure to natural or artificial sunlight and, to discontinue treatment at the first sign of skin discomfort [BNF 63, 2012]. Photosensitivity reactions are more common with doxycycline than with other tetracyclines like tetracycline, oxytetracycline, and lymecycline [Wolf, 2002].

Adverse effects

What are the adverse effects of doxycyline?

Doxycycline is a broad-spectrum antibiotic and has the potential to cause gastrointestinal adverse effects such as nausea, vomiting, and diarrhoea.

Less frequently, doxycycline may cause photosensitivity. Advise the person to minimize exposure to direct sunlight and to avoid sunlamps during the course of treatment.

Severe adverse effects are unusual with a short course. However, benign intracranial hypertension is a rare but important adverse effect of tetracyclines. If a person taking doxycyline develops headache and visual disturbances, the drug should be stopped immediately.

Oral hormonal contraception

Additional contraceptive precautions are not required during or after courses of doxycycline.

However, women should be advised about the importance of correct contraceptive practice if they experience vomiting or diarrhoea. For further information, see the section on Antibiotics in the CKS topic on Contraception - assessment.

Basis for recommendation

This information is summarized from the manufacturer's Summary of Product Characteristics [ABPI Medicines Compendium, 2012] and the British National Formulary [BNF 63, 2012].

Pseudomembranous colitis

Severe diarrhoea during or after treatment with antibiotics may be a sign of pseudomembranous colitis (PMC).

PMC is an acute, exudative colitis caused by Clostridium difficile, a Gram-positive toxin-releasing bacillus. It often follows antibiotic treatment and is usually of acute onset, but may become chronic.

PMC is a particular hazard of ampicillin, amoxicillin, co-amoxiclav, second- and third-generation cephalosporins, clindamycin, and quinolones, but few antibiotics are free of this side-effect.

For more information, see the CKS topic on Diarrhoea - antibiotic associated.

[Bartlett, 2002; Aronson, 2006; BNF 63, 2012].

Oral contraceptives

The information on oral contraceptives is based on the guidance Drug interactions with hormonal contraception issued by the Faculty of Sexual and Reproductive Healthcare [FSRH, 2011].

Clarithromycin

Dosing regimen of clarithromycin

What dosing regimen of clarithromycin should I use?

For acute bronchitis, clarithromycin 500 mg twice a day for 5 days is recommended [HPA and Association of Medical Microbiologists, 2010].

For community acquired pneumonia, clarithromycin 500 mg twice a day for 7 days is recommended [British Thoracic Society, 2009].

A dose of 500 mg twice a day (in combination with amoxicillin 500 mg three times a day) is recommended (for 7–10 days) if the person has severe pneumonia that would normally be treated in hospital (CRB-65 = 1) but admission is not possible [British Thoracic Society, 2009].

Basis for recommendation

These recommendations are based on the guidance Management of infection guidance for primary care for consultation and local adaptation issued by the Health Protection Agency (HPA) [HPA and Association of Medical Microbiologists, 2010], the British Thoracic Society guidelines for the management of community acquired pneumonia in adults: update 2009 [British Thoracic Society, 2009], Community management of lower respiratory tract infection in adults: a national clinical guideline issued by the Scottish Intercollegiate Guidelines Network [SIGN, 2002], and the British National Formulary [BNF 63, 2012].

Contraindications and cautions

Who should avoid taking clarithromycin?

Clarithromycin should be used with caution in people with:

Severe renal impairment

If the estimated glomerular filtration rate (eGFR) is less than 30 mL/minute/1.73 m2 — use half the clarithromycin dose (that is, reduce it from 500 mg twice daily to 250 mg twice daily).

Liver disease — consider avoiding clarithromycin and erythromycin, as they can cause hepatic dysfunction. Hepatic failure has been reported with clarithromycin, very rarely, in people with liver disease.

Consider the possibility of drug interactions before prescribing clarithromycin in people taking:

Aminophylline or theophylline — check theophylline levels 48 hours after starting erythromycin and adjust the dose accordingly. Interaction is less likely with clarithromycin unless theophylline levels are at the higher end of the therapeutic range.

Carbamazepine — consider azithromycin instead (interaction unlikely) or consider reducing the dose of carbamazepine by 30–50% during treatment with clarithromycin and advise the person to report symptoms of toxicity (such as dizziness, diplopia, ataxia, confusion). Clarithromycin inhibits cytochrome P450 enzyme CYP3A4, resulting in reduced carbamazepine metabolism.

Warfarin — this is an established but unpredictable interaction. Monitor the international normalized ratio (INR) and adjust the warfarin dose accordingly.

Atorvastatin or simvastatin — consider azithromycin instead, but advise the person to report muscle symptoms (interaction unlikely). Alternatively, stop atorvastatin or simvastatin for the duration of treatment with clarithromycin (inhibits metabolism of atorvastatin and simvastatin via CYP3A4).

Drugs that prolong the QT interval (such as antiarrhythmics, antipsychotics, tricyclic antidepressants) — concomitant use of two drugs that prolong the QT interval is not recommended.

Drugs that cause hypokalaemia (such as diuretics, corticosteroids, short-acting beta2-agonists) — hypokalaemia is a risk factor for QT prolongation.

Contraceptives — additional contraceptive precautions are not required during or after a course of clarithromycin or erythromycin.

However, women should be advised about the importance of correct contraceptive practice if they experience vomiting or diarrhoea.

Basis for recommendation

These recommendations are based on information from Stockley's drug interactions [Baxter, 2008], the Medicines and Healthcare Regulatory Agency (MHRA) [CSM, 1996; CSM, 2004; MHRA, 2008], the Faculty of Sexual and Reproductive Healthcare [FSRH, 2011], and the Drug and therapeutics bulletin [DTB, 1991]. In particular:

Having reviewed the available evidence, the FSRH no longer advises that additional precautions are required to maintain contraceptive efficacy when using antibiotics that are not enzyme inducers with combined hormonal methods for durations of 3 weeks or less, unless the antibiotics (or the illness) cause vomiting or diarrhoea [FSRH, 2011].

Adverse effects

What are the adverse effects of clarithromycin?

Clarithromycin may cause gastrointestinal adverse effects such as nausea, vomiting, and diarrhoea, but these are less common than with erythromycin. If adverse effects are severe, consider trying an alternative antibiotic, such as doxycycline.

Basis for recommendation

This information is taken from the British National Formulary [BNF 63, 2012].

Analgesia

Contraindications and cautions

Who should avoid taking paracetamol or ibuprofen?

Paracetamol and ibuprofen are relatively safe drugs when used for short periods, such as for treatment of acute bronchitis [Eccles, 2006]. However:

Some experts suggest that paracetamol should be avoided in people who drink dangerous quantities of alcohol.

Ibuprofen should be avoided in people with known hypersensitivity to aspirin or nonsteroidal anti-inflammatory drugs, people with renal complications, or people with a known risk of gastrointestinal bleeding. It may be prudent to use paracetamol in older people with severe infection.

Adverse effects

What are the adverse effects of paracetamol or ibuprofen?

Paracetamol and ibuprofen rarely cause adverse effects when used for short-term treatment:

Paracetamol has no notable common adverse effects when used at the correct dosage.

Ibuprofen may occasionally cause gastrointestinal adverse effects, such as discomfort, nausea, and diarrhoea.

Basis for recommendation

This information is taken from the British National Formulary [BNF 63, 2012].

Evidence

Evidence

Supporting evidence

Antibiotics for acute bronchitis

Evidence on antibiotics for acute bronchitis

Evidence from a cochrane review suggests that antibiotics have a modest benefit for people who have been diagnosed with acute bronchitis. However, acute bronchitis is a self-limiting condition, and this slight benefit should be considered in the wider context of drug-induced adverse effects, and the increased likelihood of pathogens developing resistance in the individual and in the community. There is no good evidence from RCTs to support the use of one antibiotic over another in the treatment of acute bronchitis.

A Cochrane review (search date: September 2010) identified 15 RCTs (n = 2618) that compared the effectiveness of an antibiotic with placebo or no treatment in people aged over 3 years diagnosed with acute bronchitis or acute productive cough [Smith et al, 2004].

The quality of the trials was generally good. The antibiotics studied included doxycyline, erythromycin, amoxicillin, co-trimoxazole, azithromycin, and cefuroxime.

Various outcomes were reported with the following results:

Clinical improvement: At follow-up, people who had received antibiotics (nine studies, 1754 people) were more likely to be improved clinically than those receiving placebo treatment but the benefit was small; relative risk (RR) 1.06 (95% CI 1.02 to 1.10).

Cough: At follow-up, people who had received antibiotics (four studies, 275 people) were less likely to have a cough; RR 0.61 (95% CI 0.48 to 0.79). This means that six people would need to be treated with an antibiotic for one additional person to present at follow up without a cough (NNT = 6).

Nocturnal cough: At follow-up, people taking an antibiotic were less likely to have a nocturnal cough (four studies, 538 participants); RR 0.64 (95% CI 0.49 to 0.85). This means that seven people would need to be treated with an antibiotic for one additional person to present at follow up without a nocturnal cough (NNT = 7).

Duration of symptoms: taking an antibiotic reduced the duration of feeling ill by a mean difference -0.64 days (95% CI -1.16 to -0.13).

Adverse effects were not significantly increased by antibiotics in the studies included, although there was a trend towards this (RR 1.15, 95% CI 0.92 to 1.44). The most common adverse effects were gastrointestinal disturbance, headaches, skin rash, and vaginitis. However, less than 4% of people were reported as dropping out of the trials due to adverse effects.

The authors concluded that although antibiotics were seen to be of benefit in people with acute bronchitis, the magnitude of this benefit has to be weighed against the disadvantages of antibiotic use including adverse effects, medicalisation of a self-limiting illness, the risk of resistance developing, and the cost of treatment.

Delayed and no antibiotics prescribing strategies

Evidence on delayed and no antibiotics prescribing strategies for acute bronchitis.

Evidence from two randomized controlled trials (RCTs) set in UK primary care suggests that delayed and no antibiotic prescribing strategies are effective for managing acute cough. Results showed that delayed and no antibiotic prescribing strategies significantly reduce the consumption of antibiotics and lessens beliefs that antibiotics are effective in people with acute cough. Compared with an immediate prescribing strategy, there are no significant differences in managing symptom duration and severity, and evidence statement on patient satisfaction shows that overall, people with cough are satisfied with all three management strategies (all with satisfaction rates above 70%). CKS identified a subsequent RCT which showed that delayed antibiotic prescribing for lower respiratory tract infections (LRTI) appears effective in modifying re-consultation behaviour, particularly in people with a prior history of antibiotic prescription for LRTI.

NICE identified two good quality RCTs that looked at the effectiveness of delayed antibiotics prescribing, and no prescribing strategies in people with acute cough or acute bronchitis.

One study, [Dowell et al, 2001], evaluated 191 people over the age of 16 years (in 22 Scottish practices) with uncomplicated cough who would have received antibiotics under the GP's usual practice. The participants were randomized to receive either an immediate prescription (92 people) or a delayed prescription (99 people). The inclusion criteria was acute cough with or without coryza, shortness of breath, sputum, fever, sore throat or chest tightness.

The second study, [Little et al, 2005], evaluated 807 participants aged 3 years and over, with acute uncomplicated lower respiratory tract infection. The participants were assigned to 1 of 6 groups by a factorial design: leaflet or no leaflet and 1 of 3 antibiotic groups (immediate antibiotics, no offer of antibiotics, and 14-day delayed antibiotics prescription). Approximately half of each group received an information leaflet (129 for immediate antibiotics, 136 for delayed antibiotic prescription, and 140 for no antibiotics). The inclusion criteria was cough lasting for a maximum of 21 days as the main symptom and with at least one symptom or sign localising to the lower respiratory tract (sputum, chest pain, breathlessness and wheezing).

Various outcomes were reported with the following results [Dowell et al, 2001; Little et al, 2005]:

Duration and severity of symptoms — there were no significant differences in reduction of symptom duration (cough) and the severity of symptoms among the three antibiotic management strategies (no prescribing, delayed prescribing and immediate prescribing) in adults and children.

Antibiotic consumption — compared with an immediate prescribing strategy, both delayed and no prescribing strategies significantly reduced the consumption of antibiotics for acute cough in adults (76%) and children (80%). There was no significant difference in antibiotic consumption between a delayed prescribing strategy and a no prescribing strategy.

Re-attendance — there were fewer re-attendances within 1 month with acute cough among people offered a delayed prescribing strategy or an immediate prescribing strategy compared with a no prescribing strategy. There were no significant differences in re-attendance between delayed and immediate prescribing strategies.

Adverse effects — people offered immediate antibiotics and a delayed prescribing strategy did not develop diarrhoea significantly more often compared with people offered a no antibiotic prescribing strategy.

Patient satisfaction

People (including parents and carers of children) with acute cough were satisfied with all three strategies; immediate (86%), delayed (77%) and no prescribing (72%).

When compared with an immediate prescribing strategy, people (including parents and carers of children) offered a delayed or a no prescribing strategy are significantly less satisfied (9% and 14% less satisfied respectively). However, there were no significant difference in satisfaction between a no prescribing strategy and a delayed prescribing strategy.

People (including parents and carers of children) offered a delayed or a no prescribing strategy were less likely to believe that antibiotics are effective compared with those offered an immediate prescribing strategy (35% and 28% less likely to believe, respectively). However, there is no significant difference in belief between those offered a delayed or a no prescribing strategy.

NICE thought that the differences in satisfaction rates between delayed, no prescribing and immediate prescribing could be confounded by the methods of delivery (such as ways of collecting delayed prescriptions, verbal advice provided or the amount of information provided on symptomatic treatment) rather than reflecting differences in the antibiotic management strategies.

The author concluded that a delayed or no prescribing strategy should be offered to people with acute cough who are not at an increased risk of developing complications. More studies are needed to investigate the best way to deliver a delayed prescribing strategy.

Re-consultation after one year

One study identified by CKS, [Moore et al, 2009], aimed to assess the effects of antibiotic prescribing strategy on re-consultation in the year following presentation with acute LRTI in 807 participants, aged 3 years and over. The participants were randomized to one of three prescribing strategies (antibiotics, delayed antibiotic, no antibiotic) and a leaflet. Prior antibiotic use and re-consultation were assessed by medical record review.

People who had been prescribed antibiotics for cough in the previous 2 years were much more likely to re-consult, and the use of a delayed prescription strategy was associated with reduced re-consultation in this group.

In people with prior antibiotic exposure, there was a 34% reduction in consultation rate in the no antibiotic group and a 78% reduction for the delayed antibiotic group compared with those given immediate antibiotics. This effect was not observed in people who had not been prescribed antibiotics in the previous 2 years; there was no reduction in consultations in the no antibiotic group or the delayed antibiotic group.

Antibiotics for pneumonia

Evidence on antibiotics for community-acquired pneumonia

There is a lack of evidence from randomized controlled trials (RCTs) that antibiotics are an effective treatment in people with community-acquired pneumonia. This is principally because such a trial would be unethical in an illness which may present a serious threat to life and in which there is an overwhelming consensus that antibiotics are of benefit. In the head-to-head RCTs that have been conducted, no antibiotic has proven superior to another.

A Cochrane review (search date: February 2009) identified six RCTs (n = 1857) that investigated the superiority of one antibiotic compared with another in adults (12 years and older) with pneumonia acquired and treated in the community [Bjerre et al, 2009]. The antibiotics studied were clarithromycin compared with erythromycin (two RCTs), clarithromycin compared with sparfloxacin (a fluoroquinolone unavailable in the UK), clarithromycin compared with azithromycin, clarithromycin compared with telithromycin, azithromycin compared with levofloxacin, and telithromycin compared with levofloxacin. The studies were described as being generally good.

There were few differences between the regimens investigated:

Efficacy: there were no significant differences between the antibiotics in terms of clinical, bacterial, or radiological success.

Adverse effects: there were significantly more adverse effects (mainly gastrointestinal) with erythromycin.

The authors commented on the paucity of data available, and concluded that there is insufficient evidence from RCTs to guide clinical practice on the use of antibiotics to treat community-acquired pneumonia.

Analgesics for fever and pain

Evidence on analgesics for fever and pain

Extrapolated evidence from various painful and/or febrile illnesses suggest that paracetamol and ibuprofen are both effective at reducing temperature and pain. This efficacy, together with the good safety profile of these drugs, suggests that they are suitable first-line drugs for the symptomatic treatment of acute bronchitis.

The efficacy of analgesics has not been extensively studied, mainly because they have been used for many decades and, in the case of aspirin and paracetamol, they were used as over-the-counter (OTC) drugs before regulatory bodies required evidence from randomized controlled trials (RCTs) for licensing. CKS could find no systematic reviews to support their use in cases of acute bronchitis. However, a comprehensive non-systematic review on the evidence for use of aspirin, paracetamol, and ibuprofen in the common cold and flu has been reported, and provides evidence which can be extrapolated to support their use in acute bronchitis [Eccles, 2006].

Aspirin is not generally recommended for the common cold. Although it is a component of many OTC products, it has significantly more adverse effects compared with paracetamol or ibuprofen.

Paracetamol is usually used as first-line treatment for the common cold and is suitable in adults, elderly people, and pregnant women.

Evidence for effectiveness in adults. The evidence for effectiveness of paracetamol is mainly extrapolated from its use in other conditions, such as headache, toothache, dysmenorrhoea, and post-surgical pain. Three of the most relevant trials found that paracetamol was effective in relieving pain in sore throat associated with upper respiratory tract infection. One of these RCTs also found that paracetamol reduced fever, headache, myalgia, and general discomfort.

Ibuprofen is a good alternative to paracetamol and has a longer duration of effect. It is less suitable for pregnant women and elderly people.

Evidence for effectiveness in adults. Ibuprofen has a dose-dependent effect on pain in quantities up to 400 mg, that lasts up to 6 hours. In particular, one RCT showed that ibuprofen reduced symptom severity and fever in patients with upper respiratory tract infection.

The safety and adverse effects of paracetamol and ibuprofen have been recorded from the accumulated data from numerous reports, including RCTs, cohort studies, and observational studies.

Paracetamol is well tolerated when taken correctly at standard doses. However, it is hepatotoxic in overdose, and it should be used with caution in people who have an excessive alcohol intake.

Ibuprofen is less toxic in overdose but is more likely to cause gastrointestinal adverse effects, some of which can be severe or life threatening (e.g. perforating ulcer). These effects are unlikely to occur with short-term use. Hypersensitivity reactions (e.g. asthma, rhinitis, angio-oedema, or urticaria) and renal problems are more likely to occur with ibuprofen than paracetamol.

Neither paracetamol nor ibuprofen has a negative effect on the immune system or the natural duration of respiratory tract infections.

The author concluded that paracetamol and ibuprofen are both suitable first-line treatments for the common cold and flu. Although the evidence to support a preference for one over the other was poor, it was suggested that the analgesic should be chosen according to the suitability of the individual (e.g. avoid ibuprofen in people with gastrointestinal problems, or avoid paracetamol if the person has known problems with alcohol).

Bacterial resistance

Evidence on bacterial resistance to antibiotics

Bacterial resistance to antibiotics is a significant problem in the treatment of many infections, including acute bronchitis. Although in general there has not been a large increase the prevalence of resistance in the UK, this has been observed in other countries where the prescribing of antibiotics in primary care is more widespread. Therefore, to ensure bacterial resistance does not become a major problem, prescribing antibiotics for self-limiting infections (such as acute bronchitis) should be restricted.

The Health Protection Agency reports the prevalence of resistant strains of bacteria, including the two most significant bacterial pathogens implicated in acute bronchitis, Streptococcus pneumoniae and Haemophilus influenzae [HPA, 2005].

The incidence of resistant strains of S. pneumoniae has remained approximately constant over the past 5 years.

Penicillin-resistant species of S. pneumoniae accounted for 1.2% of isolates in 2003. Intermediate resistance was found in 3.1% of isolates.

About 13% of strains of S. pneumoniae are now resistant to erythromycin.

The prevalence of resistant strains of S. pneumoniae in the UK is similar to that in other northern European countries but less than the prevalence in most southern European countries.

At present, resistance of S. pneumoniae to quinolones is not a significant problem. However, it is recommended that, if a quinolone is used, one with enhanced anti-pneumococcal activity should be selected (e.g. moxifloxacin), in order to help prevent further resistance occurring.

There has not been an increase in the level of penicillin-resistant H. influenzae in recent years. About 20% of isolates are resistant to penicillin, and this is nearly always caused by increased beta-lactamase activity. So far, there are no reports of resistance of H. influenzae to beta-lactamase-resistant cephalosporins. However, resistance to trimethoprim seems to be increasing.

More recent data from the British Society of Antimicrobial Chemotherapy (BSAC) surveillance project has similar findings.

The BSAC surveillance project has reported on pneumococcal susceptibility to various antimicrobials from both blood and respiratory tract samples in the UK and Ireland 1999/2000 to 2006/2007. BSAC found no convincing evidence of an increase in non-susceptibility over time [Farrell et al, 2008; British Thoracic Society, 2009].

94% of bacteraemia isolates and 92% of respiratory isolates were fully susceptible to penicillin.

85% of bacteraemia isolates and 88% of respiratory isolates were fully susceptible to erythromycin and, by implication, other macrolides.

The BSAC surveillance project also reported that beta-lactamase production among H. influenzae has remained relatively stable at around 15% over the study period [Morrissey et al, 2008; British Thoracic Society, 2009].

Follow-up chest X-ray in pneumonia

Evidence on follow-up chest X-ray at 6 weeks in selected groups of people with pneumonia

The British Thoracic Society recommend a follow-up chest X-ray at 6 weeks in selected groups of people, based upon consideration of the following evidence:

People with pneumonia who smoke are at high risk of having lung cancer.

There is good evidence from a number of prospective studies that people diagnosed with pneumonia who smoke are at high risk of having underlying lung cancer.

In one study 17% of smokers over the age of 60 years had underlying lung cancer [Woodhead et al, 1987].

In another study 11% of smokers over the age of 50 years with pneumonia had lung cancer [Gibson et al, 1993].

People with pneumonia and persistent or slowly resolving symptoms and signs of pneumonia are at high risk of having an underlying malignancy.

One study found that an underlying malignancy is an important cause of slow resolution of the symptoms and signs of pneumonia [Holmberg and Kragsbjerg, 1993].

Chest X-rays taken at presentation will not detect all people with an underlying malignancy.

There is evidence from a number of studies that a chest X-ray will fail to detect an underlying malignancy in about 40% of people who have a malignancy. This occurs because the pneumonia obscures the appearance of the malignancy.

In one prospective study of 236 people with community-acquired pneumonia, ten people were diagnosed with lung cancer [Woodhead et al, 1987]. Of these, 40% were not detected on the initial chest X-ray.

In another prospective study of 1011 people hospitalized with community-acquired pneumonia, an initial chest X-ray failed to detect 39% of people with underlying lung cancer [Holmberg and Kragsbjerg, 1993].

A chest X-ray will detect an underlying malignancy in most people after 6 weeks of treatment for pneumonia.

There is evidence from a prospective study of 81 people with pneumonia that had serial chest X-rays that [Mittl et al, 1994]:

Radiographic changes resolve relatively slowly after pneumonia and lag behind clinical recovery.

Complete resolution of the radiographic appearance of pneumonia occurs within 6 weeks in 73% of people.

Search strategy

Scope of search

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of chest infections - adult.

Search dates

2007 - April 2012

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

exp Pneumonia/, community acquired pneumonia.tw., exp Bronchitis/, acute bronchitis.tw.

Table 1 . Key to search terms.
Search commands Explanation
/ indicates a MeSh subject heading with all subheadings selected
.tw indicates a search for a term in the title or abstract
exp indicates that the MeSH subject heading was exploded to include the narrower, more specific terms beneath it in the MeSH tree
$ indicates that the search term was truncated (e.g. wart$ searches for wart and warts)
Sources of guidelines

National Institute for Health and Care Excellence (NICE)

Scottish Intercollegiate Guidelines Network (SIGN)

Royal College of Physicians

Royal College of General Practitioners

Royal College of Nursing

NICE Evidence

Health Protection Agency

World Health Organization

National Guidelines Clearinghouse

Guidelines International Network

TRIP database

GAIN

NHS Scotland National Patient Pathways

New Zealand Guidelines Group

Agency for Healthcare Research and Quality

Institute for Clinical Systems Improvement

National Health and Medical Research Council (Australia)

Royal Australian College of General Practitioners

British Columbia Medical Association

Canadian Medical Association

Alberta Medical Association

University of Michigan Medical School

Michigan Quality Improvement Consortium

Singapore Ministry of Health

National Resource for Infection Control

Patient UK Guideline links

UK Ambulance Service Clinical Practice Guidelines

RefHELP NHS Lothian Referral Guidelines

Medline (with guideline filter)

Driver and Vehicle Licensing Agency

NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

The Cochrane Library :

Systematic reviews

Protocols

Database of Abstracts of Reviews of Effects

Medline (with systematic review filter)

EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

NIHR Health Technology Assessment programme

The Cochrane Library :

NHS Economic Evaluations

Health Technology Assessments

Canadian Agency for Drugs and Technologies in Health

International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

The Cochrane Library :

Central Register of Controlled Trials

Medline (with randomized controlled trial filter)

EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Bandolier

Drug & Therapeutics Bulletin

TRIP database

Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

Department of Health

Health Management Information Consortium (HMIC)

Patient experiences

Healthtalkonline

BMJ - Patient Journeys

Patient.co.uk - Patient Support Groups

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

British National Formulary (BNF)

electronic Medicines Compendium (eMC)

European Medicines Agency (EMEA)

LactMed

Medicines and Healthcare products Regulatory Agency (MHRA)

REPROTOX

Scottish Medicines Consortium

Stockley's Drug Interactions

TERIS

TOXBASE

Micromedex

UK Medicines Information

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