For guidance on managing acute cough in people with suspected or confirmed COVID-19, follow our rapid guideline on managing COVID-19.
Be aware that an acute cough:
is usually self-limiting and gets better within 3 to 4 weeks without antibiotics
is most commonly caused by a viral upper respiratory tract infection, such as a cold or flu
can also be caused by acute bronchitis, a lower respiratory tract infection, which is usually a viral infection but can be bacterial
can also have other infective or non-infective causes.
For children under 5 with an acute cough and fever, follow the NICE guideline on fever in under 5s: assessment and initial management.
For adults, children and young people with an acute cough and suspected pneumonia, follow:
our COVID-19 rapid guideline on managing COVID-19 for guidance on pneumonia secondary to COVID-19
the NICE guidelines on pneumonia (community-acquired): antimicrobial prescribing and pneumonia (hospital-acquired): antimicrobial prescribing for guidance on pneumonia not secondary to COVID-19. [amended 2021]
Refer people with an acute cough to hospital, or seek specialist advice on further investigation and management, if they have any symptoms or signs suggesting a more serious illness or condition (for example, sepsis, a pulmonary embolism or lung cancer).
Give general advice to people about:
the usual course of acute cough (lasts up to 3 or 4 weeks)
how to manage their symptoms with self-care (see the recommendations on self-care)
when to seek medical help, for example if symptoms worsen rapidly or significantly, do not improve after 3 to 4 weeks, or the person becomes systemically very unwell.
Do not offer the following treatments to people for an acute cough associated with an upper respiratory tract infection or acute bronchitis unless the person has an underlying airways disease, such as asthma:
an oral or inhaled bronchodilator (for example, salbutamol) or
an oral or inhaled corticosteroid.
Do not offer a mucolytic (for example acetylcysteine or carbocisteine) to treat an acute cough associated with an upper respiratory tract infection or acute bronchitis.
Do not offer an antibiotic to treat an acute cough associated with an upper respiratory tract infection in people who are not systemically very unwell or at higher risk of complications (see recommendation 1.1.15). Give advice about why an antibiotic is not needed.
Do not routinely offer an antibiotic to treat an acute cough associated with acute bronchitis in people who are not systemically very unwell or at higher risk of complications (see recommendation 1.1.15).
Be aware that:
antibiotics do not improve the overall clinical condition of people with acute bronchitis
antibiotics make little difference to how long symptoms of acute bronchitis last (on average they shorten cough duration by about half a day)
antibiotics have possible adverse effects, particularly diarrhoea and nausea.
This recommendation has been removed.
When no antibiotic prescription is given, give advice about why an antibiotic is not needed.
If an antibiotic prescription is given, give advice about possible adverse effects of the antibiotic, particularly diarrhoea and nausea.
For people with an acute cough who are identified as systemically very unwell (ideally at a face‑to‑face clinical examination), offer an immediate antibiotic prescription (for choice of antibiotic, see recommendation 1.3.1).
Be aware that people with an acute cough may be at higher risk of complications if they:
have a pre-existing comorbidity, such as significant heart, lung, renal, liver or neuromuscular disease, immunosuppression or cystic fibrosis
are young children who were born prematurely
are older than 65 years with 2 or more of the following criteria, or older than 80 years with 1 or more of the following criteria:
hospitalisation in previous year
type 1 or type 2 diabetes
history of congestive heart failure
current use of oral corticosteroids.
For people with an acute cough who are identified as at higher risk of complications (ideally at a face‑to‑face clinical examination), consider:
an immediate antibiotic prescription (for choice of antibiotic, see recommendation 1.3.1) or
a back-up antibiotic prescription.
When an immediate antibiotic prescription is given, give advice about possible adverse effects of the antibiotic, particularly diarrhoea and nausea.
When a back-up antibiotic prescription is given, give advice about:
an antibiotic not being needed immediately
using the back-up prescription if symptoms worsen rapidly or significantly at any time.
Reassess people with an acute cough if their symptoms worsen rapidly or significantly, taking account of:
alternative diagnoses, such as pneumonia
any symptoms or signs suggesting a more serious illness or condition, such as cardiorespiratory failure or sepsis
previous antibiotic use, which may have led to resistant bacteria.
See the evidence and committee discussion on bronchodilators, corticosteroids, mucolytics, no antibiotic, back-up antibiotics and choice of antibiotic.
Be aware that some people may wish to try the following self-care treatments, which have limited evidence of some benefit for the relief of cough symptoms:
honey (in people aged over 1 year)
pelargonium (a herbal medicine; in people aged 12 and over)
over-the-counter cough medicines containing the expectorant guaifenesin (in people aged 12 and over)
over-the-counter cough medicines containing cough suppressants, except codeine, (in people aged 12 and over who do not have a persistent cough, such as in asthma, or excessive secretions).
Be aware that limited evidence suggests that antihistamines, decongestants and codeine-containing cough medicines do not help cough symptoms.
See the evidence and committee discussion on self-care.
When prescribing antibiotics for an acute cough follow:
table 1 for adults aged 18 years and over
table 2 for children and young people under 18 years.
| Treatment | Antibiotic, dosage and course length |
|---|---|
|
First choice |
Doxycycline: 200 mg on first day, then 100 mg once a day for 4 days (5‑day course in total) |
|
Alternative first choices |
Amoxicillin: 500 mg three times a day for 5 days Clarithromycin: 250 mg to 500 mg twice a day for 5 days Erythromycin: 250 mg to 500 mg four times a day or 500 mg to 1,000 mg twice a day for 5 days |
See the BNF for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment, pregnancy and breast-feeding.
The possibility of pregnancy should be considered in women of childbearing age. Doxycycline should not be used in pregnancy. Amoxicillin is the preferred antibiotic in pregnancy. Erythromycin is preferred if a macrolide is needed in pregnancy, for example, if there is true penicillin allergy and the benefits of antibiotic treatment outweigh the harms. See the Medicines and Healthcare products Regulatory Agency (MHRA) Public Assessment Report on the safety of macrolide antibiotics in pregnancy.
| Treatment | Antibiotic, dosage and course length |
|---|---|
|
First choice |
Amoxicillin: 1 month to 11 months, 125 mg three times a day for 5 days 1 year to 4 years, 250 mg three times a day for 5 days 5 years to 17 years, 500 mg three times a day for 5 days |
|
Alternative first choices |
Clarithromycin: 1 month to 11 years: Under 8 kg, 7.5 mg/kg twice a day for 5 days 8 kg to 11 kg, 62.5 mg twice a day for 5 days 12 kg to 19 kg, 125 mg twice a day for 5 days 20 kg to 29 kg, 187.5 mg twice a day for 5 days 30 kg to 40 kg, 250 mg twice a day for 5 days 12 years to 17 years, 250 mg to 500 mg twice a day for 5 days Erythromycin: 1 month to 1 year, 125 mg four times a day or 250 mg twice a day for 5 days 2 years to 7 years, 250 mg four times a day or 500 mg twice a day for 5 days 8 years to 17 years, 250 mg to 500 mg four times a day or 500 mg to 1,000 mg twice a day for 5 days Doxycycline: 12 years to 17 years, 200 mg on first day, then 100 mg once a day for 4 days (5‑day course in total) |
See the BNF for children for appropriate use and dosing in specific populations, for example, hepatic impairment and renal impairment.
The age bands apply to children of average size and, in practice, the prescriber will use the age bands in conjunction with other factors such as the severity of the condition and the child's size in relation to the average size of children of the same age.
The possibility of pregnancy should be considered in women of childbearing age. Doxycycline should not be used in pregnancy. Amoxicillin is the preferred antibiotic in pregnancy. Erythromycin is preferred if a macrolide is needed in pregnancy, for example, if there is true penicillin allergy and the benefits of antibiotic treatment outweigh the harms. See the MHRA Public Assessment Report on the safety of macrolide antibiotics in pregnancy.
See the committee discussion on choice of antibiotic and antibiotic course length.