Diagnosis

The guideline used for the intervention recommends a clinical and stepwise approach to diagnose the cause of acute cough in patients aged greater than 12 years who complain about acute cough with or without purulent sputum that have not been treated in the preceding week with antibiotics, not patients known to have chronic obstructive pulmonary disease or a chronic cough (= more than 30 days).

• First conditions such as pneumonia, pulmonary embolism, left ventricular failure (pulmonary oedema), pneumothorax, aspiration and irritation by toxic agents should be ruled out by means of history and clinical examination. Although these are not frequent conditions, and although acute cough may not be the most prominent complaint, these conditions are treatable, and possibly life-threatening. They should not be missed (level 3).

• In case of clinical suspicion of pneumonia patient at low risk for mortality or complications can be identified by means of history and clinical examination. This risk determines the place of treatment (level 2). Treating these patients at home with antibiotics is justified, ideally this decision is documented with a positive chest X-ray (level 3).

• If another cause than a respiratory infection is present (for example asthma, gastro-esophagial reflux disease, ACE-inhibitors) management needs to be adjusted accordingly. Even though such conditions may not be obvious in a first encounter, it is worthwhile to take them into account (level 3).

• If finally a respiratory infection seems to be the most likely cause, it is not feasible to distinguish between viral and bacterial infections (level 2). Furthermore this differentiation is not meaningful for the therapeutic decision (level 3).

Treatment

• In case of respiratory infections with acute (productive) cough, pneumonia excluded, antibiotics have no effect on (the duration of) the productive cough and the limitations of work or other activities. Of each ten patients after seven to eleven days more than eight are clinically improved regardless the use of an antibiotic. Less than one patient extra improves due to the antibiotic, but as many patients experience the side effects (level 1).
  The possible benefits of antibiotics are outweighed by their harm. Antibiotics are justified only in case of compromised immunity (level 3).

• We recommend to explicitate patient expectations, to reassure patients and inform them about the cause and duration of the complaints, to explain why antibiotics are not necessary, and to instruct patients when they should reconsult (level 3).

• The effectiveness of over-the-counter medicines is unclear. For the symptomatic treatment an antitussivum (dextromethorphan) or an expectorans (guaifenesine) can be prescribed (level 3).

VAN ROYEN P. Niveaus van bewijskracht: levels of evidence. Huisarts Nu 2002;31:54-7.