Chest Guidelines for managing Acute Cough in primary care services

Latest Chest Guidelines for the management of Acute Cough Due to Suspected Pneumonia or Influenza in an outpatient setting or primary care services have been released.

Cough is a common presentation to primary care or outpatient services, and cough due to either suspected pneumonia or influenza involves a subset of patients with acute cough who are thought to benefit from disease-specific investigations and therapies. The guideline explored the evidence base for their investigation and management.

Pneumonia and influenza are the eighth leading causes of death overall and the most important death related to infectious diseases in the United States. The overall annual incidence of community-acquired pneumonia (CAP) ranges from 5 to 11 per 1,000 people, with more cases occurring during the winter season. In 2006, there were approximately 4.2 million ambulatory care visits for CAP in the United States, and it is estimated that CAP has an annual economic burden that exceeds $17 billion in the United States.

These guidelines refer to patients evaluated in the outpatient setting who present with acute cough (ie, < 3 weeks in duration), accompanied by other symptoms for which the physician suspects pneumonia or influenza acquired outside of the hospital setting. The present guidelines specifically refer to a suspected diagnosis of pneumonia and influenza and do not include acute bronchitis and other upper respiratory tract infections. In addition, these guidelines exclude patients who are immunocompromised.

The steering committee developed a series of questions derived from the Grading of Recommendations Assessment, Development and Evaluation (GRADE) format that uses the patient, intervention, comparison, outcome (PICO) question format. Eight PICO questions were formulated, with four addressing the diagnostic confirmation of pneumonia and four focusing on therapeutic strategies that include recommendations on antibacterial treatment, nonantibacterial interventions (eg, short-acting bronchodilators, mucolytics, cough suppressants), and antiviral therapies. Patients with cough and suspected or confirmed pneumonia or influenza who require hospitalization should be treated using guidelines advocated by other organizations addressing those specific clinical conditions.

Summary of Recommendations

1. For outpatient adults with acute cough due to suspected pneumonia, we suggest the following clinical symptoms and signs are suggestive of pneumonia (cough, dyspnea, pleural pain, sweating/fevers/shivers, aches and pains, temperature 38°C or greater, tachypnea and new and localizing chest examination signs).

2. For outpatient adults with acute cough due to suspected pneumonia, we suggest measuring C-reactive protein (CRP) because the addition of CRP to features such as fever (38°C or greater), pleural pain, dyspnea and tachypnoea, and signs on physical examination of the chest (tachypnea and new and localizing chest examination signs) strengthens both the diagnosis and exclusion of pneumonia.

3. For outpatient adults with acute cough due to suspected pneumonia, we suggest not routinely measuring procalcitonin.

4. For outpatient adults with acute cough and abnormal vital signs secondary to suspected pneumonia, we suggest ordering chest radiography to improve diagnostic accuracy.

5. For outpatient adults with acute cough and suspected pneumonia, we suggest that there is no need for routine microbiological testing.

6. For outpatient adults with acute cough, we suggest the use of empiric antibiotics as per local and national guidelines when pneumonia is suspected in settings where imaging cannot be obtained.

7. For outpatient adults with acute cough and no clinical or radiographic evidence of pneumonia (eg, when vital signs and lung exams are normal) we do not suggest the routine use of antibiotics.

8. For outpatient adults with acute cough and suspected influenza, we suggest initiating antiviral treatment (as per Centers for Disease Control and Prevention advice) within 48 hours of symptom onset. Antiviral treatment may be associated with decreased antibiotic usage, hospitalization, and improved outcomes.