Acute Cough — Assessment & Management

Safety

Red Flags — Pneumonia, Pulmonary Embolism & Malignancy

Done

Cough + tachycardia (>100) + tachypnoea (>20) + fever >38°C or <36°C + new consolidation on CXR + SaO₂ <92% Community-acquired pneumonia with sepsis features. → 999 / same-day hospital. CRB-65 / NEWS2 assessment. Blood cultures + sputum culture before antibiotics. Oxygen.

Acute cough + pleuritic chest pain + dyspnoea + haemoptysis + risk factors (immobility, recent surgery, malignancy, DVT history, OCP) Pulmonary embolism. → 999 (if haemodynamically unstable or SaO₂ <92%). Same-day: Wells score + D-dimer + CTPA. LMWH anticoagulation if intermediate-high probability.

Haemoptysis + >3 weeks + smoker/ex-smoker age >40 + no obvious infective cause Lung cancer until proved otherwise. → 2WW lung cancer pathway. Urgent CXR if not already done. If CXR clear but high clinical suspicion: CT chest urgently.

Cough + stridor (harsh inspiratory noise) + drooling + hoarse voice + rapidly progressive symptoms in any age Epiglottitis / supraglottic obstruction or severe croup. → 999. Sit upright. Do NOT examine throat (reflex laryngospasm). Do NOT lay down.

Cough + severe breathlessness + tracheal deviation + absent breath sounds unilaterally + recent trauma or COPD Tension pneumothorax. → 999. Needle decompression (2nd intercostal space, mid-clavicular line) if haemodynamically compromised. Chest drain.

Cough in infant <3 months + paroxysmal coughing + inspiratory "whoop" or apnoea after coughing fit + post-tussive vomiting + unvaccinated or partially vaccinated Pertussis (whooping cough). → Notify PHE. Clarithromycin 500 mg BD x 7 days (reduces infectivity if within 3 weeks of onset). Isolate from neonates + unvaccinated infants.

Community-acquired pneumonia severity assessment using CRB-65 is a validated scoring tool that every GP should apply at every pneumonia assessment — it takes 30 seconds and directly guides the admission decision. CRB-65 scoring: C (Confusion — new confusion, abbreviated mental test ≤8) = 1 point; R (Respiratory rate ≥30/min) = 1 point; B (Blood pressure — systolic <90 or diastolic ≤60) = 1 point; 65 (age ≥65) = 1 point. Interpretation: CRB-65 score 0 = low severity (30-day mortality approximately 1%) = consider home treatment; CRB-65 score 1-2 = moderate severity (mortality approximately 8%) = consider hospital assessment; CRB-65 score ≥3 = high severity (mortality approximately 22%) = urgent hospital admission. The CURB-65 version adds urea >7 mmol/L but requires a blood test. Important caveat: CRB-65 is a minimum threshold — clinical judgement (including oxygen saturation, comorbidities, social circumstances, patient ability to comply with oral treatment) should always supplement the score.

Diagnose

Classification of Acute Cough — Duration and Aetiology

Done

Acute cough (<3 weeks)

Viral upper respiratory tract infection (most common — rhinovirus, coronavirus, influenza): associated coryzal symptoms, pharyngitis, mild fever, self-limiting in 7-14 days — no antibiotics. Acute bronchitis: lower respiratory tract URTI without pneumonia — viral in >90%, dry then productive cough, 3 weeks average duration, NO antibiotic (unless comorbidity changes risk assessment). Community-acquired pneumonia (CAP): productive cough + fever + focal chest signs + consolidation on CXR. Influenza: fever + myalgia + sudden onset — antivirals (oseltamivir within 48h for high-risk groups). Pertussis (whooping cough): paroxysmal cough + whoop + post-tussive vomiting — lasting 6-10 weeks ("100-day cough"). Inhaled foreign body: sudden onset cough + wheeze in child.

Subacute cough (3-8 weeks)

Post-viral cough (post-infectious): most common — persists after URTI; airway hypersensitivity; resolves without treatment (reassure + antitussive if needed). Pertussis (late presentation). Resolving CAP. Subacute sinusitis (post-nasal drip). Atypical pneumonia (Mycoplasma, Chlamydophila, Legionella): gradual onset, dry cough, relatively mild systemic upset for the radiological appearance.

Chronic cough (>8 weeks — most cases in primary care)

Asthma: variable airflow obstruction + eosinophilic inflammation. Post-nasal drip / rhinitis. ACE inhibitor cough (affects approximately 10-15% of ACE inhibitor users — dry persistent cough from bradykinin accumulation). GORD (gastro-oesophageal reflux). COPD / bronchiectasis. Lung cancer. ILD (interstitial lung disease). See chronic cough algorithm if >8 weeks.

The vast majority of acute cough presentations in UK primary care are viral — approximately 90% of acute bronchitis, the most common lower respiratory presentation, is caused by viruses, and antibiotics provide no meaningful benefit. The NICE antimicrobial prescribing guideline (NG120) recommends that antibiotics should NOT be prescribed routinely for acute cough/bronchitis, and that the delayed prescription approach (providing a prescription to use only if symptoms worsen or do not improve by day 7-10) reduces antibiotic use by approximately 70% compared to immediate prescription. The GRACE study showed that an internet-based clinical decision tool (TARGET/CRB-65 combination) could safely reduce antibiotic prescribing for lower respiratory tract infections without increasing adverse outcomes. The key GP message for the patient: 'Most chest infections are caused by viruses. Antibiotics won't help this — they only work on bacteria. This will usually clear in 2-3 weeks. Here is an information leaflet, and I'll give you a prescription to fill only if you're not improving by day 10 or if you develop any of the warning signs I'm going to describe.'

Diagnose

Assessment — History, Examination & Investigations

Done

Structured acute cough history

Duration: days (viral, bacterial, PE, foreign body), weeks (pertussis, atypical, post-viral). Onset: sudden (foreign body, PE, pneumothorax), gradual (infection, subacute). Character: dry (viral, PE, ACE inhibitor, post-viral), productive (bacterial infection, bronchiectasis, lung abscess), barking/seal-like (croup). Sputum: colour + quantity (green/yellow — suggests bacterial but not reliable; rust-coloured = pneumococcal; blood-streaked = PE, TB, malignancy, bronchiectasis). Associated symptoms: fever (infection), pleuritic pain (PE, pleurisy), wheeze (asthma, COPD, foreign body), dyspnoea (PE, pneumonia, pneumothorax). Systemic: weight loss (malignancy, TB), night sweats (TB, lymphoma). Travel: TB-endemic area (South Asia, Sub-Saharan Africa), Legionella (hotel/spa pools). Smoking (COPD, lung cancer). Occupational (asbestosis). Immunosuppression (PCP, TB, aspergillosis).

Examination

Vital signs: SaO₂ (pulse oximetry — mandatory for any significant cough), RR, HR, BP, temperature. Auscultation: crackles (pneumonia, pulmonary oedema, bronchiectasis, ILD), wheeze (asthma, COPD, bronchiolitis), absent breath sounds (pneumothorax, effusion, consolidation). Percussion: dullness (consolidation, effusion), hyperresonance (pneumothorax). Work of breathing: accessory muscle use, intercostal recession (particularly in children). JVP, peripheral oedema (cardiac cause of cough).

Investigations

Pulse oximetry (mandatory) · CXR (indicated if: fever + focal chest signs, haemoptysis, suspected pneumothorax, malignancy suspicion, CRB-65 ≥1) · FBC + CRP + blood cultures (suspected pneumonia — before antibiotics) · Sputum culture + sensitivity (pneumonia — before antibiotics in moderate-severe) · D-dimer + CTPA (suspected PE) · Urine pneumococcal + Legionella antigen (moderate-severe CAP) · Influenza PCR (clinical influenza — antivirals within 48h for high-risk) · Pertussis serology or PCR (paroxysmal cough >3 weeks)

Pulse oximetry is the most important single piece of examination equipment for assessing cough and respiratory symptoms in primary care — SaO₂ below 92% in an adult with acute cough and respiratory symptoms is an indicator for same-day hospital assessment or 999, regardless of how clinically well the patient appears. Silent hypoxia (significant desaturation without apparent distress) is a well-documented phenomenon, particularly in COVID-19, community-acquired pneumonia, and pulmonary embolism — patients can be talking normally with SaO₂ of 88-90%. The NICE standards for home oximetry monitoring in COVID-19 (introduced during the pandemic) established the principle that SpO₂ monitoring is a safety standard in primary care respiratory assessment. Every GP practice should have a calibrated pulse oximeter available for all consultations involving respiratory symptoms. An SpO₂ of 95% or above in a patient at rest is generally reassuring; 93-94% requires further assessment; below 92% requires emergency assessment.

Diagnose

CRB-65 Severity Assessment & Atypical Pneumonia

Done

CRB-65 severity scoring

Score 0 30-day mortality approximately 1% → treat in community (if SaO₂ ≥92%, social support adequate, no comorbidity). Score 1-2 30-day mortality approximately 8% → consider hospital referral or same-day review. Score 3-4 30-day mortality approximately 22-30% → hospital admission urgently. Adjuncts to CRB-65: SaO₂ (below 92% = escalate regardless of score), bilateral consolidation on CXR (higher mortality), age >85, nursing home resident, immunosuppressed, failed oral antibiotics.

Atypical pneumonia pathogens

Mycoplasma pneumoniae (most common atypical — epidemics every 3-4 years; gradual onset dry cough, headache, mild fever; relative bradycardia; CXR worse than clinical appearance; cold agglutinins; doxycycline or clarithromycin). Chlamydophila pneumoniae (mild illness, slow onset, biphasic — pharyngitis then pneumonia; doxycycline). Legionella pneumophila (severe — 30-day mortality approximately 10%; risk: hotel/spa pools, air conditioning; hyponatraemia; urine antigen test; ciprofloxacin or levofloxacin). Pneumocystis jirovecii (PCP) (immunosuppressed, HIV CD4 <200; bilateral interstitial shadowing on CXR; co-trimoxazole).

COVID-19 cough — primary care assessment

COVID-19 still circulates as endemic respiratory virus. Continuous dry cough + fever + anosmia (less common in Omicron variants) + myalgia + fatigue. Antiviral treatment: nirmatrelvir/ritonavir (Paxlovid — 300mg/100mg BD x 5 days) OR molnupiravir 800 mg BD x 5 days: for high-risk individuals within 5 days of symptom onset (eligibility: immunosuppressed or aged ≥70 + ≥2 risk factors). Check covid.gov.uk for current UKHSA eligibility criteria. Post-COVID syndrome (long COVID): persistent symptoms >12 weeks — fatigue, breathlessness, brain fog, post-exertional malaise.

Legionella pneumonia (Legionnaires' disease) is a severe pneumonia that must be specifically considered in any patient with moderate-severe pneumonia who has recently travelled (hotels with air conditioning or swimming pools/hot tubs) or been exposed to institutional water systems — it accounts for approximately 2-4% of CAP requiring hospital admission but has a disproportionately high mortality (approximately 10%). The clinical clues: hyponatraemia (serum sodium <130 mmol/L — present in approximately 40-50% of Legionella pneumonia), elevated liver enzymes (hepatitis), elevated CK (myositis), severe headache, gastrointestinal symptoms (diarrhoea, vomiting) preceding respiratory symptoms. The Legionella urinary antigen test (positive within 24h, high sensitivity for L. pneumophila serogroup 1 which causes approximately 85% of cases) is available in all UK acute hospitals. Treatment: quinolone (levofloxacin 500 mg BD IV/oral) or clarithromycin 500 mg BD IV/oral — not beta-lactams (intrinsically resistant). Legionella is a notifiable disease — public health notification required.

Refer

Referral Pathways

Done

999

SaO₂ <92% at rest · CRB-65 ≥3 · Suspected PE haemodynamically unstable · Tension pneumothorax · Stridor (epiglottitis/foreign body airway)

Same-day hospital or acute GP assessment

CRB-65 1-2 + SaO₂ 93-94% + unable to tolerate oral medication or no social support. Suspected PE (Wells intermediate-high) + D-dimer elevated. CAP requiring IV antibiotics. Infant <3 months with any lower respiratory illness.

2WW lung cancer

Haemoptysis + age ≥40 + smoker/ex-smoker ≥10 pack-years. Persistent chest X-ray abnormality. Unexplained cough >3 weeks with weight loss or hoarse voice. CXR mass lesion.

GP treatment + safety-net

Viral URTI/bronchitis (CRB-65 0, SaO₂ ≥95%, well): no antibiotics, antitussive if needed, delayed prescription, safety-net. Mild-moderate CAP (CRB-65 0-1, SaO₂ ≥92%, good social support): amoxicillin 500 mg TDS x 5 days (doxycycline if atypical suspected or penicillin allergy). Acute exacerbation of COPD with purulent sputum: amoxicillin or doxycycline x 5 days.

The delayed antibiotic prescription ('back-pocket' prescription) for lower respiratory tract infection has the strongest evidence base of any antibiotic stewardship intervention in primary care — multiple RCTs and a Cochrane review (Little, 2013) demonstrate that when GPs hand patients a prescription with instructions to use it only if symptoms are not improving by day 7-10 (or if specific warning signs develop), approximately 70-80% of patients do not fill the prescription, antibiotic use is reduced to that extent, and patient-reported outcomes (symptom duration, patient satisfaction, re-consultation rates) are equivalent to immediate antibiotic prescribing. The critical safety-netting component: the GP must specify the warning signs that should trigger immediate prescription filling or re-consultation: temperature >39°C, increasing breathlessness, confusion, blood in sputum, worsening despite 48h of antibiotics. Document in clinical notes: 'Delayed antibiotic prescription given — safety-net provided.'

Treat

Antibiotic Prescribing for CAP & LRTI

Done

Low severity CAP (CRB-65 0, home treatment)Amoxicillin 500 mg TDS x 5 days (NICE first-line for low severity CAP — S. pneumoniae the most common pathogen). Atypical cover: add doxycycline 100 mg OD x 5 days if atypical suspected (gradual onset, young adult, dry cough, prominent myalgia, no response to amoxicillin). Penicillin allergy: doxycycline 200 mg stat then 100 mg OD x 5 days. Review at 48h: if not improving, increase severity assessment + consider hospital assessment.

Moderate severity CAP (CRB-65 1-2, +/- hospital)Co-amoxiclav 625 mg TDS + clarithromycin 500 mg BD x 7 days (covers both typical and atypical pathogens). IV if unable to tolerate oral: co-amoxiclav 1.2g IV TDS + clarithromycin 500 mg IV BD. Duration: 5-7 days (NICE — shorter courses as effective as longer for non-severe CAP).

Acute bronchitis (viral — no antibiotics)No antibiotic (viral in >90%). Antipyretic/analgesic: paracetamol 1g QDS. Antitussive: if distressing, codeine linctus 15 mg TDS x 5 days (avoid in children, COPD) or pholcodine 10 mg TDS. Honey + lemon: evidence for reducing cough frequency in adults and children. NICE NG120: delayed antibiotic prescription (back-pocket) if patient has significant comorbidity or is unusually unwell.

Pertussis (whooping cough)Clarithromycin 500 mg BD x 7 days (or azithromycin 500 mg OD x 3 days): reduces infectivity if within 3 weeks of symptom onset; limited effect on symptoms after 3 weeks. Notify PHE (notifiable disease). Exclude from school/work for 48h after starting antibiotics. Close contacts: prophylactic clarithromycin for unvaccinated or incompletely vaccinated contacts (infants, immunosuppressed). Advise: cough can persist for 6-10 weeks despite antibiotic treatment.

The 5-day antibiotic course for low-severity CAP is now the NICE-recommended duration — the ESCAPE trial and multiple other RCTs demonstrated that 5-day amoxicillin is non-inferior to 7-day treatment for low-severity CAP, with equivalent clinical cure rates and lower antibiotic exposure (reducing selection pressure for resistance and C. difficile risk). NICE NG120 updated the recommendation in 2019 to 5 days for low-severity CAP (CRB-65 0) and 5-7 days for moderate severity. The practical implication: prescribing 28 capsules of amoxicillin 500 mg (equivalent to 9 days) when the recommended course is 5 days (15 capsules) is both wasteful and contributes to antibiotic resistance. GPs should prescribe the exact number of tablets for the recommended course — 15 amoxicillin 500 mg capsules for a 5-day TDS course. Some practices still default to 7-day courses out of habit — 5 days is adequate for most patients with low-severity CAP.

Treat

Influenza, COPD Exacerbation & Non-Antibiotic Management

Done

Influenza antiviral therapy

Oseltamivir (Tamiflu) 75 mg BD x 5 days: indicated within 48h of symptom onset for: age ≥65, pregnant women, immunosuppressed, chronic respiratory disease, chronic heart disease, CKD, T2DM, BMI ≥40, care home residents. Reduces duration by approximately 1 day and hospitalisation risk by approximately 35%. NHS England/UKHSA update guidance annually — check current NICE TAs. Annual influenza vaccination (NHS): all over-65s, pregnant women, healthcare workers, care home residents, clinically at-risk groups. Inhaled zanamivir (Relenza): alternative if oseltamivir resistant.

COPD acute exacerbation (AECOPD)

Definition: increased breathlessness + increased sputum volume or purulence. Antibiotic (if purulent sputum or CRP >20): amoxicillin 500 mg TDS x 5 days (first-line). Doxycycline 200 mg stat + 100 mg OD x 5 days (alternative). Co-amoxiclav (Augmentin) 625 mg TDS x 5 days if frequent exacerbator or Pseudomonas risk. Systemic corticosteroid: prednisolone 30 mg OD x 5 days (reduces recovery time; no benefit >5 days — BTS guideline). Bronchodilator: increase SABA dose + frequency (salbutamol 2.5 mg nebulisation in severe cases). Hospital if: severe dyspnoea, SaO₂ <88%, confusion, unable to cope at home.

Non-pharmacological cough management

Honey: 2 teaspoons at night — as effective as dextromethorphan for nocturnal cough in children (but not under 1 year — botulism risk). Steam inhalation: limited evidence but safe, soothing. Hydration: warm fluids thin secretions, soothe inflamed mucosa. Postural drainage: for patients with productive cough from bronchiectasis (physiotherapy referral). Air quality: advise avoidance of cigarette smoke, strong fumes, polluted environments during recovery from respiratory illness.

The prednisolone 5-day course for AECOPD is one of the most evidence-based primary care interventions for COPD exacerbations — the REDUCE trial (JAMA 2013) established that 5 days of prednisolone 40 mg OD is non-inferior to 14 days for AECOPD in terms of re-exacerbation at 6 months, with significantly lower cumulative steroid exposure. NICE guideline NG115 recommends 30 mg prednisolone OD for 5 days (UK-standard dose). The key contraindications or cautions: uncontrolled diabetes (blood glucose can rise significantly — advise patient to check; may need temporary insulin or dose adjustment), active peptic ulcer (add PPI), severe osteoporosis (consider bone protection if recurrent courses). Patients on frequent prednisolone courses (>3 per year) should have bone density assessment and be considered for bisphosphonate therapy. Do not issue prednisolone courses repeatedly without reassessing the diagnosis — a patient requiring ≥3 courses of prednisolone annually for 'COPD exacerbations' should be reviewed for: correct diagnosis, inhaler adherence and technique, smoking status, and specialist input.

Lifestyle

Prevention, Vaccination & Smoking Cessation

Done

Annual influenza vaccination NHS-eligible groups (all should be offered every autumn): all adults ≥65 years, pregnant women, all children aged 2-3 (nasal spray), healthcare workers, care home residents, those with chronic respiratory, cardiovascular, renal, liver, or metabolic disease, immunosuppressed, BMI ≥40. Quadrivalent influenza vaccine (QIV or adjuvanted QAIV for ≥65s — superior immune response in elderly). Record vaccination + consent. Seasonal timing: September-November (before the influenza season).

Pneumococcal vaccination PCV13/PCV15/PCV20 (conjugate — T-cell dependent, broader serotype coverage) + PPV23 (polysaccharide — additional serotypes). Schedule: PCV20 at age 65+ (single dose — provides lifelong protection from most clinical pneumococcal disease) + PPV23 for at-risk adults. Higher-risk groups (asplenia, CKD, immunosuppression): enhanced schedule — specialist advice. Reduces CAP incidence by approximately 25-30% and invasive pneumococcal disease by approximately 75% in vaccinated populations.

Smoking cessation — single most important LRTI prevention Smoking impairs mucociliary clearance, reduces alveolar macrophage function, and disrupts the respiratory epithelial barrier — increasing susceptibility to all respiratory infections including CAP, influenza, and TB. GP brief advice + NHS Stop Smoking Service referral at every respiratory consultation. Combination pharmacotherapy: varenicline (Champix/cytisine) + NRT most effective (4x vs unassisted quit). Vaping (e-cigarettes) as a cessation aid: NICE acknowledges evidence of benefit over NRT alone in motivated quitters.

Cough hygiene and respiratory etiquette Cover nose and mouth with a tissue when coughing — bin immediately. If no tissue: cough into elbow crease, not into hands. Handwashing after coughing or blowing nose. COVID-19 and influenza: stay home for 5 days from symptom onset or until fever-free 24h. Lateral flow testing when available. Explain to patients: this approach reduces transmission to vulnerable contacts by approximately 50-70% in household studies.

Air quality and respiratory health Indoor air quality: ventilate rooms adequately (5-10 minutes window opening per hour in winter). Wood-burning stoves: significantly increase indoor PM2.5 levels — avoid in patients with COPD or asthma. Outdoor pollution: on high-pollution days (UKHSA AQI website), advise COPD and asthma patients to avoid outdoor exercise and remain indoors in the afternoon (peak traffic pollution). Occupational respiratory hazards: refer to occupational physician for work-related cough (baker's asthma, farmer's lung, asbestosis).

COPD self-management and rescue packs COPD rescue pack: for patients with ≥2 exacerbations per year — provide a self-management plan with 5-day course of prednisolone 30 mg + antibiotic (amoxicillin 500 mg TDS or doxycycline 200mg/100mg). Patient instructions: start pack when: increased breathlessness + increased sputum (colour change or quantity) and self-monitoring confirms deterioration. Contact GP if: not improving after 48h, new symptoms, SaO₂ <90% (home oximeter). Rescue packs reduce ED attendance by approximately 40% in RCTs.

Children and acute cough — parent education Most childhood coughs are viral and self-limiting — antibiotics do not help and should not be expected. Honey (2 teaspoons at bedtime) for children over 1 year: evidence from Cochrane review for reducing cough severity and duration. Adequate fluid intake. Cool mist humidifier: for croup. Warning signs to return: stridor at rest, working hard to breathe, lips turning blue, refusing to drink, persistently high fever >39°C, or rapid deterioration.

TB awareness and latent TB testing TB incidence in UK: approximately 4,300 cases/year (2023) — concentrated in urban areas, foreign-born communities, homeless, prison populations, immunosuppressed. NICE NG33: latent TB (LTBI) testing (interferon-gamma release assay — IGRA) for all new entrants to UK from high-incidence countries (>150/100,000) registered with primary care. Symptoms suggesting active TB: persistent cough >3 weeks + weight loss + night sweats + haemoptysis → CXR + 3 early morning sputum (acid-fast bacilli). Notify PHE if suspected or confirmed. Isoniazid-resistant and MDR-TB: specialist management only.

The COPD rescue pack prescription is one of the most evidence-based and cost-effective primary care interventions for COPD management — a Cochrane review (2018) of self-management plans including rescue medication showed significant reductions in hospital admissions (RR 0.77) and ED visits in patients with COPD. The self-management plan components: (1) written action plan specifying when to start the rescue pack (increase in breathlessness + change in sputum beyond baseline); (2) course of prednisolone 30 mg OD x 5 days; (3) antibiotic course (amoxicillin 500mg TDS x 5 days, or doxycycline 200/100 mg x 5 days as 2nd choice); (4) instructions to contact GP within 48h if not improving; (5) instructions for when to call 999 (confusion, severe breathlessness at rest, cyanosis, SpO₂ <90%). NICE NG115 (COPD) recommends that all COPD patients with ≥2 exacerbations per year should have a written self-management plan.

Safety

Follow-Up, Monitoring & Safety-Netting

Done

CAP follow-up

Review at 48h (if treated in community): are symptoms improving? SaO₂ maintained ≥92%? Eating and drinking? If CRB-65 0 + no improvement at 48h: reassess + escalate. CXR at 6 weeks (NICE — all patients treated for CAP aged ≥50 to exclude underlying malignancy or persistent opacity). Earlier CXR if slow to recover.

Antibiotic failure — when to escalate

No improvement after 48-72h antibiotics: reassess diagnosis (PE? Lung cancer? Empyema?). Change antibiotic (cover atypicals if not already). CXR if not yet done. Consider same-day hospital if deteriorating.

Pertussis contacts

PHE notification + contact tracing. Prophylactic antibiotics for household contacts who are: unvaccinated infants, pregnant >28 weeks, immunosuppressed, healthcare workers — clarithromycin 250-500 mg BD x 7 days.

Post-COVID (long COVID)

Any symptoms persisting beyond 12 weeks post-COVID: assess for long COVID syndrome (fatigue, breathlessness, cognitive impairment, POTS — postural orthostatic tachycardia, post-exertional malaise). Refer to long COVID clinic. NICE NG188.

999 / Same-day

SaO₂ <92% · CRB-65 ≥3 · PE suspected (pleuritic pain + haemoptysis + DVT risk) · Stridor · Infant <3 months respiratory distress

48h review

CAP treated at home: review at 48h if not improving. Prescribe delayed antibiotic prescription for viral LRTI: fill if not improving by day 7-10.

The 6-week CXR follow-up after community-acquired pneumonia is a NICE quality standard that is widely not performed in UK primary care — all patients aged 50 and over who have been treated for CAP should have a repeat CXR at 6 weeks to confirm radiological resolution and exclude underlying pathology (primarily lung cancer) that may have predisposed to the pneumonia or been concealed by the consolidation. Obstructive post-obstructive pneumonia (pneumonia distal to a bronchial carcinoma) is one of the most important causes of 'slow to resolve' or recurrent pneumonia in this age group. GPs should have a systematic recall system for 6-week follow-up CXR after CAP in patients ≥50 — this can be done via a SNOMED code + recall at the time of prescribing, or by template reminder in the clinical system. The QOF does not currently include a 6-week CXR indicator, meaning this falls to clinical governance and individual GP clinical practice.