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GETTY caused by infection . Be alert for other causes , such as asthma , bronchiectasis , lung cancer , interstitial lung disease and foreign-body inhalation .
The best approach With antibiotic resistance on the rise , it is vital that all healthcare professionals stand up to patients who demand an inappropriate prescription .
So , how should we manage the person with a new cough with coloured phlegm ? Anyone severely ill should be considered for same-day hospital review , where a decision on admission will be made . Most of those not admitted should not be offered an antibiotic .
The patient can be told that the cough is likely to last for three to four weeks and that taking an antibiotic is likely to shorten the symptoms by only about half a day , while putting them at risk of side-effects such as diarrhoea and nausea , and future antibiotic resistance . 1 This can be backed up with a patient information leaflet . 3 , 4 It is also good to use this opportunity to promote smoking cessation where appropriate .
In medical school , I was taught that in multiple choice questions , options containing the words ‘ always ’ or ‘ never ’ were likely to be wrong , as general medicine is rarely so black and white . The same applies to a decision not to give antibiotics to a coughing patient , as there are cases where one is indicated . A common example is the patient with COPD , for whom increased sputum volume and purulence is a sign of an acute exacerbation for which NICE advises consideration of both oral steroids
References 1 NICE CKS . Chest infections – adult . 2021 . bit . ly / 3vG6gUh 2 NICE CKS . Cough . 2021 bit . ly / 35KTnwW 3 RCGP . Treating Your Respiratory Tract Infection patient leaflet . bit . ly / 35uTAEN 4 Patient . Information on cough . bit . ly / 3HD5OZ9 5 NICE CKS . Scenario : Acute exacerbation of COPD . bit . ly / 3pyvkbY 6 WHO . Antibiotic resistance . bit . ly / 3vzk96t and antibiotics , specifically taking into account colour changes in the sputum when deciding on antibiotics . 5
It is also suggested that we ‘ consider ’ an immediate or back-up antibiotic prescription for people who are at higher risk of complications . These include : 1
• Those with a pre-existing condition affecting the heart , lungs , kidneys or liver .
• Those who are immunosuppressed .
• Those with neuromuscular disease . This also applies to patients over 80 with more than one of the following conditions ( two or more in over-65s ):
• Diabetes mellitus
• Admission in the previous year
• History of congestive heart failure
• Current use of oral steroids .
Some areas have access to point-of-care testing for C-Reactive protein ( CRP ), which identifies if there is inflammation in the body . A CRP of < 20 mg / L can be used to reinforce a decision not to give antibiotics . If the CRP is 20-100 mg / L a delayed prescription might be given ; a patient with a CRP of > 100 mg / L will need antibiotics .
In summary , the colour of the sputum does not usually inform the need for antibiotics , except in COPD . With the prospect that without urgent action we may be heading for a post-antibiotic era , 6 it is vital all healthcare professionals stand up to demands for inappropriate antibiotics . If we all sing from the same hymn sheet then , slowly but surely , we can conquer this urban myth .
Dr Toni Hazell is a GP in north London