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Evidence Review National Institute for Health and Care Excellence APG Cough (acute): draft for consultation Acute cough (including acute bronchitis): antimicrobial prescribing guideline Evidence review August 2018 Draft for consultation DRAFT FOR CONSULTATION Contents Disclaimer The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian. Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties. NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn. Copyright © NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: DRAFT FOR CONSULTATION Contents Contents Contents .............................................................................................................................. 4 1 Context .......................................................................................................................... 6 1.1 Background ........................................................................................................... 6 1.2 Managing self-limiting infections ............................................................................ 6 1.2.1 Self-care .................................................................................................... 7 1.2.2 No antibiotic prescribing strategies ............................................................. 7 1.2.3 Antibiotic prescribing strategies .................................................................. 8 1.3 Safety information ................................................................................................. 8 1.3.1 Safety netting ............................................................................................. 8 1.3.2 Medicines safety ........................................................................................ 9 1.4 Antimicrobial resistance ....................................................................................... 10 1.5 Other considerations ........................................................................................... 11 1.5.1 Medicines adherence ............................................................................... 11 1.5.2 Resource impact ...................................................................................... 11 2 Evidence selection ..................................................................................................... 13 2.1 Literature search ................................................................................................. 13 2.2 Summary of included studies............................................................................... 13 3 Evidence summary ..................................................................................................... 18 3.1 Non-pharmacological interventions ..................................................................... 18 3.1.1 Honey ...................................................................................................... 18 3.1.2 Herbal remedies ....................................................................................... 20 3.2 Non-antimicrobial pharmacological interventions (self-care medicines) ............... 22 3.2.1 Oral analgesia .......................................................................................... 22 3.2.2 Expectorants ............................................................................................ 23 3.2.3 Antitussives .............................................................................................. 24 3.2.4 Antihistamines and decongestants ........................................................... 26 3.3 Non-antimicrobial pharmacological interventions (prescribed medicines) ............ 27 3.3.1 Mucolytics ................................................................................................ 27 3.3.2 Bronchodilators ........................................................................................ 27 3.3.3 Corticosteroids ......................................................................................... 29 3.4 Antimicrobials ...................................................................................................... 30 3.4.1 Back-up antibiotics ................................................................................... 30 3.4.2 Antibiotics compared with placebo in adults ............................................. 31 3.4.3 Antibiotics compared with placebo in children .......................................... 33 3.4.4 Choice of antibiotic ................................................................................... 35 3.4.5 Antibiotic dosage, duration and route of administration ............................ 35 4 Terms used in the guideline ...................................................................................... 36 4.1.1 Acute cough ............................................................................................. 36 4.1.2 Acute bronchitis ....................................................................................... 36 4 DRAFT FOR CONSULTATION Contents Appendices ...................................................................................................................... 37 Appendix A: Evidence sources .................................................................................. 37 Appendix B: Review protocol ..................................................................................... 40 Appendix C: Literature search strategy ..................................................................... 48 Appendix D: Study flow diagram ................................................................................ 56 Appendix E: Evidence prioritisation .......................................................................... 57 Appendix F: Included studies ..................................................................................... 59 Appendix G: Quality assessment of included studies .............................................. 60 G.1 Non-pharmacological interventions .......................................................................... 60 G.2 Non-antimicrobial pharmacological interventions (self-care medicines) ............... 60 G.3 Non-antimicrobial pharmacological interventions (prescribed medicines) ........... 61 G.4 Back-up antibiotics .................................................................................................... 62 G.5 Antibiotics ................................................................................................................... 63 Appendix H: GRADE profiles ...................................................................................... 64 H.1 Honey for children with acute cough ........................................................................ 64 H.2 Herbal medicines ........................................................................................................ 68 H.3 Oral analgesia ............................................................................................................ 80 H.4 Expectorants ............................................................................................................... 85 H.5 Antitussives ................................................................................................................ 86 H.6 Antihistamines and decongestants........................................................................... 91 H.7 Mucolytics ................................................................................................................... 94 H.8 Bronchodilators .......................................................................................................... 96 H.9 Corticosteroids ......................................................................................................... 100 H.10 Back-up antibiotics ................................................................................................. 102 H.11 Antibiotics ............................................................................................................... 107 Appendix I: Studies not-prioritised ........................................................................ 117 Appendix J: Excluded studies ................................................................................. 119 5 DRAFT FOR
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