Intended for healthcare professionals

Practice Rational Testing

Investigation of “non-responding” presumed lower respiratory tract infection in primary care

BMJ 2011; 343 doi: (Published 13 October 2011) Cite this as: BMJ 2011;343:d5840
  1. James D Chalmers, clinical research fellow ,
  2. Adam T Hill, consultant physician
  1. 1Department of Respiratory Medicine, Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, UK
  1. Correspondence to: J Chalmers jamesdchalmers{at}

Most lower respiratory tract infections in primary care are self limiting, and laboratory and other investigations should be reserved for patients with specific risk factors

Learning points

  • Among patients prescribed an antibiotic for lower respiratory tract infection in primary care, 20-25% will present again within four weeks

  • Symptoms of lower respiratory tract infection usually resolve without specific treatment or investigation in a median of three weeks from first consultation

  • In most patients laboratory and other investigations are unlikely to be helpful and should be guided by specific risk factors

  • Microbiology testing is of little value in most patients. Sputum culture is recommended for patients with chronic lung disease with sputum production and for patients with suspected pneumonia who are not responding to initial therapy

  • Chest radiography is most useful if an alternative diagnosis (such as malignancy) is being considered

A 49 year old woman presents to her general practitioner for the second time with a cough. She first presented a week ago with a four day history of cough with purulent sputum. She reported fever but had no haemoptysis, chest pain, or recent weight loss. She had never smoked. Clinical examination was unremarkable. She was prescribed a one week course of amoxicillin 500 mg three times daily. She has presented again, reporting that the cough has not improved.

What is the next investigation?

The problem

Lower respiratory tract infections managed in primary care comprise a spectrum of disorders including acute bronchitis, community acquired pneumonia, and exacerbations of airways disease. Most lower respiratory tract infections are self limiting, and several studies in the United Kingdom and internationally suggest that antibiotic treatment does not significantly reduce recovery time.1 2 Historically, sputum purulence was regarded as an indicator of bacterial infection and an indication for antibiotic treatment. Recent data from over 3000 patients with acute cough in primary care showed that …

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